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A Case Study in Breathing Mechanics and the Pelvic Floor

;Aparna Rajagopal, PT, MHS is the lead therapist at Henry Ford Macomb Hospital's pelvic dysfunction program, where she treats pelvic rehab patients and consults with the sports therapy team. Her interests in treating peripartum patients and athletes allowed her to recognize the role that breathing plays in pelvic dysfunction. She has co-authored the course, "Breathing and the Diaphragm: Pelvic and Orthopedic Therapists", which helps clinicians understand breathing mechanics and their relationship to the pelvic floor.

A few months ago a young woman with a diagnosis of dyspareunia was referred to me. She had been a gymnast through her teens and now worked out regularly. She reported being unable to use tampons throughout her life, experiencing difficulty with undergoing pelvic examinations, and inability to have intercourse with her partner all through her married years. She also had a history of long-standing constipation and urinary symptoms including increased voiding frequency and the feeling of incomplete emptying.

Her examination included significant overactivity of her abdominals. A very chest dominant pattern of breathing with very limited lower lateral costal expansion, limitations in thoracic mobility, a fairly rigid rib cage with a very narrow infra sternal angle, connective tissue restrictions of the abdominal, pelvic areas, decreased flexibility of her hamstrings, and weakness of her Glut Max muscles. There was significant guarding and an internal assessment of pelvic floor muscles was not performed initially due to associated discomfort.

Throughout the first few sessions, we worked on releasing her first rib, the scalenes, latissimus dorsi, and quadratus lumborum muscles, and worked on reducing the connective tissue restrictions in the abdominal and pelvic regions. We also spent time improving rib cage and thoracic spine mobility and reducing the chest dominant pattern of breathing; while trying to establish improved abdominal compliance and lateral costal expansion with inhalation. All this, along with techniques aimed at improving neuromuscular control of her Gluteus Maximus without excess compensatory pelvic floor muscular assistance led to enough improvement in a few sessions to allow for an internal pelvic floor muscle assessment to be performed.

The patient's job activities required constant vocalization and I found that she contracted her neck, her abdominal, and pelvic floor muscles very strongly with any vocalization and did not relax the muscles after she finished vocalization. The patient was educated on softening her vocalization, and on a more controlled release of air through the glottis with more gradual abdominal and pelvic floor contractions while performing glottal/vocalization exercises. The patient was very keen on continuing her fitness-related activities through all of her therapy. Manual internal pelvic floor muscle assessment performed with standing activities revealed that although she did not particularly find her workout routine very taxing she tended to exhale extremely forcefully with each repetition of the exercise. This forceful exhale was naturally accompanied by very strong recruitment of her abdominals and her pelvic floor muscles, and once again there was decreased relaxation after cessation of her exercises. The treatment process involved making the patient aware of breath patterns and her gripping, nonrelaxing quality of the contractions of the pelvic floor and the abdomen and how she could gain some relaxation by utilizing her breath.

In addition to continuing to receive pelvic therapy from me, the patient consulted with Leeann, a sports-trained therapist, for 2 sessions to set up a fitness program. Leeann set up a program for the patient to strengthen her core and gluteal muscles while monitoring the pelvic floor externally. The fitness program progressed with challenging exercises in non-weight bearing and quadruped positions which were then progressed to kneeling and then standing. An important focus during the development of this program was on monitoring the patient's strength of exhaling and ensuring pelvic floor relaxation with breathwork between repetitions ensuring that there was no reverting to the old habit of gripping.

The patient's complaints for which she initially sought pelvic therapy were completely resolved. The patient's pelvic pain symptoms were resolved with treatment directed at the thorax, the breath, vocalization and the glottis, and lower extremity muscle strength. Very little time was spent on conventional manual techniques applied directly to the pelvic floor musculature.

In the Herman and Wallace course, you will learn skills to effectively assess the thorax, the diaphragm, breathing patterns, thoracic mobility inclusive of joint mobility, and myofascial connections. Come and learn how postural changes can affect the biomechanics of how the body performs and in turn affect intra-abdominal pressure. Learn easy effective strategies that will help you in your care of patients with low back pain and pelvic floor dysfunction the very next day. Hope to see you in class!

;Aparna Rajagopal will be co-teaching Breathing and the Diaphragm: Pelvic and Orthopedic Therapists on May 15-16, 20201 with her colleague Leeann Taptich. This course instructs practitioners on breathing mechanics and their relationship to the pelvic floor.

