Is There Anything New for Pelvic Floor Physiotherapists?

If you rehabilitate motor control and movement you should know this

Background

The various manifestations of pelvic floor disorders are a common problem and constitute a burden on society. There are various schools of thought which sometimes result in biased research and incorrect research methods.  There is a general rule of thumb with regards outcomes for general exercise for any problem around the body - about two thirds of people respond enough to be statistically different. What about the other one third and why not aim for better than a minimally detectable change on outcome measures? There are also some other important concepts in rehab: sub-classification is better than no sub-classification and the more specific you are, the better the result. Although our research was not originally developed for pelvic floor physiotherapists, there are some direct uses and benefits for pelvic floor rehabilitation. Following this, we expanded some of our research to specifically apply to pelvic floor rehab.  

Sub-classification

It is very clear that there is a group of patients who cannot correctly contract their pelvic floor when asked (approximately one - third). Our research predicts who will learn specific motor control exercise. We have also developed interventions utilizing: primitive reflex inhibition, specific sensory motor function, and motor imagery learning, to rehabilitate those who cannot learn.

Lumbar Cylinder & Correct Application

There are numerous reasons why a patient may not respond to rehabilitation including the ability to learn (as above) and poor compliance, however the rehabilitation may not be complete. It is critical to appreciate that the pelvic floor is part of an integrated cylinder. This cylinder also includes transversus abdominus, the diaphragm (local and global role), lumbar multifidus and psoas major. As well, the global movement system needs to adequately protect the pelvis and not allow significance stress on the local muscle system. Too often this is neglected. It is critical to understand this may be a functional mechanism for the loss of control (see below). Common problems include: (1) lack of precision with specific motor control; (2) too quickly integrating into function; (3) concurrently prescribing exercises that are not specific and may interfere with the precision of the motor control you are trying to treat

(1) Are you confident you could blindly say you are doing the exercises correctly while two other people watch on real time ultrasound? If so, great. If not, you need a refresher.

(2) Do you know when true learning has taken place? Are you using the same concepts of precision when integrating into function as when learning?

(3) Do you know the effect of other exercises on the global or local muscle system in your patient? If not, don't prescribe them.

(4) Do you know how to rehabilitate the specific local role of the pelvic floor?

Functional Mechanisms

Prescribing exercises without understanding the functional mechanisms causing the loss of control is analogous to empiric therapy. Too often these are enough to change symptoms a little and then people plateau or get better and then have recurrences. We have done a systematic review of the functional mechanisms and developed intervention strategies for each. Targeted therapy is better than non targeted.

Psoas major

Here are some brief research findings for those of you who still feel psoas major is nasty, tight has increased tone:

• The biomechanics of psoas major show it is too close to the axis of rotation to produce much spinal movement. It can contribute to the lumbar lordosis
• Segmental atrophy occurs in the whole psoas major with low back pain associated with pathology.
• Segmental atrophy occurs in posterior psoas major in general low back pain
• Posterior and anterior psoas major has different nerve supplies.
• The EMG for anterior psoas shows major shows it is variable like other global muscles in low back pain
• The EMG and biomechanics show it is not the dominant hip flexor. It has less EMG activity than iliacus. Biomechanics clearly show that TFL and rectus femoris have much larger lever arms

Implications for pelvic floor rehab

My dissection work clearly shows that the psoas fascia is continuous with the inside covering of the transversus abdominus muscle and is continuous with the pelvic floor fascia. It is impossible for it not to have some mechanical effect on these. There is likely a neurophysiological relationship as well since psoas has the ability to act as a link between the top and bottom of the lumbar cylinder. In any case, specific exercises for psoas major have the ability to facilitate the pelvic floor.

Has you ever noticed that plantar flexion and hip flexion occurs in many people who are struggling with emptying their bladder?

Deep Sacral Gluteus Maximus

While dissecting cadavers in 2001 to gain insight into the old debate back then regarding the distinction between pubococcygeus, puborectalis and ilio/ischiococcygeus, I decided to dissect gluteus maximus. Given the previous findings of separate distinct groups of fibers in other muscles (e.g. psoas, anconeus, upper trapezius) I thought there could be something similar in gluteus maximus. As the fibers were stripped away piecemeal, fibers were identified that did not cross the hip, but only went from the sacrum to the pelvis. Clearly they did not move the hip. It would seem logical that they could act as a local stability muscle for the SIJ. The next day in the clinic I developed cues for them. Like magic they helped, but even better, the same cues could also be used for lumbar multifidus. Finally there was something better than "swell the muscle". We also took this into the lab and found this did something unique for the SIJ that was different than other fiber populations of gluteus maximus. Further dissection showed that these deep sacral gluteus maximus fibers were continuous with the fascia of the inferior aspect of the levator plate so these could be used as a facilitation strategy for the pelvic floor.

