4/16/17 1 An Orthopedic View of a Pelvic Floor Patient

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An Orthopedic View of a

Pelvic Floor Patient

Lila Bartkowski-‐Abbate, PT, DPT, MS, OCS, WCS, PRPCNew Dimensions Physical Therapy

75 Plandome Road 611 Broadway – Suite 503Manhasset, NY 11030 New York, NY 10023

Lila Bartkowski-‐Abbate, Copyright 2017

History of Women’s Health Problems:

• World Health Organization:• Conceptualization of health: considers health to be a state of complete physical, mental, and social well-‐being.

• How does that apply to women? Haven’t women been considered all along?


• US Public Health Service identifies 5 criteria that a disease or condition must meet in order to be a women’s health condition.

• Eg: Pregnancy or Menopause• Osteoporosis


• Examples of Women’s Health Issues:1.Reproductive health2.Gynecologic disorders3.Eating disorders4.Osteoporosis5.Breast cancer / lymphedema6.Lung cancer, other gynecologic cancer7.Sports medicine injuries specific to women or that are prevalent in women8.Chronic pain / fibromyalgia9.Issues of domestic violence and sexual abuse and torture to women10.Heart disease


What is the reality of a Women’s Health Therapist and who do we treat?

• Men

• Women

• Children


Recognition in Women’s Health

• APTA created the Women’s Health Certification Specialty in 2011 (WCS)

• In the literature, we are now being addressed as pelvic health therapists

• PRPC – Pelvic Health Rehabilitation Practitioner, Certified (Herman & Wallace)

• CAPP -‐ Certificate of Achievement in Pelvic Physical Therapy (APTA)


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What types of dysfunction do we see?

• Stress Incontinence, Urinary Urge Incontinence, Urinary retention• Pre-‐natal & Post-‐partum symptoms• Fecal Incontinence & Chronic Constipation• Abdominal Pain• Pelvic Pain: vaginismus, vulvodynia, post-‐pelvic fractures, MVA• Coccyx Pain/SIJ Dysfunction• Sexual Dysfunction: erectile dysfunction, penetrative pain, ejaculation pain, testicular pain • Sitting Pain: Coccyx pain, ischial tuberosity pain


Parallels and Differences of Traditional vs. Pelvic PT• Understanding of pelvic anatomy

• Looking above and below a joint

• Relationship of lumbar spine/LE to the pelvis

• Muscle dysfunction – muscle problem, just in a different place

• Muscles get too weak = incontinence, or too tight = pain & spasm


Bony Landmarks1. Symphysis pubis 4. Pubic rami2. Ischial tuberosities 5. Sacrotuberous ligament3. Coccyx


Modalities

• Heat, Ice• Ultrasound• Interferential for pain• TENS for pain• Real-‐time Ultrasound (RTUS)


Manual Therapy Techniques

• Cyriax Cross-‐Friction Massage• Traditional Massage Technqiues• Connective-‐Tissue Mobilization vs Skin Rolling

• External and Internal Work• Intra-‐vaginal• Intra-‐rectal


Neuromuscular Re-‐education

• Deep Breathing Exercises

• Squat & Drop – muscle release

• Retraining muscles for proper coordination

• Biofeedback training

• RTUS


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Therapeutic Exercise

• Strengthening Exercises – for those who are weak

• Stretching Exercises – for those who are tight

• Understanding when to do each – takes understanding of condition


Cycle of the Problem:

PELVIC FLOOR COMPONENT

ORTHOPEDIC COMPONENT


Orthopedic Component

• Postural Screen:• Pelvic stability starts at the cranium and ends at the feet

• How much does forward head, thoracic kyphosis and lumbar lordosis play a role in pelvic stability?


Does normalizing bony landmarks create pelvic stability?


Core Strength

What does that mean for pelvic stability?

• Term of the past???

• Poor coordination• Weakness = Pain • How do our patients view core strength?


How are PTs determining strength and pelvic stability? What is normal?

• Objective measures that we can use:• Palpation of Diastesis Recti – using calipers or RTUS• One-‐legged standing test (OLS)• Active straight leg raise (ASLR)

• addresses core coordination• pelvic floor muscle weakness• gives the therapist a good place to start


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What is normal arthrokinematics& muscle coordination for pelvic stability?


