Pilates with Kierstin! Slingshot Lunges on the Reformer

Just in time for your New Year’s Resolutions, here’s another awesome exercise from Kierstin Elliot, Pilates Teacher at Beyond Basics Physical Therapy!

Goal: Strengthen the glutes and balance 

Exercise: Slingshot Lunges on the Reformer

Set Up: Standing on the floor with right foot near foot bar and left foot against the shoulder rest. Keep left knee straight and tilt upper body forward creating one long diagonal line from head to back toes. Use one blue spring as resistance. Belly button and chin are tucked in with neck lengthened and shoulders rounded back.

Execution: Inhale to send pelvis back into lunge bending the front knee 90 degrees while reaching arms forward and keeping the pelvis level and squared off to the front. Keep shoulders away from ears. Exhale to straighten the front knee, lower arms to sides, and return to your starting position.

Focus: Be sure to keep proper alignment throughout the spine. Lumbar spine should be elongated and supported throughout the entire exercise. Maintain core connection by dropping bottom ribs towards the top of your hips bones. Hips should also be level and squared off to the front- make sure there’s no pelvic rotation during lunges.

Importance: One of the best exercises for strengthening your glutes! This exercise also enhances your ability to stabilize the pelvis and lower back while connecting to the core for improved balance.

Modifications: Limit the range of motion in standard position, or drop back knee to the carriage. Dropping the back knee may draw more focus to the quad, making the exercise feel more like a stretch, however, the focus should still be held on standing glute. For an added challenge, grab a set of 3 pound free weights for your arms for added core control.

Bringing Things into Balance: The Relationship Between Low Back Pain and the Pelvic Floor

By: Katie Parrotte, PT, DPT, OCS, CFMT

Back Pain or Fitness (2)The Occurrence of Low Back Pain

Low back pain is the most common cause of disability and lost work time among working-age adults in industrialized countries (1). In fact, the worldwide prevalence of chronic low back pain has been estimated to be 11.9% of the population on a given day, and 23.2% of the population in a one-month period (2). That is a significant number of people! Determining effective treatments for low back pain can be challenging for various reasons: 1. there are no clearly defined risk factors that predict the development or outcome of low back pain; 2. most patients do not present with any significant findings physiologically or anatomically; 3. and pain can generate and spread at numerous locations within the nervous system, and can constantly change (1).

Treatment of Low Back Pain

There are many challenges associated with low back pain diagnosis and outcomes. Because of this, and the fact that so many people across the globe are impacted by it, there are many options out there for treating this condition. Some methods that have been proven to be effective are spinal manipulation (a high-velocity thrust applied directly on the vertebrae, or backbones, to improve movement and decrease pain), trunk coordination, strengthening, and endurance exercises (to target deep abdominal and back muscles that help to stabilize the spine), general fitness exercise, and patient education (1). These types of interventions are certainly helpful and have allowed many individuals experiencing low back pain to return to their daily lives. However, perhaps the areas that are being addressed with these interventions are not getting to the whole story… There is another area of the body that plays a significant role in the stability of the back but does not regularly get addressed with standard treatment to low back pain: the pelvic floor.

Treating the Pelvic Floor to Address Low Back Pain

Several studies have looked at incorporating pelvic floor-specific strengthening programs in the treatment of chronic low back pain. One study looked at women who were experiencing low back pain and urinary incontinence (the involuntary leakage of urine) (3), while two others looked at individuals experiencing chronic low back pain independently in men and women (4, 5). In all three studies, investigators compared “routine” physical therapy to routine physical therapy plus the addition of pelvic floor strengthening. Results revealed that incorporating pelvic floor strengthening decreased low back pain, decreased the incidence of urine leakage in the case of urinary incontinence, improved function based on specific questionnaires, and increased pelvic floor strength and endurance (3-5). This strengthening was completed by either performing isolated pelvic floor contractions (4, 5), or performing abdominal and pelvic floor muscle contractions while performing specific stabilizing exercises (3).

The Relationship Between the Pelvic Floor and the Low Back

Why did strengthening the pelvic floor make a difference in the above studies? This is likely because the pelvic floor is one of the muscle groups that contributes to overall spine stability; the others include the diaphragm, the transverse abdominis (a lower abdominal muscle), and deep muscles in the low back (3). Several studies out of Norway and Sweden have revealed that in women without pain, the pelvic floor activates just prior to arm or leg movement (6-8). This is important because it reveals that when the pelvic floor is working efficiently, it provides stability to the trunk and pelvis, allowing for functional postures and movements to occur.

Conclusion:

The pelvic floor is an important stabilizer of the spine and pelvis, and activates just prior to movement to allow for efficient function. When an individual is experiencing low back pain, not only do the abdominals and low back muscles require strengthening, focusing on the pelvic floor can help to eliminate pain and resume daily function.

If you or someone you know is struggling with unresolved low back pain, make an appointment with a pelvic floor physical therapist today for further assessment. Feel free to contact our midtown office at 212-354-2622 or our downtown office at 212-267-0240, or visit our website (www.beyondbasicsphysicaltherapy.com) for more information!

Thank you so much for reading our blog.

