PAIN, PILATES & THE PAIN, PILATES & THE PELVIC FLOORPELVIC FLOORPAIN: PELVIC GIRDLE PAINPAIN: PELVIC GIRDLE PAIN

PILATES: POOR TECHNIQUESPILATES: POOR TECHNIQUESPELVIC FLOOR PELVIC FLOOR -- INSTABILITYINSTABILITY

Objectives:Objectives:

To make this lecture as interactive as To make this lecture as interactive as possible!possible!Define pelvic girdle instability (Define pelvic girdle instability (pgipgi))Define pelvic girdle pain and testsDefine pelvic girdle pain and testsImpact of Impact of pilatespilates and/or core stabilityand/or core stabilityIndentifyIndentify poor recruitment patternspoor recruitment patternsDescribe strategies for recruitmentDescribe strategies for recruitment

Osteopaths are in unique position Osteopaths are in unique position to treat pelvic dysfunctionto treat pelvic dysfunction

We assess the musculoskeletal structureWe assess the musculoskeletal structureWe can assess emotional effects on motor We can assess emotional effects on motor controlcontrolWe can assess core recruitmentWe can assess core recruitmentWe can assess breathingWe can assess breathingWe can assess the pelvic floorWe can assess the pelvic floorTeach correct recruitmentTeach correct recruitment

The Buzzards are circling!The Buzzards are circling!

Pilates Pilates –– classes full of back ptsclasses full of back ptsPilates Pilates -- cheapercheaperPhysiotherapists Physiotherapists -- Osteopathic techniquesOsteopathic techniquesPhysiosPhysios –– Core MusclesCore MusclesPaul Paul ChekChek –– TrainersTrainers

Pelvic Girdle InstabilityPelvic Girdle Instability

Failure to transfer load through the PelvisFailure to transfer load through the PelvisFailure in any of following systems:Failure in any of following systems:

1.1. Form closure ,Form closure ,–– bones, ligaments and capsulesbones, ligaments and capsules2.2. Force closure Force closure –– muscles and fasciamuscles and fascia3.3. Motor control Motor control –– specific timing of muscle specific timing of muscle

activation during loadingactivation during loading4.4. Emotions! Which can affect global stabilisers, Emotions! Which can affect global stabilisers,

breathing , posture and stabilitybreathing , posture and stability

Emotions affect posture and visa versaEmotions affect posture and visa versaPregnancy, the pressure effects of Pregnancy, the pressure effects of carrying a baby, the effects on the pelvic carrying a baby, the effects on the pelvic floor during the birthfloor during the birthPoor recruitment patterns Poor recruitment patterns Breathing affects the pelvic floor and Breathing affects the pelvic floor and motor and force controlmotor and force controlTrauma, genetics structureTrauma, genetics structure

Factors affecting PG stabilityFactors affecting PG stability

StabilityStabilityCollectively all four systems produce Collectively all four systems produce approximation of joint surfaces (approximation of joint surfaces (Jacob & Jacob & KisslingKissling 1995 1995 SturessonSturesson et al 2000)et al 2000)

Consequently the ability to effectively transfer Consequently the ability to effectively transfer load through the pelvis is dynamic and depends load through the pelvis is dynamic and depends on:on:Optimal function of the bones, joints, and Optimal function of the bones, joints, and ligaments (ligaments (VleemingVleeming et al 1990 et al 1990 a,ba,b))Optimal function of the muscles and fasciaOptimal function of the muscles and fascia(Hungerford 2003)(Hungerford 2003)Appropriate neural function (Hodges et al 2001)Appropriate neural function (Hodges et al 2001)EmotionsEmotions

Form closureForm closureThe bony elementsThe bony elements

Osteopathic Osteopathic paradiseparadiseBony elementsBony elementsRequire force Require force closureclosureAlignment Alignment

Force closureForce closure

This term is used to indicate the muscles This term is used to indicate the muscles and fascia used in stabilising the SI jointsand fascia used in stabilising the SI jointsThe core muscles areThe core muscles are1) Diaphragm1) Diaphragm2) pelvic Floor2) pelvic Floor3) Multifidus3) Multifidus4) Transverse Abdominus4) Transverse Abdominus5) Thoracolumbar fascia5) Thoracolumbar fascia

