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The Local Stabilizing Muscles and Lower Limb Injuries

Today's post on the Pelvic Rehab Report comes from faculty member Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD, PRPC. Allison instructs the ultrasound imaging courses, the next of which will be Rehabilitative Ultra Sound Imaging: Women's Health and Orthopedic Topics in Baltimore, MD on Jun 12, 2015 - Jun 14, 2015.

In the past several decades there has been quite a bit of research regarding stabilization of the low back and pelvic ring. We as therapists have changed our focus from working more of the global stabilization muscles to the local stabilizing muscles; the transverse abdominis, the lumbar multifidus, and the pelvic floor. Both research studies and clinical experience has shown us what a positive difference working on these muscles can makes for back pain and pelvic ring pain, as well as for the risk of injury in the back and pelvic ring. However, what does it do for risk of injury for the lower limb? In 2014, Hides and Stanton published a study looking at the effects of motor control training on lower extremity injury in Australian professional football players. A pre- and post-intervention trial was used during the playing season of the Australian football league as a panel design. Assessment included magnetic resonance imaging and measurements of the cross-sectional area of the multifidus, psoas, and quadratus lumborum, as well as the change in trunk cross-sectional area due to voluntary contraction of the transverse abdominis muscle. A motor control program included training of the multifidus, transversus abdominis, and the pelvic floor muscles using ultrasound imaging for feedback that then progressed into a functional rehabilitation program was used with some of the players. Injury data was collected throughout the study. Results showed that a smaller multifidus or quadratus lumborum was predictive of lower limb injury during the playing season. Additionally, the risk of sustaining a severe injury was lower for players who received the motor control intervention.

This is interesting and intriguing information. Yes, there are many factors that are involved in sustaining an injury during a sport. However, it would be a good idea to do a quick screen of the local stabilizing muscles before a playing season, whether it is a professional player or an adolescent player. Do adolescents really have issues with weakness in their local stabilizing muscles? Yes! Clinically I have seen adolescent players who display back pain and other issues related to weakness in their core muscles. Usually this occurs after they have gone through a growth spurt, but some of these adolescent athletes did not recover, even several years after the large growth spurt.

What a nice community service it would be to screen a local sports team for strength of the local stabilizing muscles in order to decrease injuries! It would also be nice to see additional research regarding this topic! To learn more about recent research and how to use ultrasound imaging to accurately assess and treat the local stabilizing muscles, join me at Johns Hopkins in Baltimore this June for the Rehabilitative Ultrasound Imaging for the Pelvic Girdle and Pelvic Floor course.



Hides JA, Stanton WR. Can motor control training lower the risk of injury for professional football players? Med Sci Sports Exec. 2014; 46(4): 762-8.

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Have you tried Ultrasound Imaging to Evaluate Prolapse?

Today's post is written by faculty member Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD, PRPC. You can join Allison in her Rehabilitative Ultrasound Imaging: Women's Health and Orthopedic Topics course, which takes place in Baltimore this year, June 12-14.

Since the mid 1990’s the POP-Q has been used to quantify, describe and stage pelvic organ prolapse. A series of 6 points are measured in the vagina in relation to the hymen. In a recent years, translabial ultrasound imaging has been used to look at the pelvic organs and the pelvic floor. A skilled practitioner can view pelvic floor muscle contractions, as well as Valsalva maneuvers and the effects each of these have on the pelvic organs. For example funneling of the urethral meatus, rotation of the urethra, opening of the retrovesical angle, and dropping of the bladder neck and uterus can be viewed using ultrasound imaging of the anterior compartment during Valsalva maneuvers. Pelvic organ descent seen on ultrasound imaging has been associated with symptoms of prolapse.