K5 (2)

Katie Parrotte, PT, DPT, OCS, CFMT practices at our midtown location.

If you have questions about orthopedic, pelvic, or sports physical therapy, including back pain, BBPT is offering free phone consults to those living in the greater NYC area for a limited amount of time!

Beyond Basics Physical Therapy

212-354-2622 (42nd Street Location)

212-267-0240 (William Street Location)

Sources

 

1. Beattie PF. 2016. Current concepts of orthopedic physical therapy – the lumbar spine: physical therapy patient management using current evidence, 4th edition. (p. 3) Orthopedic Section – APTA.

2. Hoy D, Bain C, Williams G, et al. A systematic review of the global prevalence of low back pain. Arthritis Rheum. 2012; 64 (6): 2028-2037. doi:10.1002/art.34347.

3. Ghaderi F, Mohammadi K, Sasan RA, et al. Effects of stabilization exercises focusing on pelvic floor muscles on low back pain and on urinary incontinence in women. Urology. 2016; 93: 50-54.

4. Mohseni-Bandpei MA, Rahmani N, Behtash H, et al. The effect of pelvic floor muscle exercise on women with chronic non-specific low back pain. Journal of Bodywork & Movement Therapies. 2011; 15: 75-81.

5. Bi X, Zhao J, Liu Z, et al Pelvic floor muscle exercise for chronic low back pain. Journal of International Medical Research. 2012; 41 (1): 146-152.

6. Sjodahl J, Gutke A, Ghaffari G, et al. Response of the muscles in the pelvic floor and the lower lateral abdominal wall during the active straight leg raise in women with and without pelvic girdle pain: an experimental study. Clinical Biomechanics. 2016; 35: 49-55.

7. Stuge B, Saetre K, Hoff BI. The automatic pelvic floor muscle response to the active straight leg raise in cases with pelvic girdle pain and matched controls. Manual Therapy. 2013; 18: 327-332.

8. Sjodahl J, Kvist J, Gutke A, et al. The postural response of the pelvic floor muscles during limb movements: a methodological electromyography study in parous women without lumbopelvic pain. Clinical Biomechanics. 2009; 24: 183-189.

A Holiday Gift for You! BBPT is Offering Free Consults for People Living in the Greater NYC Area!

Group Serious 2

Any persistent pain or chronic back or pelvic pain can be tough. It is tough to have and often times it can be extremely isolating. Many of our patients have to go through a number of clinicians before they even get a diagnosis of pelvic floor dysfunction. If you are reading this blog, you probably have some questions about pelvic floor dysfunction and if physical therapy is right for you.

We are here to help. If you are living in the Greater New York Area and have some questions about orthopedic, sports or pelvic floor dysfunction and if physical therapy is right for you, I encourage you to call our office. For a limited period of time, we are offering free 15-minute phone consults with our licensed physical therapists to patients in the greater New York Area. For those of you living outside this area, a fee may apply to the consult but can be applied towards payment for a PT visit if you chose to visit us. Don’t miss this opportunity to learn more about your pelvic floor and what PT can do for you.

The Physical Therapists at Beyond Basics also treat orthopedic (sport and joint injuries), pediatric pelvic floor dysfunction and orthopedic injury, and much more. Give us a call to discuss how PT can help with any one of these issues!

All the best,

Beyond Basics Physical Therapy

212-354-2622 (42nd Street Location)

212-267-0240 (William Street Location)

PH101: I’m Pregnant – Help!

 

Having a baby is exciting, fascinating, and nerve-wracking. If you have never been through the process before, chances are you have a lot of questions and concerns about what changes your body will go through during your pregnancy, what the birthing process entails, and how your recovery will go once you’ve had your baby.

Join us and childbirth specialist, Ashley Brichter, in our Pelvic Health class to discuss the ins and outs of having a child.

Register at pelvichealth101.eventbrite.com   today.

Location:

110 East 42nd Street, Suite 1504

New York, NY

10017

Time: 7pm on November 8,  2018

Pelvic Health 101 Fall 2018

Hypo-ed up? The use of Hypopressive Abdominal Exercise in Pelvic Floor Dysfunction

balloons

Joanna Hess, PT, DPT, PRC, WCS

I’m a recent transplant to NYC. For the last four years, I was living abroad and working at a interdisciplinary sports hospital. I loved learning about physiotherapy culture around the world. We each had different contributions – the Greek wheel, Scandinavian eccentrics, Australian pain science, and Spanish hypopressives. Hypopressive exercises were magic exercises that helped resolve low back pain, prolapse, incontinence, and diastasis recti abdominis. So of course, I wondered, “Are Americans missing the boat?”

What are hypopressive exercises? And how do they work?