Altered patterns of pelvic bone motion determined in subjects with posterior pelvic pain using skin markers

• Preactivation of the TrA, Oblique Internus, Multifidus, Pubococcygeus and Glut Max induce posterior rotation of the ilium relative to the sacrum• Increases tension on the posterior SI ligaments and posterior thoracolumbar fascia before load transfer onto the supporting leg• Co-‐activation of the trunk and hip muscles increases spinal stiffness and increases compression and stiffness of the SIJ

Lila Bartkowski-Abbate, Copyright 2017Hungerford,Gilleard,Lee 2004

Altered patterns of pelvic bone motion determined in subjects with posterior pelvic pain using skin markers

• Posterior rotation of the (ilium) inominate in relation to the sacrum is a position for stability during transfer load• Anterior rotation occurred in symptomatic subjects during weight bearing. • Anterior rotation is a non-‐optimal pattern• Abnormal articular and neuromyofascial function during increased vertical loading through the pelvis.

Lila Bartkowski-Abbate, Copyright 2017Hungerford,Gilleard,Lee 2004

Optimal Pelvic Stability

• Normalized biomechanical movement, along with appropriate muscle coordination paired with optimal strength create core strength and stability.


Pelvic Floor Muscles & SIJ

• Subjects with SIJ pain syndrome were different in their activation of the pelvic floor muscles, so:

A.Is it the joint problem that caused the PFM dysfunction?

B.Is it the PFM dysfunction that caused a deficit in the force closure mechanism of the SIJ?

Avery 2000

Lila Bartkowski-Abbate, Copyright 2017

Evidence of Altered Lumbo-‐Pelvic Muscle Recruitmentin the Presence of SIJ Pain

• Delayed onset in patients with SIJ pain:• Internal Oblique• Multifidus • Glut max in the supporting leg during hip flexion with SEMG

• Alteration in strategy for lumbopelvic stabilization • Disruption load transference through the pelvis

Lila Bartkowski-Abbate, Copyright 2017Hungerford 2003

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Analyze the findings:

• Internal Oblique• Multifidus • Glut max in the supporting leg during hip flexion with SEMG

• IO firing was poor secondary to rib flare, over-‐dominant rectus?• Poor multifidi firing pattern secondary to increased lumbar lordosis, poor TA strength, lumbar vertebrae positioned into rotations creating poor firing patterns?• Glut max – does the patient have normalized hip extension, normal capsular ROM or stiffness into relative anterior translation?


Pelvic Joint ControlPosteriorly:Sacral position stabilized by: Multifidus (to S4)Coccygeus (ischiococcygeus)

Anteriorly:Pubic symphysis stabilized by:PubococcygeusTrAInternal oblique

Lee 2005


Posteriorly:Sacral position stabilized by • Multifidus (to S4)• Coccygeus (ischiococcygeus)

Anteriorly:Pubic symphysis stabilized by • Pubococcygeus• TrA• Internal oblique

• The orthopedic therapist can address >50% of muscle firing patterns• Pelvic health therapist will further look at:• Coccyx deviations: internal & external• Internal pelvic floor muscle assessment


• Viewed as the composite function of three systems:• Osseo-‐ligamentous system -‐ provides a passive subsystem• Muscular system -‐ provides an active subsystem• Neural control system -‐ controls the subsystems


Spinal Segmental Stabilization (Hodges)

Local Stabilizing System

• Intertransversarii• Interspinals• Longissimus thoracis

• Iliocostalis lumborum• Multifidus

• Quadratus (medial)• Transversus abdominus

• Internal oblique• Pelvic floor muscles

• includes deep muscles which have origin or insertion on the lumbar vertebrae and the pelvic floor muscles of the pelvis

Hodges


Global Stabilizing System

• Longissimus thoracis• Iliocostalis lumborum• Quadratus (lateral)• Rectus abdominus• External oblique• Internal oblique • Global stabilizing system-‐ large, superficial

muscles of the trunk that move the spine and transfer the load from the thoracic to the pelvis

Hodges


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CHECK FOR ABDOMINAL FUNCTION


What is diastesis recti?Thinning or splitting of the linea alba which is the connective tissue connecting two ends of the rectus abdominus

Linea alba 1. Thins2. Splits



Causation and contributing factors?