Until now the relationship between ultrasound and clinical findings has not been examined. A recent study by Dietz set out to see if there is an association between clinical prolapse findings and pelvic descent seen on ultrasound. Data was obtained on 825 women seeking treatment at a urogynecological center for symptoms of lower urinary tract or pelvic floor muscle dysfunction. Five coordinates of the POP-Q scale were measured and compared to ultrasound measures of descent. All data was blinded against other data obtained. Clinically, 78% of the women were found to have a POP-Q stage of 2 or greater. It was found that all coordinates were strongly associated with ultrasound measures of descent. The association was almost linear, particularly for the anterior compartment. This means that ultrasound measures can be used to quantify prolapse and be comparable to the POP-Q. Proposed cutoffs have been made for the bladder, uterus, and rectum in relation to the pubic symphysis.

It is exciting to see ultrasound use in the quantification and identification of more gynecological disorders. The use of translabial ultrasound imaging is growing and continuing to be researched. It is an exciting field to be a part of and I look forward to seeing where this research goes. I believe it will be used to help improve surgical procedures as well candidate selection for surgery. Join more for more discussion regarding translabial ultrasound imaging and learn how to view these images in Rehabilitative Ultrasound Imaging for the Pelvic Girdle and Pelvic Floor in Baltimore this June!

Dietz HP, Kamisan Atan I, Salita A. The association between ICS POPQ coordinates and translabial ultrasound findings: implications for the definition of ‘normal pelvic organ support’. Ultrasound Obstet Gynecol. 2015; April.

 

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Allison Ariail - Featured Herman & Wallace Instructor

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with Herman & Wallace instructor Allison Ariail, PT, DPT, CLT-LANA, PRPC, BCB-PMD

Allison Ariail

How did you get started in pelvic rehab?

I got started in pelvic rehab by treating and specializing in SIJ and low back dysfunction. I used ultrasound imaging to retrain the local core muscles including the transverse abdominis, lumbar multifidus, and the pelvic floor muscles. In treating these patients, not only did they improve with respects to their back pain, but their incontinence improved as well! I then started getting referrals from doctors for incontinence patients. So I took PF1 and as they say, the rest is history! I know that pelvic rehab is my calling. I am impassioned about this subject and love treating these patients. I also thoroughly enjoy teaching about the pelvic floor and the pelvic ring. I truly feel I am one of the lucky ones to actually love what I do!

What do you find most rewarding about treating this patient population?

I am passionate about treating this patient population because it makes such a difference in their lives! I have had more patients than I like to admit say that if they did not find me and get on my schedule, they would have killed themselves due to their pain. This is so sad and alarming to me that individuals have gotten to the point of considering those thoughts. I feel blessed that I am in a position to not only improve their lives in the physical sense but also in the emotional one by lessoning their pain and improving their outlook on life! To me there is nothing more rewarding than seeing this dramatic of a change in a patient.

What do you find most rewarding about teaching?

One reason I love teaching is because it is a way to help improve the lives of more people suffering with pelvic disorders! There are not enough therapists that specialize in the pelvic floor and by teaching other therapists how to appropriately treat pelvic floor dysfunction, it positively impacts more people’s lives! I always find it magical when a course participant is hesitant and nervous to take the course. Then after the course they are excited and enthusiastic to treat this patient population and to learn more about this field. This is very rewarding to me and a reason I look forward to teaching each and every course.

If you could get a message to all therapists about pelvic rehab, what would it be?

One message I would try to get out to therapists about pelvic rehab is to get out and talk about it! Discuss what you do with physicians, the community, as well as people you meet in every day life. Often, when someone finds out what you do, you will get questions asked of you. However, don’t wait for this! There are so many women and men suffering in silence thinking that there is nothing they can do. So get out there and tell them what you do and how you can help can improve lives! Don’t be hesitant or shy, be energetic and excited to share your knowledge and educate the public about what we do as pelvic therapists!

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Dysmenorrhea

This post was written by Allison Ariail, PT, DPT, CLT-LANA, PRPC, BCB-PMD. You can catch Allison teaching the Pelvic Floor Level 1 course in May in Los Angeles.