Hypopressive abdominal exercises (HAE) were developed by Marciel Caufriez as a response to the obsession with “the core” and the corresponding exercises (primarily crunches) that would increase downward pressure. Hypopressive abdominal exercises use a pressure gradient between the thorax (the upper part of your trunk) and abdominal cavity to create a “vacuum” effect. By creating a vacuum that draws pressure upward, your body automatically recruits transverse abdominis (TrA) and pelvic floor muscles (PFM). Both the PFM and TrA are core muscles and are important in many functions. The HAE sequence begins with static positions and progresses to dynamic and difficult movements. The set up for the exercise is:

  1. Three breaths filling the ribs making sure the sides are expanding.
  2. Breathe in focused on expanding ribs out and lower ribs up while minimizing belly movement.
  3. Then, breathe out working on spinal elongation and keeping ribs up and out. Hold the exhale for creating the vacuum and relaxing the diaphragm. The belly button should start to move up.
  4. Close the throat as if you were at the end of a swallow to lift, expand, inflate rib cage further increasing the vacuum and pressure differential—like an inhale, but without taking in air.

In diaphragmatic breath, inhalation causes the diaphragm to descend which increases intra-abdominal pressure and a reflexive eccentric contraction of the pelvic floor and abdominal wall(an eccentric contraction occurs when the muscles lengthen). Exhalation is a passive return to the diaphragm’s resting position and if it is a complete exhalation, the PFM and TrA will also contribute some activity. For the hypopressive vacuum, inhalation relies on upper chest and neck muscles instead of the respiratory diaphragm and intercostals (rib muscles). The inhalation lifts the rib cage up and gives more volume. The exhalation activates the PFM and TrA to compress the abdomen which increases the pressure of the abdomen. The pressure difference between the diaphragm is augmented by the closed inspiration and creates the vacuum that creates this automatic response. With HAE, the abdominal cavity has the same increase in pressure, possibly more, than with diaphragmatic breath, but because of the suction upwards, it feels like a different pressure.

What’s the relationship between hypopressive exercises and core coordination?

As measured by surface electromyography (EMG) and dynamic ultrasound, HAE consistently have comparable or less activation of the pelvic floor muscle and transverse abdominis than isolated, well-cued exercises (1-4). However, to increase TrA contraction, HAE with pelvic floor muscle contraction recruits more fibers more than pelvic floor contraction alone (4). HAE biases activation of deeper stabilizers–transverse abdominis, internal obliques, and pelvic floor over the more superficial rectus abdominis and external obliques(6). No research has evaluated the HAE claims of decreased downward abdominal cavity pressure. While HAE are progressed with consideration for increasing challenge, they are not incorporated into everyday positions which has an impact on the body’s ability to integrate into a task.

So, will hypopressive exercises fix my problems?

The solution for downward pressure gone wrong is not forcing upward pressure, but addressing why the body lost its adaptability for life’s demands. I rarely use hypopressive abdominal exercises as treatment for problems of the pressure system–pelvic organ prolapse, stress incontinence, diastasis recti abdominis, lumbar disc herniations, and ventral hernias. Studies show that HAE do not have an advantage over conventional TrA and PFM exercises (8) in losing postpartum weight (9), improving pelvic organ prolapse symptoms (2,4,5), or correcting diastasis recti (10).

Besides being less effective than conventional exercises for strengthening and symptom relief, HAE exchange downward and outward pressure for upward pressure and compensatory muscle patterns. This could show up as gastroesophageal reflux disorder (GERD), hiatal hernias, hyperinflated lungs with increased sympathetic drive (and immediate lightheadedness), restricted diaphragm, forward neck posture, or thoracic outlet syndrome. The respiratory diaphragm has a mechanical advantage for respiration over upper chest and neck muscles which have other postural functions.

Escaping gravity is not yet sustainable which means, normal life—breathing, digestion, walking, and laughing—includes downward pressure. If the goal is to decrease pressure on the pelvic floor, lying down with hips elevated, headstand, downward dog, or inversion table—none of these translate into movements of everyday life, but they also do not alter the body’s normal respiration and stabilization patterns. “First do no harm.”

If someone is having difficulty isolating the PFM and TrA, I would connect with diaphragmatic breath, vary effort level, try different verbal and manual cues, and modify the relative position of the pelvis to the spine (7). After correcting the mechanical “pressure problem,” I would use HAE if an individual is still having great difficulty identifying the transverse abdominis and over-recruiting the rectus abdominis. But, I then would progress out of HAE to a isolated strengthening progression integrated into functional movements. HAE is also one of many tools that can help in decreasing acute low back pain associated with muscle spasm.

I nod at the centuries of wisdom of yoga that note benefit from hypopressive practices for posture, digestion, invigoration, and automatic recruitment of core stability. But let’s also remember the time-tried basics of a healthy movement-filled lifestyle. As more studies are published, I look forward to learning more about subgroups and larger functional goals for which HAE have benefit. For now, the magic bullet for pelvic floor dysfunction is not hypopressive abdominal exercises. Isolated pelvic floor and transverse abdominis activation may be old-school, but are well-researched with strong support and are overwhelmingly more beneficial than HAE at addressing symptom alleviation and muscle strengthening.

 

Thank you so much for reading our blog, if you think physical therapy can help you. Please give us a call at either our midtown location 212-354-2622 or our downtown location 212-267-0240. We are offering free phone consultations at both offices for a short period!