1. Abdominal laparoscopic surgery

2. Abdominal full-‐thickness surgery

3. Umbilical hernia4. Pregnancy5. Genetic connective tissue

make-‐up6. Poor abdominal coordination7. What is keeping the ends of

the rectus apart? Lila Bartkowski-‐Abbate, Copyright 2017


Diastasis Recti Controversy

• Measurement by finger widths is unreliable

• Much of the time it was incorrect when compared to Real-‐Time Ultrasound (RTUS) measurements

• What’s the best way to measure it in the clinic? Depends upon your clinic’s goals. Finger-‐width is easy for the patient to self-‐measure.

Diastesis Rectus Abdominus (DRA) Prevelance

• 66% of women have a DRA in their third trimester and 53% persist immediately post-‐partum.• 36% remain AbN widened @ 7 wks (Boissonnault & Blaschat, 1998)• No change at 1 year post-‐partum (Coldron, et al 2008)• 52% of women with PFD (SUI or POP) have a DRA (Spintznagle ,et al 2007)

Lee, Lecture Discover the Pelvis, 2010

• We take this idea and transfer it to the more global population: why are men and children becoming urinary incontinent and/or have long-‐lasting low back pain?


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Linea Alba at Rest

< 45 years old

• Supraumbilical >10 mm • Umbilical Ring >27 mm • Subumbilical >9 mm

> 45 years old

>15 mm

>27 mm

>14 mm

Lila Bartkowski-Abbate, Copyright 2017 Lila Bartkowski-Abbate, Copyright 2017


Diastesis = Low back pain & urinary incontinence and abdominal pain?



Diastasis Recti Correction• How do we bring the rectus abdominus ends together?

• Passive realignment of the muscle, then isolation of recruitment

• Head lift alone isolates the rectus abdominus

• Adding a posterior pelvic tilt increases the SEMG activity

Diastasis Recti Correction

Sheet wrapped around the thorax for approximation of the rectus abdominus – brings the ends of the rectus closer togetherHead lift Hold 3-5 seconds30 reps


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What if the first step doesn’t work?1. Check lumbar spine bony position2. Clear out myofascial restrictions that

are keeping the ends of the rectus from coming back together

3. Rectus stripping – soft-‐tissue technique

4. Check rib position and look for rib flaring

5. What are the obliques doing?6. Normalize spinal curves7. Normalize hip ROM & strength8. Teach functional positions: avoid curl

up and down with transitional movements: use log rolling


1. Understand lumbar mechanics along with basics of flexion and extension and how to treat each dysfunction

2. Understanding of the myofascial clock and clearing out soft-‐tissue restrictions

3. Look for rib flaring and use of McConnell taping treatment

4. Basic hip mobilizations5. Basic movements that create more vs

less diastesis

What you need to do….1. Check lumbar spine bony position2. Clear out myofascial restrictions that

are keeping the ends of the rectus from coming back together

3. Rectus stripping – soft-‐tissue technique4. Check rib position and look for rib

flaring5. What are the obliques doing?6. Normalize spinal curves7. Normalize hip ROM & strength8. Teach functional positions: avoid curl

up and down with transitional movements: use log rolling

What skill-‐set you need to have….

1. Understand lumbar mechanics along with basics of flexion and extension and how to treat each dysfunction

2. Understanding of the myofascial clock and clearing out soft-‐tissue restrictions

3. Look for rib flaring and use of McConnell taping treatment

4. Basic hip mobilizations5. Understanding of basic movements

that create more vs less diastesisLila Bartkowski-‐Abbate, Copyright 2017

Testing and Assessment (Lee)Integrating Lab & Lecture

• Clinical evaluation for Hip/Pelvis/SIJ:

1. One-legged standing test (OLS)2. ASLR- raising one leg in supine and isolation of TrA, PF, Multifidus3. Decompression


TESTING for SIJ StabilityOne-‐legged Standing Test (OLS)• Standing• Palpate ilium @ ASIS and hug around entire ilium• Palpate S2 using 2 finger pads of digits 2 & 3• Distance between thumbs should stay the same or get a little smaller• Ilial anterior rotation – distance is greater• Indicates lack of stability• Have patient contract:• TrA, Pelvic floor, both• Use guide wire imaging


Active Straight Leg Raise (ASLR)

• Proven to be valid, reliable and specific to determine:• load transfer between the lumbosacral spine and lower extremities.