Blog by  Allison Ariail

Dysmenorrhea is the medical term used for painful menstruation. Symptoms usually begin 1 or 2 days before or the first day of menstruation and include headache, low back and thigh pain, abdominal pain, nausea and vomiting, diarrhea, and excessive fatigue. Sixty percent of women suffer from dysmenorrhea, with many of these women being incapacitated for up to 3 days each month due to symptoms. There are two types of dysmenorrhea. Primary dysmenorrhea is menstrual pain that is not caused from another disorder or disease. Secondary dysmenorrhea is menstrual pain that is due to a disorder in the pelvic organs including endometriosis, fibroids, adenomyosis, pelvic inflammatory disease, cervical stenosis, or infection. In the past, treatment approaches for primary dysmenorrhea have included the use of non-steroidal anti-inflammatories, hormonal contraceptives, vitamins, and acupuncture. There have not been many studies that look at how physical activity influences the degree of pain for women with primary Dysmenorrhea. However, clinical experience has shown me that some women who begin exercising regularly decrease their dysmenorrhea symptoms compared to what they previously experienced. So I have done a search to find some studies that address this matter.

A Cochrane review found only one study that used a control group. In this study, the experimental group participated in a 12-week walking or jogging program at 70-80% of heart rate range, 3 days a week for 30 minutes. Moos’ Menstrual Distress Inventory was used to measure outcomes. This was given pre-training, post-training, and during the premenstrual and inter-menstrual phases for the three hormonal cycles measured. There were significant lower scores on the Moos’ Menstrual Distress Inventory during the menstrual phase in the group that participated in exercise compared to the control group. Additionally, there was a negative linear trend in scores over the three observed cycles for the training group with no linear trend seen in the control group.1 So the exercise group lessoned the degree of their symptoms over the three months by participating in the walking program!

A study by Maceno de Araujo et al. looked at the severity of primary dysmenorrhea symptoms before and after participating in a two month Pilates exercise regimen 2 times per week for 60 minutes. Outcome measures used included visual analog scale and McGill Pain Questionnaire. Although this study did not use a control group and the number of participants was low (n=10), it did show significant changes in pain scores during menstruation when comparing little to no exercise to a regular exercise program of Pilates. Pain scores due to menstruation prior to the study were 7.89 ± 1.96, and dropped to 2.56 ± .56 with the exercise program!

I found these articles interesting and began to wonder how many women we as therapists could help by knowing this information! I do not think that we as pelvic heath therapists are reaching this population of patient diagnoses. Yes, starting an exercise regimen, especially a walking program, sounds easy to us as physical therapists or occupational therapists. However, it can be daunting to a woman who has not previously participated in any type of exercise program. Meeting with some of these women who suffer from primary dysmenorrhea and evaluating any musculoskeletal dysfunctions that are present, then prescribing an appropriate exercise routine that is individualized for that patient can help the patient stay committed to the program. In finding this information, I am excited to pass it along to my patients and future patients in hopes of improving their life and lessening their discomforts! Join me to discuss this topic as well as others related to the pelvic floor in Los Angeles at PF1!

1. Brown J, Brown S. Exercise for dysmenorrhea. Cochrane Database of Systematic Reviews 2010, Issue 2. Art. No.: CD004142. DOI: 10.1002/14651858.CD004142.pub2.

2. Macêdo de Araújo L; Nunes da Silva JM; Tavares Bastos W; Lima Venutra P. Pain improvement in women with primary dysmenorrhea treated with Pilates. Revista Dor. 2012; 13(2).

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Hyaluronic Acid for Vaginal Dryness

This post was written by H&W instructor Allison Ariail PT, DPT, CLT-LANA, BCB-PMD, PRPC, who will be presenting Pelvic Floor Level 2B in Houston at the end of February.