Joanna Hess is a treating therapist at our downtown location

Joanna Lee Hess

References

1. Brazalez BN, Lacomba MT, Mendez OS, Martin MA. The abdominal and pelvic floor muscular response during a hypopressive exercise: dynamic transabdominal ultrasound assessment. Br J Sports Med. 2018;52(Suppl 2):A22

2. Resende AP, Stüpp L, Bernardes BT, Oliveira E, Castro RA, Girão MJ, Sartori MG. Can hypopressive exercises provide additional benefits to pelvic floor muscle training in women with pelvic organ prolapse?. Neurourology and urodynamics. 2012 Jan;31(1):121-5.

3. Resende AP, Torelli L, Zanetti MR, Petricelli CD, Jármy-Di Bella ZI, Nakamura MU, Júnior EA, Moron AF, Girão MJ, Sartori MG. Can Abdominal Hypopressive Technique Change Levator Hiatus Area?: A 3-Dimensional Ultrasound Study. Ultrasound quarterly. 2016 Jun 1;32(2):175-9.

4. Stüpp L, Resende AP, Petricelli CD, Nakamura MU, Alexandre SM, Zanetti MR. Pelvic floor muscle and transversus abdominis activation in abdominal hypopressive technique through surface electromyography. Neurourology and urodynamics. 2011 Nov;30(8):1518-21.

5. Bernardes BT, Resende AP, Stüpp L, Oliveira E, Castro RA, Jármy di Bella ZI, Girão MJ, Sartori MG. Efficacy of pelvic floor muscle training and hypopressive exercises for treating pelvic organ prolapse in women: randomized controlled trial. Sao Paulo Medical Journal. 2012;130(1):5-9.

6. Ithamar L, de Moura Filho AG, Rodrigues MA, Cortez KC, Machado VG, de Paiva Lima CR, Moretti E, Lemos A. Abdominal and pelvic floor electromyographic analysis during abdominal hypopressive gymnastics. Journal of bodywork and movement therapies. 2018 Jan 1;22(1):159-65.

7. Sapsford R. Rehabilitation of pelvic floor muscles utilizing trunk stabilization. Manual therapy. 2004 Feb 1;9(1):3-12

8. Martín-Rodríguez S, Bø K. Is abdominal hypopressive technique effective in the prevention and treatment of pelvic floor dysfunction? Marketing or evidence from high-quality clinical trials?. Br J Sports Med. 2017 Sep 4:bjsports-2017.

9. Sanchez-Garcia JC, Rodriguez-Blanque R, Sanchez-Lopez AM, et al. Hypopressive abdominal physical activity and its includence on postpartum weight recovery: a randomized control trial. JONNPR. 2017; 2 (10): 473-483.

10. Gomez FR, Senin-Camargo FJ, Cancela-Cores A, et al. Effect of a hypopressive abdominal exercise program on the inter-rectus abdominis muscle distance in postpartum. Br J Sports Med 2018;52(Suppl 2):A21

It’s all connected: How pelvic floor dysfunction can contribute to hip pain

Yoga 2

Kaitlyn Parrotte, PT, DPT, OCS, CFMT (practices at our midtown office)

Hip pain can have a significant burden on function and quality of life. While there are many causes, prevailing research shows that hip pain is common in both athletic and older populations (1,2). In athletes, groin pain accounts for 10% of all visits to sports medicine centers, and groin injuries account for up to 6% of all athletic injuries (1). In older adults, a diagnosis like osteoarthritis is common, and is ranked as the eleventh highest contributor of global disability (2). While research often focuses on specific populations of people or diagnoses, when put together, it reveals that general hip pain is a common problem affecting a significant portion of the general population. There are many diagnoses that exist to describe hip pain, with the ultimate goal to develop the most effective course of treatment. Traditionally, when someone with hip pain visits a doctor, a physical examination will be performed, which includes assessing for tenderness, swelling, or redness, and determining the range of motion at the hip joint. The doctor may also recommend imaging, such as an x-ray or MRI, as well as lab tests (3). While this can provide a physician with valuable information, such examinations have the risk of missing causes of pain from nearby structures, such as the pelvic floor.

 

The pelvic floor muscles are three layers of muscles that attach to the lower aspect of each half of the pelvis from side-to-side and from the pubic bone to the tailbone, front-to-back. These muscles support the pelvic organs, as well as contribute to trunk stability, and play a significant role in bowel and bladder control and efficiency, as well as sexual function (4). The muscles that make up the deepest of the pelvic muscles, include the levator ani and coccygeus, as well as the obturator internus on the sides (5). The pelvic floor is interconnected to many key structures in the body, and dysfunction here can affect seemingly unrelated parts of the body. Below are two cases of unresolving hip pain, where assessment and treatment of the pelvic floor helped to promote a return to recreational activities.

 

Case 1: A BICYCLIST

A 32-year-old male professional cyclist came to physical therapy with complaints of pain in his right hip and groin, mainly with prolonged sitting and cycling. This began soon after he suffered severe bruising on his right hip from a fall, with a tear of two hip muscles (tensor fascia lata on the front and gluteus medius on the side). Prior to this, he had a history of multiple leg injuries due to cycling, but had never complained of any pelvic floor issues. Upon examination, decreased hip range of motion was also discovered. Initially, he received ten sessions of “standard physical therapy,” which included stretching, joint mobilization, soft tissue release, dry needling, and exercise.