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Connecting Breath and the Pelvic Floor

Aparna Rajagopal, PT, MHS is the lead therapist at Henry Ford Macomb Hospital's pelvic dysfunction program, where she treats pelvic rehab patients and consults with the sports therapy team. Her interests in treating peripartum patients and athletes allowed her to recognize the role that breathing plays in pelvic dysfunction. She has just joined the Herman & Wallace faculty and co-authored the new course, "Breathing and the Diaphragm: Pelvic and Orthopedic Therapists", which helps clinicians understand breathing mechanics and their relationship to the pelvic floor.
Aparna was kind enough to introduce herself to us here on The Pelvic Rehab Report.

Aparna Rajagopal, PT, MHSThank you for your time Aparna! To start, tell us a little bit about yourself.
My name is Aparna. I’ve been a physical therapist for 22 years. About 16 years ago I switched focus from orthopedics to treating pregnancy and postpartum patients and that’s where my initial interest in pelvic care started. In 2006 following my pregnancy and birth of my daughter, my interest in pelvic care grew with my special interest becoming pelvic pain.

I teach and mentor the pelvic health therapists within the fairly large hospital system that I work at and collaborate with our spine center team and our sports team.

What can you tell us about this new breathing course that is not mentioned in the “course description” and “objectives” that are posted online?
Physical therapy has evolved and continues to evolve as we speak. Regional inter dependence, wherein the different systems interplay, and one structure influences another, is fascinating. No longer is the body considered and treated as independent fragmented pieces. The ‘core’ with the contribution of the Diaphragm and the pelvic floor is so much more than just the Transverse Abdominis and the Multifidus working together. Fascial restrictions of the lower abdomen and the pelvis can influence how the low back feels, thoracic stiffness can influence the interplay between the various abdominal muscles by way on their insertion into the lower ribs, musculo- skeletal pain and postural deviations can stem from incorrect breathing patterns etc.

Normal breathing rate is about 10 times every minute. Breathing incorrectly reinforces wrong movement patterns tens of thousand times a day with negative consequences on the musculoskeletal system.

This course offers an in depth look at the diaphragm from the perspective of both orthopedic and pelvic therapists and attempts to tie in the diaphragm to the thoracic spine, the ribs, the pelvic floor, the core, posture and finally the athlete.

What essential skills does the breath course add to a practitioner’s toolkit?
The practitioner will walk away with the ability to view the patient as a “whole”. It offers a different perspective on neck and back pain, posture/ alignment along with the ability to assess for and connect breathing and the diaphragm to stability/ the core, continence issues and the Autonomic Nervous System.

As therapists we already do a great job of addressing strength issues, assessing and correcting posture, mobilizing etc. You can add to your treatment options by learning how the diaphragm works in concert with other muscles (especially the abdominals) and systems, identifying breathing pattern dysfunctions and postures, and movement patterns which may be linked to breathing pattern dysfunctions. This understanding is beneficial for both orthopedic and pelvic patients.

What inspired you to create this course? What void does this new offering fill?
I have used breathing and evaluation of the diaphragm as a part of pelvic care for several years now. As the mentor for the pelvic program at my hospital, and as a part of the spine team and sports team, I work with pelvic therapists, orthopedic therapists, manual certified therapists, and sports certified therapists. Through my interactions I have come to realize that although many of the therapists are aware that the Diaphragm and breathing are important, they are unsure of how to assess for dysfunctions and address those dysfunctions. I initially started conducting classes within the hospital system. At the same time Leeann who is a sports certified therapist and holds a manual therapy certificate and I started collaborating on our patients. Using a combination of her knowledge and effective manual techniques with my pelvic care and breathing techniques we realized that along with my pelvic patients; our back and neck patients, and her sports patients were all benefitting from this combined approach. We realized along the way that we had information worth sharing with our colleagues that would benefit them in treating their patients, and started classes within the hospital system and that is how this class was born!

What was your process like creating this course?
As a trained pelvic therapist, I have incorporated and used breath and the diaphragm in my treatment for over a decade. Leeann and I have created this course using a combination of our clinical experiences, our education in our respective chosen paths of patient care, and most importantly using recent and relevant research articles from journals to guide us extensively in creating this course.

Breathing and the Diaphragm: Pelvic and Orthopedic Therapists is a new course being offered next March 27-29, 2020 in Sterling Heights, MI, and again on December 11-13, 2020 in Princeton, NJ. It is created and taught by Aparna Rajagopal, PT, MHS and Leeann Taptich, PT, DPT. Come learn how the diaphragm and breathing can affect core and postural stability through intra-abdominal pressure changes. As an integrated approach, the course looks at structures from the glottis and the cervical region to the pelvic floor and helps in understanding a multi component system that works together.

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