• Can identify and isolate the weakest link. • TrA• PF• Multifidus

Mens, 2006


ASLR Test

• Helps clinician determine:

A.Whether it is appropriate to start exercises to increase stability.

B.Whether to start techniques to decrease compression and excessive stability.


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ASLR TestAbnormal strategies cause:•Excessive joint compression•Loss of mobility•Increases in IAP •Restriction of ribcage mobility for respiration •Reduced postural control•Pain•Dysfunction


ASLR Test•


•Ask patient to alternatively actively lift straight leg off table approximately 12” off table.•Ask pt if it is more difficult to lift one than the other.•Observe for the following substitution strategies:Abd Wall bulgingTrunk rotationBreath holdingThoracic spine extension

Lee LJ 2006

ASLR TestMedial compression

Compression at anterior pelvis at ASIS for Transversus AbdominusCompression at anterior pelvis at pubic symphysis is Anterior Pelvic Floor Compression at posterior pelvis at ischial tuberosities is Posterior Pelvic FloorCompression at posterior pelvis at PSIS is MultifidusCompression at combinations simulates multiple musclesLook for easier lifting of leg

LEE, LJ 2006Lila Bartkowski-Abbate, Copyright 2017

ASLR Test -‐ Decompression


If none of those work, patient may be too stable.

Decompression: Thoracic erector spinaeAnterior/posterior cranial

Start with myofascial release,breathing, TrP release, strain-counter strain

Lee LJ 2006

McConnell Tape for Diastesis Recti

Lila Bartkowski-‐Abbate, Copyright 2017 Lila Bartkowski-‐Abbate, Copyright 2017

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Abdominal PainVisceral & Musculoskeletal Causes and Treatment


CONTRIBUTION OF THE VISCERA


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When is the abdominal pain occuring?

Related to Food/Ingestion

• During the eating phase?

• During the digestion phase?

• 1-‐2 hours after eating?

Related to Movement/Locomotion

• Standing/walking• Where in the quadrant of the abdomen?

• Do they have a diastesis?


Overview of the Superficial Organs


Stomach

• The stomach is a muscular organ located on the left side of the upper abdomen. The stomach receives food from the esophagus.

• As food reaches the end of the esophagus, it enters the stomach through a muscular valve called the lower esophageal sphincter.


Large Intestines


1. The large intestine has four parts: cecum, colon, rectum, and anal canal.

2. Partly digested food moves through the cecum into the colon, where water and some nutrients and electrolytes are removed.

3. The remaining material, solid waste called stool, moves through the colon, is stored in the rectum, and leaves the body through the anal canal and anus.


Function of the Sigmoid Colon


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When to refer out to a pelvic health therapist? • Abdominal pain related to eating• Abdominal surgical history that seems more complicated than basic scar management can release• Abdominal pain complicated by gas and bloating• Abdominal pain relating to bowel movements• Abdominal related to sexual activity

• Refer to MD• Red flags: fever, sweats, non-‐orthopedic nature of their symptoms


CONTRIBUTION OF THE MUSCULOSKELETAL SYSTEM TO THE CAUSATION OF ABDOMINAL PAIN


• Abdominal posturing shifts the internal center of gravity up toward the chest: “forces man to swing between hypertension and slackness (inefficiency)”.

Durkheim, “Hara: The Vital Centre of Man”


Shortened Psoas

1. Minimizes the passive pumping action to the bowel

2. Decreases respiration which indirectly moves the organs from a cranial to caudal motion

3. Decreases normal hip extension which decreases glut strength


Iliopsoas

• Positioned to travel with the aorta move through the thorax and are postioned adjacent to the ascending and descending colon.• Contraction/relaxation of iliopsoas creates passive bowel motility.


• Psoas functions as a counter-‐balance to the rectus, maintaining a centered anterior-‐posterior relationship.• However, all the abdominals muscles are directly balanced by the length of the hamstring.• The balance between the iliopsoas complex, the abdominals and the hamstrings maintain a functional relationship.

• Koch, L. The Psoas Book, 1997.


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How do we retrain the deep core muscles?