However, after only minimal improvement, he was referred to a pelvic floor specialist for further evaluation where increased muscle tone and tenderness in multiple pelvic floor muscles (both obturator internus muscles and both iliococcygeus muscles) were discovered. Also, weakness of a pelvic floor contraction was also noted (6). Based on response to treatment, his hip pain decreased significantly from his current treatment of pelvic floor dysfunction, though it was completely missed in the initial testing.

But how does pelvic floor dysfunction contribute to hip pain? The correct treatment was missed because this connection was missed. Consider the anatomy and mechanics of the hip and pelvis. The gentleman described above is a professional cyclist, which means that whenever he is on his bicycle, he must flex (bend) his hip up to 90 degrees. More hip motion does not tend to occur because it would cause the pelvis to become unstable on the small seat (7). When the hip is bent, the femoral head (ball of the ball-and-socket joint) must flex (bend up), abduct (move to the side), and rotate in towards the groin (8). As the pedal is pushed downward, the hip moves into an extension (straightening) position. Although the hip never reaches a fully straightened position when cycling because he is seated, the hip moves through between 40 and 43 degrees of total motion with each cycle of the pedal (7). So, when the hip is moving into that straightened position, that femoral head must extend (move back), adduct (move sideways toward the groin), and rotate out away from the groin. While the movements of ball of the hip are small, as they are occurring with the confines of the socket in the pelvis, it is important to remember what muscles are in close proximity (8).

Besides the extensive list of hip flexors and gluteus muscles, there are several muscles that sit on the inner side of each hip and the bottom layer of the pelvis – the muscles of the pelvic floor. The two muscles that are of the most interest in this case are the obturator internus and the iliococcygeus muscles, as tightness and tenderness were found in each pair. The obturator internus muscle contributes to the walls of the pelvic floor, on each side of the pelvis. and sits on the inner side of the hip joint. The iliococcygeus muscle attaches on one end into the tendinous arch of the obturator fascia, so there is only dense connective tissue joining this muscle and the obturator internus (5).

When the hip is in a bent position the obturator internus muscle abducts the hip, or moves it to the side, away from midline; however, when the hip is extended (straightened) this muscle rotates the hip outward. For the iliococcygeus muscle, its role is one of support for the pelvic contents and lifting for the pelvic floor (5). Considering all these factors, it can be theorized that when the hip is in a bent position at the top of the pedaling cycle the obturator internus is activated through the abduction (sideways) motion of the ball of the hip, and continues to be activated as the hip straightens since the ball is rotating outward. Furthermore, because the iliococcygeus muscle is attached to the obturator internus muscle through a dense strip of connective tissue, it must work harder to help support this obturator muscle throughout the cycling activity. Thus, these muscles have become overused and shortened with regular and intense cycling required of a professional, who likely had some abnormal muscle activation or movement strategies prior to his pain due to previous injuries.

With the specially trained pelvic floor physical therapist, the pelvic floor connective tissue was mobilized internally over two treatment sessions, in addition to the cyclist performing hip stabilizing exercises. After the first session, there was an immediate and significant improvement in hip range of muscle and pelvic floor muscle contraction; furthermore, sitting pain was resolved. After the second session (7 days later) this gentleman was discharged from PT as he was pain free in sitting and cycling. In a follow up call one month after discharge, he was still pain free without altering training (6). This dramatic change occurred because the release of connective tissue in the pelvic floor decreased tension and trigger points in the obturator internus and iliococcygeus muscles. Thus, his hip range of motion and pain were normalized, and he was able to return to competitive cycling without restrictions.

Case 2: A RUNNER

A 45-year-old female was referred to physical therapy by her gynecologist with an initial diagnosis of left hamstring strain, toward the top of the thigh, related to distance running. This woman was an experienced marathon runner, who ran an average of 30-40 miles per week. She presented to her first PT appointment with pain in her left sit bone, with diffuse aching radiating into her left buttock and pubic bone; she stated her pain began about 4 months prior to her first PT session. The mechanism of injury was “pulling a muscle” while trying to avoid falling on a trail run. At that time, she immediately felt pain near her sit bone, but was able to complete her run. Eventually, as her symptoms progressed, she stopped running, and was only able to tolerate about 15 minutes of sitting. By her fourth PT visit, her pain had decreased, but continued mildly with sitting and shifted into her left pubic bone. She also reported a deep ache that could not be touched from the outside. She was referred to a pelvic floor specialist for further evaluation; upon internal assessment of the pelvic floor, significant tenderness and reproduction of the “deep ache” was found in her left levator ani and obturator internus muscles, as well as increased muscle tone. Furthermore, contraction of these muscles was weak, and she presented with poor relaxation of the same muscles. (9).

The hamstring muscles attach to the sit bone, and in running help to extend the hip and control the knee (10). Due to the location of this woman’s complaints, initial treatments focused on pain management, such as sitting on a wedge or donut to relieve pressure on her sit bone, as well as core strengthening exercises like the plank, and gluteus and hamstring strengthening exercises. Since the patient reported relief of sit bone pain, except with prolonged sitting by her fourth visit, it was logical to directly address the hamstring and gluteus muscles; however, these are not the only muscles in the area of the hip (9).

