What's New for Pelvic Floor Therapists?

There hasn't been a lot of new information for pelvic health therapists lately. There are a few new things to help.

Motor Skill Learning

Motor Imagery and Musculoskeletal Body Image is required for motor skill learning of specific motor control exercises or general pelvic floor rehab. It is intimately linked to the neurodevelopmental process. Isn't it logical that you would normally form a good body image and motor imagery skill? Numerous people do not have adequate motor imagery (e.g. atypical birth history and early life development). This is can be constant or positional. A structured motor imagery assessment should be carried out. If poor, it is treated with the neurodevelopmental process (specific rolling and crawling rehab broken down with the specific primitive and postural reflexes developed in infancy). It can also be treated with relearned the motor imagery process.

Midline as a Sensory System. This is a whole new strategy to look at movement and motor control. The pelvic region is frequently adversely affected by poor midline awareness. Poor midline awareness has implications for motor control, motor imagery, and pain. Improving this will allow rehabilitation for many of the poor motor skill learning problems associated with the pelvic floor. It is treated with the above process as well as specifically targeting midline positions and tasks.

Not Everyone Can Learn Motor Skills
We must accept that some people just have poor motor skill learning abilities. The Motor Control Abilities Questionnaire screens them with high accuracy so you don't waste your time. This combined with a simple subjective history nearly makes this assessment 100% accurate. The treatment is largely neurodevelopmental and sensory motor.


Central Pain
The most common cause (by far) of central pain is chronic low grade systemic inflammation. We can screen this with the NICE-Q screen. It is treated with a targeted dietary / lifestyle approach.
  https://smarterehab.blogspot.com/2019/12/are-co-morbid-medical-symptoms.html
 https://smarterehab.blogspot.com/2019/12/modified-ketogenic-diet-and-supplement.html

The next most common cause is poor sensory motor gating. This is assessed and treated with specific sensory discrimination techniques.


New Strategies to Facilitate the Pelvic Floor

Primitive Reflex Inhibition is a new and exciting way to influence muscle tone around the trunk. There are numerous ways primitive reflex inhibition can be used by pelvic health therapists:

• Normalize muscle tone of the pelvic floor and trunk
• Stimulate pelvic floor contractions
• Improve sensation of pelvic floor contractions
• Improve and normalize symmetry of the levator plate at rest and during contractions
• Improve motor imagery of the pelvic floor

Psoas major has strong fascial connections to and is continuous with the pelvic floor fascia. Psoas major is a key muscle for joint control in the lumbar spine, SIJ and hip. During dissection, the pelvic floor can move by pulling on psoas major. While visualizing the pelvic floor on ultrasound, the levator plate can be stimulated by a specific exercise for psoas major. As well, the sensation a pelvic floor contraction can be reduced during a specific exercise for psoas major. Asymmetrical pelvic floor contractions (as seen on transabdominal views) can frequently be corrected by a specific exercise for psoas major. How many people find it easier to go to the toilet when flexing the hip or trunk? Is this psoas major or a primitive reflex? Likely both.


Deep Sacral Gluteus Maximus (DSG) is the deeper, medial aspect of gluteus maximus. It does not cross the hip joint so does not extend the hip. It has a unique function separate from the cranial and caudal fibres of gluteus maximus and acts to improve force closure of the SIJ. During dissection, the fascia of the DSG is continuous with the levator plate. While visualizing the pelvic floor on ultrasound, the levator plate can be stimulated by a specific exercise for DSG.
Gibbons SGT 2007 The role of psoas major and deep sacral gluteus Vleeming A, Stoeckhart R and Mooney V. Movement, Stability and Lumbopelvic Pain, 2nd Edition, Churchill Livingstone, Edinburgh

Gibbons SGT, Comerford MJ and Emerson P 2002 Rehabilitation of the stability function of psoas major. Orthopaedic Division Review. Jan / Feb. 7-16

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

For an English version see: https://www.researchgate.net/profile/Sean_Gibbons

Deep Hip Intrinsics have strong fascial connections to the plate. Specific exercises can the pelvic floor.

Bladder Stability. On dissection, pyramidilis had a strong fascial connection to the neck of the bladder. Is it possible that the orientation of the bladder (at rest or during movement) can be enhanced by efficient abdominal control? We do not know yet if it can physically influence the position of the bladder neck.

The whole lumbar cylinder. This one isn't really new. It is now well understood that trunk motor control is intimately linked with pelvic floor and continence control. However, it should be appreciated that the whole cylinder should coordinate together. It is also now understood that the lumbar-SIJ-hip stability mechanisms overlap. Therefore, pelvic health therapists should know how to rehabilitate the lumbar-SIJ-hip from an and specific motor control perspective.

Fact: the commonly discussed topic of making the pelvic floor worse with transversus abdominis rehab IS NOT substantiated by evidence. It would be wise to review the letter to the editor by Sapsford et al 2010 (Neurourol Urodyn. 2010 Jun;29(5):800-1; author reply 802-3. : 10.1002/nau.20861.) Systematic review: Abdominal or pelvic floor muscle training. Sapsford R, Hodges P, Smith M.
Comment on; Evidence for benefit of transversus abdominis training alone or in combination with pelvic floor muscle training to treat female urinary incontinence: A systematic review. [Neurourol Urodyn. 2009]

There have been a few new publications on incontinence in males who have had a prostatectemy by the Hodges group which are worth a read!

Neurourol Urodyn. 2020 Jan 24. doi: 10.1002/nau.24291. [Epub ahead of print]

Do features of randomized controlled trials of pelvic floor muscle training for postprostatectomy urinary incontinence differentiate successful from unsuccessful patient outcomes? A systematic review with a series of meta-analyses.

Hall LM1, Neumann P2, Hodges PW1.

Neurourol Urodyn. 2020 Feb 6. doi: 10.1002/nau.24301. [Epub ahead of print]

Influence of body position on dynamics of the pelvic floor measured with transperineal ultrasound imaging in men.

Cowley D1, Stafford RE1,2, Hodges PW1.

Urol Oncol. 2019 Dec 24. pii: S1078-1439(19)30494-6. doi: 10.1016/j.urolonc.2019.12.007. [Epub ahead of print]

Reconsideration of pelvic floor muscle training to prevent and treat incontinence after radical prostatectomy.

Hodges PW1, Stafford RE2, Hall L2, Neumann P3, Morrison S4, Frawley H5, Doorbar-Baptist S6, Nahon I7, Crow J8, Thompson J9, Cameron AP10.

This post is an update from: 
 https://smarterehab.blogspot.com/2016/12/is-there-anything-new-for-pelvic-floor.html