• Postural re-‐education• Check ribs/check for rib flare• Turn off the overactive psoas


Psoas Hyperactivity

• 2008. Edelstein J. Rehabilitating Psoas Tendonitis: A Case Report. HSSJ 2009; 5: 78-‐92• 43 y.o. female referred to PT with dx of bilateral hip labral tears and psoas tendonitis. • Sxs: popping and pain in both hips x 3 years and hx of LBP.• Pilates made her low back pain worse


• Radiographs detected R-‐sided anterior acetabular bone spur• Patient went to prior PT for core strengthening and psoas lengthening.• 4 months of PT with symptomatic improvement, but still with bilateral hip pain• Patient sought treatment at HSS• MRI confirmed bilateral labral tears.


Psoas Rehab for Hyperactive Psoas• Psoas Inhibition Technique

• Facilitation of quadriceps and tibialis anterior• Coincident inhibition of the hamstrings and psoas

• Trunk curl with only scapular off the mat• Prone e-‐stim on multifidi in prone with ipsilateral psoas with knee into pillow when the stim was on• Followed by upright standing and moving into striding with cueing • Pilates Reformer with full foot series – engages functional core control and stability while moving the lower extremities• Psoas Bum Walk – promotes isolated psoas strengthening• Standing and walking posture reviewed

An overactive muscle must first be inhibited and then functionally strengthened.


Psoas Inhibition• Facilitate anterior tibialis and quadruceps• Inhibit hamstring and psoas•Movement is to dig heels into table as to push self up the treatment table


Normalizing multifidi firing during ambulation

• While connected to e-‐stim to facilitate multifidi• Have patient push knee into table during contraction to simulate normal multifidi firing pattern during ambulation


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Psoas Bum Walk

• Developed by Erl Pettman• Without moving laterally, have patient scoot forward to strength the psoas • Patient has to advance forward only using the psoas• Alternate R to L buttock


WHAT IS THE IMPACT OF THE PELVIC FLOOR MUSCLES?


Referred pain patterns of abdominal pain

• Do we think about the pelvic floor muscle group as a co-‐contributor to abdominal pain? • Is abdominal pain an extension or progression of low back pain?• During your pelvic examination:• think about is there laxity in the anterior vs. posterior compartment?• Is there overactivity in the anterior vs. posterior compartments?


HOW DO WE TREAT ABDOMINAL PAIN?


Check List• Postural Screen – back to the basics• Are normal spinal curves present?• Are the ribs flared?• Are the rings rotated?• Does the rectus fire appropriately?• Is there diaphragmatic breathing and passive expiration?• Is there true normal hip extension?• Is the psoas overactive and uncoordinated? • Is iliacus bound down?• Diastesis present?


To Decrease Thoracic Kyphosis

• Towel rolls• ½ foam roller• Full foam roller• Lie supine over Bosu/Ball• Medicine ball roll on SPLie over roll for 5 minutes in the AM & PM –using the low-‐load/creep theory

Pectoralis major stretch with every rest room visit


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Lumbar Lordosis Correction

• Is it caused by gluteus weakness or tight hip flexors?

IT DOESN’T REALLY MATTER

• Intervention will require the correction of both


Lack of True Hip Extension

• Compensations can be seen in many ways• Increased lumbar lordosis: tight psoas, quadriceps• Excessive sacral mobility: is ilium medially/laterally glided? Iliacus tightness, pubococcygeus tightness? Is there sacral-‐ilial disassociation?• Increased pelvic torsion during ambulation• Decreased relative hip anterior translation• Knee hyperextension• Medial/Lateral heel whip during FF push off• Obturator internus tight


• Hip Flexor Stretch

• Use Bosu or mat/towel

• Isolation of the gluteus maximus and minimizing lumbar lordosis



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Conclusion


• Orthopedic dysfunction is the major contributing factor to patient’s c/o:• Low back pain: core coordination training needed• Urinary Incontinence: core coordination & pelvic floor muscle training• Abdominal pain: psoas overactivity, organ dysfunction & core coordination

• When correction of many of the orthopedic components fail, it is then time to refer to a pelvic floor physical therapist:• Low back pain: core coordination training needed & pelvic floor muscle overactivity• Urinary Incontinence: core coordination & pelvic floor muscle training• Abdominal pain: psoas overactivity, organ dysfunction & core coordination


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How to find a pelvic health therapist?

• www.apta.org• Find a PT

• Women’s Health

• www.hermanwallace.org• Practitioner Directory

• abbate@nd-‐pt.com


BREAK FOR DELEGATE MEETINGNEXT IS LAB…..


4/16/17 1 An Orthopedic View of a Pelvic Floor Patient

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