Primitive Reflexes

Primitive reflexes are brain stem-mediated, complex automatic movement patterns that commence in utero.  If primitive reflex persist beyond their average lifespan they may begin to interfere with proper CNS development and could indicate neurological impairment. They present in conditions such as learning difficulties or movement disorders in children and adults.  PR can also reappear due to altered sensory input into the CNS (musculoskeletal injury) or altered processing (i.e. concussion) as well as many other conditions.  The presence of PR will influence motor control and may indicate altered CNS neurocognitive processing. The presence of significant PR can interfere with normal rehabilitation. 

Primitive reflexes have long been regarded as being involved in bed wetting and incontinence in children, specifically the spinal gallant.

We have demonstrated that positions that mimic primitive reflexes influence abdominal hollowing. In clinical practice using transabdominal real time ultrasound imaging, the levator plate can appear asymmetrical or during voluntary contraction appears to have asymmetrical activity. Although this can frequently be rehabilitated, it can instantly be changed by inhibiting the primitive reflexes relating to this.

Specific Sensory Motor Function

Everyone agrees that sensory motor function is important. Why isn't sensory motor rehabilitation as specific as the other rehab? Making it more specific has a better result.

Treatment of Central Sensitization and Body Image Pain

Understanding the functional mechanisms of central pain provides many options for the rehabilitation of central pain related to pelvic floor dysfunction.

Motor Imagery

Motor imagery is essential for pelvic floor rehabilitation. This should not be taken for granted. The inability to perform motor imagery is part of specific learning difficulties and a portion of the population fundamentally lack this ability. There is an evidence based remediation in the education field. We have developed a way to use this in musculoskeletal patients.

Breathing

Do you know what normal breathing is and how to rehabilitate it? If so, great. If not, you should know how. The local role of the diaphragm is not needed for everyone, but it isn't going to hurt to know it.

General Exercise & Tone

It is unknown why general exercise (functional exercise and aerobic activity) benefits musculoskeletal symptoms or pelvic floor symptoms. There are numerous potential reasons, with likely multiple contributing factors rather than one mechanism alone. We recently conducted a systematic review of factors related to tone and could not reach any conclusions except that there are no agreed upon terms and no reliability or validity studies. This is a subjective description and physiotherapists should be careful in how they describe this in relation to superficial or pelvic floor muscles.

Summary

Regardless of how much knowledge you have in pelvic floor rehab you will benefit from knowing:

• Screening who can learn specific motor control exercise and correct sub-classification
• Psoas major and deep sacral gluteus maximus to facilitate the pelvic floor
• Primitive reflex inhibition
• Specific sensory motor function
• Normal breathing pattern
• Strategies for the treatment of central pain
• Rehab of motor imagery
• Integrate the whole lumbar cylinder with precision and normal breathing
• Functional mechanisms of loss of control
• Global muscle control  

       References

      Parfrey K, Gibbons SGT, Drinkwater EJ, Behm DG 2014 Head and limb position influence superficial EMG of abdominals during an abdominal hollowing exercise. BMC Musculoskeletal Disorders. 15:52. DOI: 10.1186/1471-2474-15-52 (Highly accessed)

     Gibbons SGT 2015 Can manual therapists diagnose instability of the sacro-iliac joint?

     Manuelletherapie. (German). 19(05): 211-216. DOI: 10.1055/s-0035-1570013

    Gibbons SGT, Strassl H 2012 Can altered movement pattern and muscle imbalance be related to FAI and other hip disorders? Manuelletherapie. (German). 16(3): 119-131. DOI: 10.1055/s-0032-1322424

   Gibbons SGT 2011 Neurocognitive and sensorimotor deficits represent an important sub-classification for musculoskeletal disorders – Central Nervous System Coordination. Journal of the Icelandic Physical Therapy Association. 38 (1): 10-12

    Gibbons SGT 2008 Retraining of asymmetry in recruitment of transversus abdominis. Orthopaedic Division Review.  March/April: 29-34

   Gibbons SGT 2007 Assessment and rehabilitation of the stability function of psoas major. Manuelletherapie. (German) 11:177-187. DOI: 10.1055/s-2007-963466

 

    Gibbons SGT 2007 The role of psoas major and deep sacral gluteus maximus in lumbo-pelvic stability. In: Vleeming A, Stoeckhart R and Mooney V.  Movement, Stability and Lumbopelvic Pain, 2^nd Edition, Churchill Livingstone, Edinburgh

Gibbons SGT 2016 Psoas major: Myths, misconceptions and strategies for rehabilitation.