When this woman was assessed by a pelvic floor specialist, weakness, tightness, and tenderness were discovered in her obturator internus and levator ani muscles on the side of her pain (9). As discussed in the first case, the obturator internus muscle makes up part of the wall of the pelvis and sits just inside of the pelvis, past the hip joint (5). With running, an efficient hip will move between 50 degrees flexion (bending up) and 10 degrees of extension (straightening back) (10). Thus, when the hip is flexing, the obturator internus is likely assisting with abduction of the ball of the hip joint, and when the hip is extending the obturator internus muscle is likely active in outward rotation of the ball (5,8). The levator ani muscles attach from the pubic bone in the front to the back portion of the pelvis, and play an important role in stabilizing the pelvis and the pelvic contents (5). Considering the mechanics of running, the obturator internus and levator ani muscles were likely working hard to promote a good running pattern, and when she tripped on a run, these muscles were overexerted. Then they continued to overwork to compensate for the pain and weakness demonstrated by her hamstring muscles.

In addition to exercises for hamstring and gluteal muscles, internal release of the left levator ani and obturator internus muscles was performed, as well as gentle isometric contractions for strengthening and lengthening of pelvic floor for relaxation. After 7 additional sessions over a 2-month period, this woman’s pain had decreased greatly, she was able to tolerate sitting for more than two hours, she was able to hop on her left leg without pain, and her hip and pelvic floor muscle strength improved. After six months, she had returned to running, and had recently completed a marathon without pain (9).

Conclusion

In summary, augmenting treatment with the addition of direct pelvic floor interventions in each of the above cases significantly improved each person’s remaining symptoms, and allowed them to return to their prior activities without restrictions. This demonstrates the importance of considering the pelvic floor in the diagnosis and treatment of hip pain – these patients both had injuries that were initially missed because the pelvic floor was not considered as a possible cause of hip pain, yet emerging evidence is linking pelvic floor dysfunction to otherwise intuitively unrelated injuries. This also highlights the need for further research in this area to minimize the occurrence of unnecessary procedures and medications, and to ensure that individuals can return to their daily activities with minimal disruption of their quality of life.

If you or someone you know is struggling with unresolving hip pain, make an appointment with a pelvic floor physical therapist today for further assessment. Feel free to contact our midtown office at 212-354-2622 or our downtown office at 212-267-0240, or visit our website (www.beyondbasicsphysicaltherapy.com) for more information! We are offering free phone consultations at both offices for a short period!

Thank you so much for reading our blog.

Katie Parrotte, PT, DPT, OCS, CFMT practices at our Midtown Location

K5 (2)

 

SOURCES

  1. Prather H, Colorado B, Hunt D. 2014. Managing hip pain in the athlete. Physical Medicine and Rehabilitation Clinic of North America, 45(4), 789-812.
  2. Cross M, Smith E, Hoy D, et al. 2014. The global burden of hip and knee osteoarthritis: estimates from the global burden of disease 2010 study. Annals of the Rheumatic Diseases, 73(7), 1323-1330.
  3. Osteoarthritis. Retrieved from https://www.mayoclinic.org/diseases-conditions/ osteoarthritis/diagnosis-treatment/drc-20351930.
  4. Continence Foundation of Australia. Pelvic Floor Muscles. Retrieved from: https://www.continence.org.au/pages/how-do-pelvic-floor-muscles-help.html.
  5. Drake R, Vogel AW, Mitchell AWM. 2009. Grey’s anatomy for students. Elsevier Health Sciences.
  6. Navot S, Kalichman L. 2016. Hip and groin pain in a cyclist resolved after performing a pelvic floor fascial mobilization. Journal of Bodywork and Movement, 20, 604-609.
  7. Timmer CAW. 1991. Cycling mechanics: a literature review. Journal of Sports Physical Therapy, 14(3), 106-113.
  8. McGalliard M, Sizer PS, Ezell D. 2016. Current concepts of orthopedic physical therapy, 4th edition. (p. 7) Orthopedic Section – APTA.
  9. Podschun L, Hanney WJ, Kolber MJ, et al. 2013. Differential diagnosis of deep gluteal pain in a female runner with pelvic involvement: a case report. International Journal of Sports Physical Therapy, 8(4), 462-471.
  10. Running Biomechanics. Retrieved from https://www.physio-pedia.com/Running_ Biomechanics.

Mind the Gap: Diastasis Recti Abdominis and What We Don’t Know: Part I

asphalt-communication-commuter-221310

Joanna Hess, PT, DPT, PRC, WCS

Summer holidays are approaching. You’re lounging at the beach and feeling quite proud of the ruffled swimsuit that guards the battle marks of the mom bod—the wrinkly and poochy belly. On the horizon, a woman in string bikini framing her flat tummy joins the four children sitting next to you. She must be their nanny, or maybe the children were adopted, or she probably had a surrogate. But after a short conversation, she reveals that in fact is the biological mother of these children and that she carried to full term. And when you awkwardly compliment her on the restoration of her college-era body, she nonchalantly shrugs and says, “Genetics? Maybe the coconut oil that we brought back from Bali?”