Pelvic girdle painPelvic girdle pain

The European Commission, Research The European Commission, Research DirectorateDirectorate--General, Department of Policy, General, Department of Policy, CoCo--ordination and Strategy developed ordination and Strategy developed guidelines for the management of low guidelines for the management of low back pain using an evidence based back pain using an evidence based approachapproachPGP was designated as a subPGP was designated as a sub--group of group of lower back painlower back pain

PainPainPGP PGP –– non optimal joint stability non optimal joint stability Between posterior iliac crest and Between posterior iliac crest and glutealgluteal foldfoldLong dorsal ligamentLong dorsal ligamentRadiate in the posterior thighRadiate in the posterior thighPubic symphysisPubic symphysisDiminished endurance for sitting/standing/standing Diminished endurance for sitting/standing/standing Turning over in bed is painfulTurning over in bed is painfulExclude lumbar coursesExclude lumbar coursesPregnancyPregnancySpecific testsSpecific tests

Pelvic Pain TestsPelvic Pain Tests4 validated tests4 validated tests

1.1. 1.Modified trendelenburg test 1.Modified trendelenburg test –– anterior anterior rotation on symptomatic SIJ rotation on symptomatic SIJ (Hungerford B, (Hungerford B,

GilleardGilleard W, Lee, D, W, Lee, D, ClinClin BiomechBiomech 20042004))

2.2. Posterior Pelvic Pain Posterior Pelvic Pain ProvationProvation Test P4Test P43.3. Active Straight Leg Raise Active Straight Leg Raise ((VleemingVleeming, , MensMens))

4.4. Faber PatrickFaber Patrick5.5. Pubic Pubic symphysealsymphyseal painpain6.6. Palpation !Palpation !

Modified TrendelenburgModified Trendelenburg

Patient weight bears on one legPatient weight bears on one legAssess for Assess for nutationnutation and and counternutationcounternutationVleemingVleeming, Lee et al :, Lee et al :

1.1. Posterior rotation on non symptomaticPosterior rotation on non symptomatic2.2. Anterior rotation on symptomaticAnterior rotation on symptomatic3.3. Anterior rotation poor strategy to Anterior rotation poor strategy to

stabilisestabilise

Lets Stand on One Leg!Lets Stand on One Leg!

Try the modified Trendelenburg for your Try the modified Trendelenburg for your selvesselvesPerson next to you Person next to you –– assess your assess your strategiesstrategiesOne leg with other hip flexed One leg with other hip flexed Can you do it what are your patterns?Can you do it what are your patterns?

ACTIVE STRAIGHT LEG RAISINGACTIVE STRAIGHT LEG RAISING

Patient supine on couchPatient supine on couchRaise leg 20 cm off the bedRaise leg 20 cm off the bedAssess relative difficultyAssess relative difficultyWatch for bracing strategiesWatch for bracing strategiesUse compression to reassessUse compression to reassessMensMens, , VleemingVleeming et al Spine 2002et al Spine 2002

Faber Patrick TESTFaber Patrick TEST

Patient in supine Patient in supine positionpositionFlex the leg and put Flex the leg and put foot of the tested side foot of the tested side on the opposite knee on the opposite knee lowering the leg into lowering the leg into further abduction further abduction

POSTERIOR PAIN POSTERIOR PAIN PROVOCATION PROVOCATION TESTTEST(ostgaard(ostgaard 1991)1991)

This test has been This test has been validated by validated by OstgaardOstgaard, , VleemingVleeming, , Lee in many separate Lee in many separate clinical trialsclinical trials

Butt grippingButt gripping

Over reliance on the Over reliance on the piriformis, posterior piriformis, posterior pelvic floor and pelvic floor and releasing of the releasing of the abdominalsabdominalsLeads to inverse Leads to inverse pyramidpyramid