Allison Ariail

Dyspareunia, or pain during or after intercourse, can be very upsetting and frustrating to a woman. One cause of dyspareunia is vaginal dryness. As estrogen levels decrease, the vaginal tissues can have less moisture, elasticity, and become thinner. This not only can affect postmenopausal women, but also post-partum women, and women who are on estrogen-blocking medication due to cancer or for treatment of fibroids. One of the common and effective treatments for this vaginal dryness includes estrogen creams, or hormone replacement. However, what does a woman do if she is not able to use an estrogen cream, due to an estrogen receptor positive cancer? One possibility is hyaluronic acid. Hyaluronic acid is a substance naturally found throughout connective, epithelial, and neural tissue. You may be more familiar with hyaluronic acid as the substance injected into joints for osteoarthritis. However, there have been some recent published studies comparing the use of hyaluronic acid to estrogen replacement.

In 2011, Ekin et al. published a study comparing the use of hyaluronic acid vaginal tablets with estradiol vaginal tablets. Two groups of postmenopausal women with atrophic vaginitis were studied. One group used estradiol vaginal tablets (n=21) for 8 weeks, while the other group used hyaluronic acid tablets (n=21) for 8 weeks. Outcomes consisted of the degree of vaginal atrophy, vaginal pH, vaginal maturation index, and a self-assessed 4-point scale. Both groups had relief of vaginal symptoms, improved epithelial atrophy, decreased vaginal pH, and increased maturation of the vaginal epithelium. The group on estradiol did have greater improvements, however, it was determined that the hyaluronic acid vaginal tablets was effective enough to be considered an alternative treatment for those who wanted to avoid the use of a local estrogen treatment.

In 2013, Chen et al. published a study comparing the use of hyaluronic acid gel to estriol cream. Women were randomized into two groups, using the hyaluronic acid vaginal gel, or the use of estriol cream (n=72 each group) for 30 days. Outcome measures included a visual analog scale for vaginal dryness, and three other vaginal symptoms. Also measured were lab tests of the vaginal micro-ecosystem, vaginal pH, vaginal US, and incidence of adverse events. Results showed both groups had improvement without a statistically significant difference between the groups.

These two studies show that hyaluronic acid may be an alternative to hormone replacement. This is good news for women who suffer from vaginal dryness and cannot use hormone replacement therapy, or even localized hormone replacement therapy due to the use of anti-estrogen medications! The improvement of vaginal dryness can significantly improve dyspareunia symptoms for many women. To learn more about dyspareunia, as well as other causes of pelvic pain, join me in Houston for PF2B!

References

Chen, J., Geng, L., Song, X., Li, H., Giordan, N., & Liao, Q. (2013). Evaluation of the Efficacy and Safety of Hyaluronic Acid Vaginal Gel to Ease Vaginal Dryness: A Multicenter, Randomized, Controlled, Open?Label, Parallel?Group, Clinical Trial. The journal of sexual medicine, 10(6), 1575-1584.

Ekin, M., Ya?ar, L., Savan, K., Temur, M., Uhri, M., Gencer, I., & K?vanç, E. (2011). The comparison of hyaluronic acid vaginal tablets with estradiol vaginal tablets in the treatment of atrophic vaginitis: a randomized controlled trial. Archives of gynecology and obstetrics, 283(3), 539-543.

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A Pelvic Floor History Lesson

This post was written by H&W instructor Allison Ariail PT, DPT, CLT-LANA, BCB-PMD. Allison will be instructing the Pelvic Floor Level 1 course Boston this October.

Allison Ariail

Several weeks ago some of my fellow faculty members and I were discussing the resting tone of the pelvic floor. These days we take it for granted that we know there is constant low-level activity in the pelvic floor and anal sphincter in order to provide continence. However, how did this information come about? I took it upon myself to do some research to find out the beginnings of this knowledge. What I found was interesting and thought I would share.