As the power of airbrushed social media images expand, the Cinderella stories of mummy tummy to model abs give hope to the many moms scrolling mindlessly on our phones passing the wee hours of childcare. These stories are powerful and inspiring, but do not reflect most of our situations, nor answer many elusive questions about diastasis recti abdominus.

What is Diastasis recti abdominis and why do we care?

Diastais recti abominis (DRA) is the excessive separation between the two sides of the rectus abdominis (the six pack muscle), which creates a pooching of the belly, particularly with difficult tasks. For this blog, the background information focuses on pregnancy related DRA while the application of the information can be used for any one with DRA. During the third trimester 100% of women have a DRA, defined as a separation >2 cm below the umbilicus (1). One answer to why we care about DRA is that we want our stomachs to look normal if not flat. The wrinkly skin stomach has not reached mass popularity on the runways. Another reason we care is because DRA has been assumed to predispose a long term sequelae of breakdown in the body. The cosmetic appearance associated with DRA improves as the inter-recti distance (IRD), the width between the bellies of the rectus abdominis, decreases.

As physical therapists, we screen for DRA in order to gain a larger understanding of how the body is working together. Many of us assume that the lack of stability in the front of the body will lead to compensations in other parts of the body—primarily the diaphragm, pelvic floor, and back. Dysfunction in these areas have been documented to be higher during pregnancy and the post-partum period (2). Physical therapists regularly address DRA when patients present with low back pain (LBP), pelvic floor dysfunction, pelvic pain, and urinary incontinence (3). A couple of studies looking at post-partum women seeking medical care for abdominal pain and pelvic floor dysfunction show a higher incidence of DRA in this populations (4,5). However, this is not to say that the DRA causes or predicts these conditions.

In recent prospective studies using ultrasound assessment, the assumption that DRA correlates to pelvic floor dysfunction and low back pain (LBP) is challenged. The findings suggest no relationship but even a possible protective mechanism of DRA during pregnancy, with no difference in LBP symptoms at one year postpartum regardless of DRA status. Of course, this is a statement of generalization to a study population and does not reflect the outliers, individual predispositions and presentation.

DRA During Pregnancy

No differences were found in pelvic floor function or in urinary incontinence between women regardless of DRA status, during or after pregnancy. Women presenting with DRA in their 2nd trimester were more likely to have higher vaginal resting pressures, strong pelvic floor muscles strength, and better endurance of pelvic floor muscles. The set of women with 2nd trimester DRA had lower BMI before pregnancy and during pregnancy with trend increased general physical activity (6)

DRA Post-Partum

Interestingly, women who at 6 weeks postpartum did not have a DRA were more likely to have a pelvic organ prolapse > Stage 2 (6). DRA status (none or mild) had no relationship with low back pain at 6 months (1) and 12 months postpartum (7). This corroborates another study showing no difference for DRA in women reporting LBP and that severity of DRA does not predict intensity of LBP when present (5). Heavy lifting >20x/week was shown to be a risk factor for postpartum DRA, but not age, pre-pregnancy BMI, 2nd trimester BMI, weight gain, caesarean or vaginal delivery, abdominal circumference at 35 weeks, hypermobility (p – 0.06), cardio and strength exercise, general abdominal and pelvic floor exercise (1). From the research available, we cannot predict from a group of postpartum women with DRA who will have symptoms that affect their daily living.

Looking a Little Deeper at Diastasis Recti Abdominis

As assumptions about DRA and its relationship to long term dysfunction start to shift, what is important to identify in a DRA presentation is also changing. The literature and clinical practice related to DRA mainly looks at the IRD, or the separation between the right and left muscle bellies of the rectus abdominis However, the focus on the widening of the linea alba may be less important than the ability of the linea alba to transfer forces and contribute to the stability of the abdominal muscles (8). A wide linea alba that holds tension and stabilizes the front of the abdomen with increased intra-abdominal pressures through functional task may be more desirable than a narrow linea alba with distortions that loses force and allows abdominal pressure to push forward through functional task. A pulled-apart and taut rubber band hold tension better than a relaxed and crumpled band. The width and depth of the linea alba need to be contextualized within the individual’s posture, daily movement, and functional core adaptability. The literature has yet to identify subgroups that would likely explain why some people have DRA that self-resolve and among those who don’t, why it impacts cosmetics and function in some people and not in others, why it seems to be a protective mechanism for some pelvic floor and low back conditions and exacerbating in others.

The linea alba is often connected to the rectus abdominis because of the focus of the IRD as a marker of DRA. However, the linea alba actually is the anatomical and functional intersection of all the abdominal muscles—the rectus abdominis, the internal and external obliques, and transverse abdominis, which is seen at a microscopic level with different angles of fibers in the linea alba. In a cadaver study looking at the collagen of the linea alba without DRA, previously pregnant women had thinner linea alba, but greater widths. Females who were previously pregnant had higher ratio transverse to oblique fibers—60% for females and 37.5% for males. The female cadaver that had never been pregnant had infraumbilical fibers more similar to males (9). The small size of this study limits its application, but perhaps an increase of transverse abdominis muscle activity in the lower abdominals is represented in the higher number fibers, and that this adapted activity resolved the DRA for these women.