Inverted pyramidOf

support

•Posterior •Pf over•active

Poor stability

PiriformSitz bonTight hi

Pilates and Core StabilityPilates and Core Stability

Pilates uses the concept of activating the core Pilates uses the concept of activating the core muscles to stabilise and improve flexibility, muscles to stabilise and improve flexibility, mobility and timing recruitmentmobility and timing recruitmentDoes it achieve this?Does it achieve this?In some classes this may occur In some classes this may occur –– it is much it is much more likely to happen in a one to one settingmore likely to happen in a one to one settingWhy don’t osteopaths use this as an assess and Why don’t osteopaths use this as an assess and treatment tooltreatment toolAnswer Answer –– we can! Some already dowe can! Some already do

Problems of Pilates ClassesProblems of Pilates Classes

? Ability to the teacher? Ability to the teacherThe number of participantsThe number of participantsThe amount of scrutiny and correctionThe amount of scrutiny and correctionIncorrectly activatingIncorrectly activatingIncorrectly breathing Incorrectly breathing Advanced ExercisesAdvanced Exercises

Pilates and the Pelvic FloorPilates and the Pelvic Floor

? Teachers achieve pf contraction? Teachers achieve pf contractionNeural damageNeural damageSubstitution strategySubstitution strategyZip and hollow Zip and hollow Strong Abs, weak pfStrong Abs, weak pf

Testing our stabilising structuresTesting our stabilising structuresLets activate our own core in the way you know Lets activate our own core in the way you know bestbestKeep it activated and take a breath inKeep it activated and take a breath inCan you breathe normally?Can you breathe normally?Now ask the person sitting next to you to assess Now ask the person sitting next to you to assess you thoracic movement by standing behind you you thoracic movement by standing behind you and trying to shift the ribcage by wiggling it and trying to shift the ribcage by wiggling it laterally to either sidelaterally to either sideNow let go of the core and allow a reassessment Now let go of the core and allow a reassessment of the thoracic cage of the thoracic cage –– what happenedwhat happened

Palpate your transverse abdominusPalpate your transverse abdominus

Sit on the edge of the chair with feet Sit on the edge of the chair with feet planted hip distance apart on floorplanted hip distance apart on floorNow place your index and middle fingers Now place your index and middle fingers two inches in and down from the ASIStwo inches in and down from the ASISNow activate your coreNow activate your coreWhat do you feel?What do you feel?A subtle tensioning or A subtle tensioning or A bulging into your fingertips?A bulging into your fingertips?

Now assess your breathingNow assess your breathing

Place your hands across lower ribcage Place your hands across lower ribcage fingertips just touchingfingertips just touchingTake a deep breath in Take a deep breath in –– what do you feel what do you feel or experienceor experienceNow breathe outNow breathe outThis time inhale into your hands, This time inhale into your hands, compressing your ribcage very slightlycompressing your ribcage very slightlyWhat do you notice?What do you notice?

BreathingBreathingNow place your hands on your external Now place your hands on your external obliquesobliques’ ’ attachment to the ribcageattachment to the ribcageTake a deep breath in and exhale Take a deep breath in and exhale –– what do you what do you feelfeelNow take a breath in and breathe out through Now take a breath in and breathe out through pursed lips as if blowing onto a dandelion. pursed lips as if blowing onto a dandelion. –– was was it any different.it any different.Patients who are EO dominant in their Patients who are EO dominant in their exhalation often narrower waists and a little exhalation often narrower waists and a little belly lower in their abdomen they are pushing belly lower in their abdomen they are pushing their pelvic organs downwards their pelvic organs downwards –– leading to a leading to a poor stabilising strategypoor stabilising strategy

Sub Optimal recruitmentSub Optimal recruitment

Real Time UltrasoundReal Time Ultrasound

RTUS of Trans ABRTUS of Trans AB

Pelvic Floor ActivationPelvic Floor Activation

Lets get personal!Lets get personal!Sit with your right hand under your right Sit with your right hand under your right ischialischial tuberositytuberosity and your left under your and your left under your left oneleft oneNow do a pelvic floor contractionNow do a pelvic floor contraction-- what do you feel?what do you feel?Is it equal, does raise, lower or not move Is it equal, does raise, lower or not move at allat all

