Pelvic Floor Therapy
We have had the pleasure to have a guest speaker, Calvin Wong (Physiotherapist & Clinic Director at Woodland Physiotherapy), come in to present and share with us at Kin Lab on his passion and knowledge in regards to pelvic floor dysfunction and how it can relate to pelvic or lower back pain (LBP) that you may be experiencing.
To better understand how the pelvic floor and abdominal wall can relate to pelvic pain/LBP, we will go over the anatomy of the pelvic floor and what encompasses it. The structures (mainly sexual organs) of the pelvic floor differs between males and females.
In males, the pelvic floor consists of the external genitalia to the bladder while in women this includes the uterus, ovaries, and fallopian tubes. The pelvic floor less knowingly works with the abdominal wall and diaphragm. The pelvic floor consists of 3 layers; superficial, middle, and deep layers. The superficial layer consists of the superficial perineal pouch which functions as sphincters (openings) for the bladder, bowel, and vaginal outlets (in women). There is a direct continuity between the adductors of the thigh and this layer of the pelvic floor. The middle layer consists of the deep perineal pouch, which functions to serve as sphincters (for the urethra). Lastly, the deep layer has direct continuity and functions with the hip musculature (ex: piriformis, obturator externus), in which dysfunction of the pelvic floor can refer pain to the regions such as the low abdomen, groin, and buttocks.
The pelvic floor muscles have a variety of functions, but the main function that we will look at in this post is the production of intra-abdominal pressure. The pelvic floor muscles work in conjunction with the diaphragm and abdominal muscles to create intra-abdominal pressure as shown in the diagram on the right.
There are different methods to assess the pelvic floor muscles.
1. EMG (electromyography)
➔ Provides muscle activity of pelvic floor muscles via, however, is not very reliable on its own and can cause irritation from probes used.
2. Digital Palpation
➔ Considered unreliable and insensitive. Limited access to urogenital diaphragm in men.
3. Real-time Ultrasound
➔ Provides transabdominal and trans-perineal imaging and allows for indirect measures of pelvic floor activity. It can be beneficial in providing visual feedback to patient’s and the practitioner to more accurately assess the pelvic floor and abdominal wall
On its own, ultrasound would be the best option in terms of accurately assessing the pelvic floor and abdominal wall. However, multiple assessments can be used in conjunction to provide a better picture for the practitioner.
Low Back & Pelvic Pain
When looking at the relationship between low back and pelvic pain, these are considered umbrella terms that encompass a wide range of conditions with varying underlying mechanisms. There is no current consensus regarding pathophysiology, however diagnosis of exclusion can be performed with methods such as STI testing, genetic testing, blood tests, and urologic investigations, to help create a more accurate prognosis.
In the current literature, it is suggested the pelvic floor dysfunction/low back pain heavily relates to resting muscle tone and activation. There are two components of muscle tone: an active and passive component. With chronic pelvic pain, there is often an excessive protection/reaction of the pelvic floor muscles, indicative of a higher resting muscle tone. Factors that could contribute to this include fear of pain, psychological stress or trauma, sexual trauma, excessive pressure from above (due to intra-abdominal bracing via Valsalva maneuver or forced breathing), and bladder fullness.
Observations from ultrasound studies on Men and Women with pelvic pain have suggested that:
1. There will likely be higher resting muscle tone in pelvic floor muscles in patients with pelvic pain. Findings were observed via ultrasound where more acute anorectal angles and a smaller levator hiatus were used as indicators. (Morin et.al, 2014).
2. A loss of relaxation capacity in patients experiencing pelvic pain/discomfort (Loving et al., 2014)
3. Weakness in muscle testing and potential loss of pelvic floor muscle function leading to sexual dysfunction and bowel/bladder incontinence (Davis et al., 2001).
General Training Considerations:
Patients with acute or chronic pelvic pain are often observed to have overactivity of the pelvic floor muscles. Strategies to address overactivity include relaxation techniques, abdominal wall re-training, and stretching for the pelvic floor. In these scenarios, we want to move away from suboptimal strategies that could be related to abdominal bracing, breathing holding, and internal/external oblique dominance.➔ Incontinence, Sexual Dysfunction
Patients that experience incontinence or sexual dysfunction often but not always been observed to have underactive pelvic floor muscles. This is frequently seen in individuals post-operatively (prostatectomy, TURP) and can be associated with nerve trauma due to incision or cauterization during the surgical procedure. With underactivity of the pelvic floor muscles, the goal of treatment will be to promote motor recruitment, strength, and endurance while incorporating appropriate abdominal wall and respiratory training. Patient progression into multiple postures and positions and allowing for training to be task-specific.
Strength, endurance, and hypertrophy training have been suggested to be beneficial in improving pelvic floor outcomes pre and post-operatively!
That is it for this in-service post! We would like to thank Calvin Wong from Woodland Physiotherapy once again for coming in and presenting to us on such an interesting topic as pelvic floor health is an area that is often overlooked in individuals with pelvic pain. If you are someone who may be experiencing pelvic floor health issues or pain, I would recommend checking out Calvin and his team at Woodland Physiotherapy.
Summary written by Calvin Vu