Hormones may possibly play a role of the development of DRA for some women, but because DRA persist well after post-partum hormones return to normal. In men, hormones are unlikely to be the primary driving cause of persistent DRAs. Women who are breastfeeding do have a higher relationship with unresolved DRA until breastfeeding is concluded (5). However, no research has been conducted on this relationship and may add to another subgroup to explain the variance of women who spontaneously resolve and others who never resolved their DRAs.

 

Joanna is a treating therapist at our downtown location. Stay tuned for the next installment on this topic, Mind the Gap Part II: Diastasis Recti Abdominis: What we Can do About it.

To call and make an appointment with our expert PTs call:

212- 354- 2622 (Midtown)

212-267-0240 ( Downtown)

 

References:

1. da Mota PG, Pascoal AG, Carita AI, Bø K. Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Manual therapy. 2015 Feb 1; 20(1):200-5.

2. Lee DG, Lee LJ, McLaughlin L. Stability, continence and breathing: the role of fascia following pregnancy and delivery. Journal of bodywork and movement therapies. 2008 Oct 1; 12(4):333-48.

3. Keeler J, Albrecht M, Eberhardt L, Horn L, Donnelly C, Lowe D. Diastasis recti abdominis: a survey of women’s health specialists for current physical therapy clinical practice for postpartum women. Journal of Women’s Health Physical Therapy. 2012 Sep 1; 36

4. Spitznagle TM, Leong FC, Van Dillen LR. Prevalence of diastasis recti abdominis in a urogynecological patient population. International Urogynecology Journal. 2007 Mar 1; 18(3):321-8

5. Parker MA, Millar LA, Dugan SA. Diastasis Rectus Abdominis and Lumbo‐Pelvic Pain and Dysfunction‐Are They Related?. Journal of Women’s Health Physical Therapy. 2009 Jul 1; 33(2):15-22.

6. Bø K, Hilde G, Tennfjord MK, Sperstad JB, Engh ME. Pelvic floor muscle function, pelvic floor dysfunction and diastasis recti abdominis: Prospective cohort study. Neurourology and urodynamics. 2017 Mar 1; 36(3):716-21.

7. Sperstad JB, Tennfjord MK, Hilde G, Ellström-Engh M, Bø K. Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. Br J Sports Med. 2016 Jun 20:bjsports-2016.

8. Lee D, Hodges PW. Behavior of the linea alba during a curl-up task in diastasis rectus abdominis: an observational study. journal of orthopaedic & sports physical therapy. 2016 Jul; 46(7):580-9.

9. Axer H, Keyserlingk DG, Prescher A. Collagen fibers in linea alba and rectus sheaths: II. Variability and biomechanical aspects. Journal of Surgical Research. 2001 Apr 1; 96(2):239-45.

10. Liaw LJ, Hsu MJ, Liao CF, Liu MF, Hsu AT. The relationships between inter-recti distance measured by ultrasound imaging and abdominal muscle function in postpartum women: a 6-month follow-up study. journal of orthopaedic & sports physical therapy. 2011 July.

11. Coldron Y, Stokes MJ, Newham DJ, Cook K. Postpartum characteristics of rectus abdominis on ultrasound imaging. Manual therapy. 2008 Apr 1;13(2):112-21.

12. Boissonnault JS, Blaschak MJ. Incidence of diastasis recti abdominis during the childbearing year. Physical therapy. 1988; 68(7):1082-6

13. Chiarello CM, Falzone LA, McCaslin KE, Patel MN, Ulery KR. The effects of an exercise program on diastasis recti abdominis in pregnant women. Journal of Women’s Health Physical Therapy. 2005 Apr 1; 29(1):11-6.

14. Benjamin DR, Van de Water AT, Peiris CL. Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy. 2014 Mar 1; 100(1):1-8.

15. Pascoal AG, Dionisio S, Cordeiro F, Mota P. Inter-rectus distance in postpartum women can be reduced by isometric contraction of the abdominal muscles: a preliminary case–control study. Physiotherapy. 2014 Dec 1; 100(4):344-8.

16. Sancho MF, Pascoal AG, Mota P, Bø K. Abdominal exercises affect inter-rectus distance in postpartum women: a two-dimensional ultrasound study. Physiotherapy. 2015 Sep 1; 101(3):286-91.

17. Litos K. Progressive therapeutic exercise program for successful treatment of a postpartum woman with a severe diastasis recti abdominis. Journal of Women’s Health Physical Therapy. 2014; 38(2):58-73.

18. Gillard S, Ryan CG, Stokes M, Warner M, Dixon J. Effects of posture and anatomical location on inter-recti distance measured using ultrasound imaging in parous women. Musculoskeletal Science and Practice. 2018 Apr 1; 34:1-7.

19. Kirk B, Elliott-Burke T. The Effect of Visceral Manipulation on Diastasis Recti Abdominis (DRA): A Case Series.