Pelvic Floor in actionPelvic Floor in action

Female Patients with PGPFemale Patients with PGP

PostpartumPostpartumSuffered lower back pain, pubic symphysis pain during Suffered lower back pain, pubic symphysis pain during pregnancypregnancyHave learnt poor strategies for stabilisingHave learnt poor strategies for stabilisingOver reliance on the posterior pelvic floor and piriformis Over reliance on the posterior pelvic floor and piriformis Diane Lee calls this the tail wagging the dogDiane Lee calls this the tail wagging the dogIeIe breath holding, external oblique dominance internal breath holding, external oblique dominance internal oblique recruitment etc. oblique recruitment etc. They need to be retrained in their recruitment They need to be retrained in their recruitment –– as as osteopaths we can teach this with a few simple osteopaths we can teach this with a few simple techniquestechniques

Prolapse TypesProlapse Types1.1. CystoceleCystocele2.2. HysteroceleHysterocele3.3. ElytroceleElytrocele4.4. RectoceleRectocele

What the Research saysWhat the Research says1.1. StugeStuge et al Spine 2004 et al Spine 2004 –– Efficacy of treatment Efficacy of treatment

Program on Specific Stabilising exercises Program on Specific Stabilising exercises ––disability was reduced by more than 50% for disability was reduced by more than 50% for the exercise group. Negligible changes in the exercise group. Negligible changes in control group after 1 year follow upcontrol group after 1 year follow up

2.2. RostRost C et al C et al ActaActa ObstetObstet GynaeGynae Scand 2006 Scand 2006 Prognosis of women with pelvic pain during Prognosis of women with pelvic pain during pregnancy pregnancy –– long term follow uplong term follow up

3.3. O’Sullivan et al Spine 2002 O’Sullivan et al Spine 2002 –– Altered motor Altered motor control strategies in SIJP during ASLRcontrol strategies in SIJP during ASLR

Treatment techniquesTreatment techniquesUse 4 tests to assess patternUse 4 tests to assess patternTeach lateral costal breathing EOTeach lateral costal breathing EOExplain the effect of posture and emotion Explain the effect of posture and emotion on breathing and pain perception and on breathing and pain perception and promotionpromotionpalpate multifiduspalpate multifidusAssess recruitment of their Trans AB in a Assess recruitment of their Trans AB in a sidelying positionsidelying position

Teach use of the abdominal muscle and Teach use of the abdominal muscle and anterior pelvic floor anterior pelvic floor pubococcygeuspubococcygeus in in stabilising the pelvis. Widen stabilising the pelvis. Widen sitzsitz bones bones release through posterior pelvic floorrelease through posterior pelvic floorTeach how to use pelvic floor to sit and Teach how to use pelvic floor to sit and stand via visual images of the stand via visual images of the sitzsitz bonebone

Assess pelvic floor recruitment and teach Assess pelvic floor recruitment and teach how to recruit how to recruit –– explain the relevance to explain the relevance to their pelvic health and conditiontheir pelvic health and conditionRetrain poor techniques, Retrain poor techniques, ieie chest gripping, chest gripping, butt gripping (piriformis)butt gripping (piriformis)

PyramidOf support

Correct use ofTransverse Ab

Wide sitz bones and use ofthe anterior pelvic floor

Retraining Muscle SystemsRetraining Muscle Systems

teach recruitment Of PF and T/A

Restore correctstabilisation

Correct breathing

Restore mobility& osseous alignment

Identify poorStabilisation strategies

IdentifyPGI

SummarySummary

We can identify PGI by tests and then we can We can identify PGI by tests and then we can influence:influence:

1.1. BreathingBreathing2.2. Core activationCore activation3.3. Pelvic floor functionPelvic floor function4.4. Emotion and motor controlEmotion and motor control5.5. This makes us more effective and our patients This makes us more effective and our patients

more satisfiedmore satisfied6.6. We can keep the buzzards at bay!We can keep the buzzards at bay!