2nd Congresso International Fisioterapy Movimento. Malaga, Spain, Oct 8-9

Gibbons SGT 2014 Sub-classification, diagnosis and rehabilitation of musculoskeletal body image disorders. 62nd Annual Scientific Meeting of the Canadian Association of Physical Medicine and Rehabilitation. St. John's, June 18-21

Gibbons SGT 2012 Facilitating neuroplasticity for pain, movement and function.  Manitoba Physiotherapy Association. April 13; Winnipeg, Manitoba

Gibbons SGT 2012 Why does motor control change? Influences of primitive reflexes and body image in the lower limb. Quebec Manual Therapy Association Symposium (AQPMO). February 11; Montreal, Quebec 

Gibbons SGT 2011 Neurocognitive and sensorimotor deficits represent an important sub-classification for musculoskeletal disorders – Central Nervous System Coordination. Proceedings of: Icelandic National Physical Therapy Conference. Feb 25; Reykjavik, Iceland

Gibbons SGT 2010 Primitive reflexes are associated with poor motor control, psychological conditions and learning difficulties.  Proceedings of: Finnish National Physiotherapy Conference. Nov 19-20; Tampere, Finland

Gibbons SGT 2010 Neurocognitive deficits should be considered in musculoskeletal pain. Proceedings of: Finnish National Physiotherapy Conference. Nov 19-20; Tampere, Finland

Gibbons SGT 2010 What exercise for which patient? Prescriptive clinical prediction rules for low back pain. Proceedings of: MACP Conference – “The Great Debate”, Sept 25-26; London, England

Gibbons SGT 2010 The relevance of neurocognitive deficits in treating musculoskeletal pain. Proceedings of: ECT 2010 - “Neurological concepts and impact of manual therapy on pain”, Sept 23-25; Antwerp, Belgium

Gibbons SGT 2010 Benefits and limitations with specific motor control rehabilitation Proceedings of: ECT 2010 - “Neurological concepts and impact of manual therapy on pain”, Sept 23-25; Antwerp, Belgium

Gibbons SGT 2010 What does chronic pain have in common with learning difficulties?  Proceedings of: Neurodynamics & The Neuromatrix Conference. April 15-17; Nottingham, England

Gibbons SGT 2010 Influence of cognitive learning factors on psychosocial factors and central sensitization. Proceedings of: Neurodynamics & The Neuromatrix Conference. April 15-17; Nottingham, England

Gibbons SGT 2009 The role of psoas major and deep sacral gluteus maximus in lumbo-pelvic stability. The Second International Congress on Musculosqueleta and Sport Rehab. May 13-16; Belo Horizonte, Brazil

Gibbons SGT 2009 Implications of cognitive learning function for outcome prediction, performance and rehabilitation. The Second International Congress on Musculosqueletal and Sport Rehab. May 13-16; Belo Horizonte, Brazil

Gibbons SGT 2008 The role of proprioception & sensory motor function in rehabilitation, cognitive function & outcome prediction. The 7^th National Symposium of the Kuwaiti Physical Therapy Association. November 12-13; Kuwait City, Kuwait

Gibbons SGT 2005 Integrating the psoas major and deep sacral guteus maximus muscles into the lumbar cylinder model.  Proceedings of: “The Spine”: World Congress on Manual Therapy.  October 7-9; Rome, Italy.

Gibbons SGT 2005 Muscle function and a critical evaluation. Proceedings of: The 2^nd International Conference on Movement Dysfunction.  “Pain and Performance: Evidence & Effect”. September 23-25; Edinburgh, Scotland

Gibbons SGT 2016 Is neurocognitive function associated with the ability to perform motor imagery in adults with musculoskeletal pain? A retrospective case control study. Proceedings of: “Cognitive Vitality”  The CAPM&R 64^th Annual Scientific Meeting. May 25-29, London, Ontario. Journal of Rehabilitation Medicine

Gibbons SGT 2016 Are a battery of obstetric and neurodevelopmental variables are associated with a subgroup of fibromyalgia and un-classified pain patients. A retrospective case control study. Proceedings of: “Cognitive Vitality”  The CAPM&R 64^th Annual Scientific Meeting. May 25-29, London, Ontario. Journal of Rehabilitation Medicine

Gibbons SGT 2016 Is neurocognitive function associated with the ability to perform motor imagery in adults with musculoskeletal pain? A retrospective case control study. Proceedings of: “Cognitive Vitality”  The CAPM&R 64^th Annual Scientific Meeting. May 25-29, London, Ontario. Journal of Rehabilitation Medicine

Gibbons SGT 2016 Are a battery of obstetric and neurodevelopmental variables are associated with a subgroup of fibromyalgia and un-classified pain patients. A retrospective case control study. Proceedings of: “Cognitive Vitality”  The CAPM&R 64^th Annual Scientific Meeting. May 25-29, London, Ontario. Journal of Rehabilitation Medicine

 Sean GT Gibbons BSc (Hons) PT, MSc Ergonomics, PhD (c), MCPA