In the late 1940’s and early 1950’s the belief was held that the pelvic floor and external anal sphincters were inactive at rest, like other striated muscle throughout the body. Activity was believed to be initiated by afferent impulses from the rectal ampulla and anal canal. In 1953 Floyd and Walls found activity in the external anal sphincters at rest, even during sleep. In 1962 Parks, Porter, and Melzak published a study examining the pelvic floor muscles and the external anal sphincters using electromyography recordings. They also found activity in these muscles at rest. They hypothesized the activity was maintained by spinal reflex. These researchers looked at the activity in a healthy population, a paraplegic population, and a population that had undergone a rectal excision. When examining the paraplegic population (all subjects had complete SCI injuries above L3), they did identify activity of the pelvic floor at rest.

With respects to the rectal excision population, they examined patients whose rectums were removed, but the somatic muscles, external sphincters, and the levator ani remained with innervation intact and the muscles were sutured to provide a muscular pelvic floor. These patients also exhibited activity in the pelvic floor and anal sphincter at rest. These patients were important to the study in order to rule out that the reflex was not coming from somewhere in the rectal wall. Additionally, these researchers discovered this resting activity that was present the anal sphincter was inhibited during defecation in response to a certain degree of rectal distension.

So what did all of this new information mean to these researchers? It meant that the pelvic floor and external anal sphincter were unique due to the fact they were activated at rest, and without this activation continence would not be maintained. They determined the activation to be reflex and termed it “postural reflex of the pelvic floor.” Additionally, they termed the inhibition due to rectal distension “the rectal inhibitory reflex,” which also was due to a reflex arc. This new information was groundbreaking for the time and lead to other research that provided us with the knowledge that we have today! Thank goodness for these researchers as well as the many others who have furthered the advancement of knowledge about the pelvic floor!

Learn more about Allison and the Pelvic Floor Series by visiting our website!

1. Floyd, Walls. Electromyography of sphincter ani externus in man. J. Physiol. 122: 599, 1953.

2.Parks, Porter, Melzak. Experimental study of the reflex mechanism controlling the muscles of the pelvic floor. Dis. Colon Rectum. 5 (6): 407. 1962.

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Mother's Day and Healthy Moms

Allison Ariail

This post was written by H&W instructor Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD. Allison will be instructing the Care of the Postpartum Patient course in Houston in June.

As Mother’s day weekend approaches, I take time to think about the dramatic changes in life that occur with the birth of a baby! No one is quite prepared for how much their life will change with the birth of their child, especially their first child! There are numerous changes that occur in a woman’s life during the pregnancy and into the postpartum time, both emotionally and physically. Any woman who has had a baby knows our bodies do not revert back to the exact body we had prior to pregnancy. New moms may be left with changes in their body that can greatly affect their function. Physical therapy in the postpartum time can greatly improve a woman’s well-being and function. We can treat a woman for back pain, diastasis rectus separations, incontinence, thoracic outlet syndrome, nerve damage that occurred during delivery, and many more issues a woman may present with. We also are a listening ear for the new mom going through many changes and hormonal upheaval. It is important to stay open and listen in a non-judgmental way. New moms are inundated with unsolicited advice in a way that no other patient population is. Having a safe place to come and get treated physically can help her emotionally as well.

During pregnancy and the postpartum time many habits are formed that if not changed can influence and shape how a woman lives the rest of her life. For example, night time voiding is common for pregnant women. If a woman continues to void every time she gets up with the baby in the middle of the night once she delivers, she may continue or even worsen her habit, thus creating an issue that will greatly affect her overall sleep health and well-being for the rest of her life. Having an objective person educate a woman about some of these habits can be very enlightening for an individual!

Receiving therapy in the postpartum time can influence a woman’s overall health in the immediate future as well as down the road. There are special things to consider when treating a postpartum woman and a women’s health therapist is the best person to treat her.

You can learn about special topics that affect a postpartum woman in Care of the Postpartum Patient course. The next time this course is being offered is June7-8 in Houston, Texas. So as mother’s day comes upon us, let’s celebrate the amazing journey we and other moms take in becoming a mom. Let us embrace the remarkable changes that occur physically and emotionally and thank our own mothers, as well as ourselves, for being willing to undergo these changes!

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Biofeedback and the Local Stabilizing Muscles

Allison Ariail

This post was written by H&W instructor Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD. Allison will be instructing the Rehabilitative Ultrasound course in Seatlte in May.

In the past decades, evidence has been established showing the importance of the local stabilizing muscles, including the transverse abdominis, the lumbar multifidus, and the pelvic floor muscles on the stability of the pelvic ring and lumbar spine. Many therapists have embraced this knowledge and incorporate a specific stabilization program into their plan of care for patients with dysfunction in the lumbar spine or pelvic ring. This plan of care can be more time consuming for the therapist since we are no longer simply prescribing strengthening exercises to the patient, but instead are using neuromuscular re-education to retrain recruitment patterns and improve motor control. For many patients, learning to activate these muscles can be very difficult and frustrating. This is where biofeedback comes in. For years, women’s health therapists have been using biofeedback to retrain the pelvic floor muscles. Biofeedback is the process of bringing unconscious physiological processes to consciousness and gaining control over it. These same principles can be used in retraining the lumbar multifidus and the transverse abdominis, in addition to the pelvic floor. Currently, biofeedback methods used in treating low back pain include rehabilitative ultrasound imaging (RUSI) and the pressure cuff. My preferred method is using RUSI. This tool not only provides biofeedback for the patient but allows for real-time assessment of the muscle activation. Thus, providing the clinician valuable feedback on timing of recruitment and strategy used by the patient that would not be assessed with palpation alone.

Giggins et al recently released a literature review that covered different forms of biofeedback used in rehabilitation. Interestingly, there is little evidence to support the use of pressure cuff. Some of the research reported found significant increases in gluteus medius and internal oblique activity. In 2013, Grooms et al also determined that correlation and likelihood coefficients indicate that the pressure cuff is likely of minimal value to detect transverse abdominis activation. I personally have had patients referred to me from other therapists to confirm whether or not they were activating their transverse abdominis. In previous treatments, the patients had been using the pressure cuff and palpation by the therapist as confirmation of proper activation. What I found was consistently the patients were not achieving good contractions in their transverse abdominis muscles. Most of these patients were able to learn in one or two sessions how to properly contract their transverse abdominis, and were later able to progress to performing a co-contraction of all the local stabilizers during motor tasks.

Hides et al published a study that demonstrated a specific stabilization rehabilitation program using RUSI was successful in decreasing pain, increasing muscle cross sectional area, and improving motor control in elite cricket players that had previously experienced low back pain. This is a great example of how neuromuscular re-education using RUSI works for the patient when the therapist is using it as both an assessment tool, as well as a biofeedback tool.

So far the limiting drawback of RUSI is the cost of the ultrasound unit. However, companies are constantly coming out with more affordable units making this useful tool more available for clinics. If you are interested in learning more about using US imaging as both an assessment and biofeedback tool join me in Seattle this May for a course that addresses the use of Rehabilitative Ultrasound Imaging in conjunction with a specific stabilization program.

References:

Giggins, Persson, Caulfield. Biofeedback in Rehabilitation. Journal of Neuroengineering and Rehabilitation.2013; 10:60.

http://www.biomedcentral.com/content/pdf/1743-0003-10-60.pdf

 

Grooms, Grindstaff, Croy et al. Clinimetric Analysis of Pressure Biofeedback and Transversus Abdominis Function in Individuals With Stabilization Classification Low Back Pain. JOSPT.2013; 43(3):184-193

http://www.jospt.org/doi/abs/10.2519/jospt.2013.4397

 

Hides, Stanton, Wilson et al. Retraining motor control of abdominal muscles among elite cricketers with low back pain. Scand J Med Sci Sports.2010; 20: 834-842.

http://www.ncbi.nlm.nih.gov/pubmed/19804578

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