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1 3D Trunk Training for the Female Runner Missouri Physical Therapy Conference Spring 2018 No Disclosures Jennifer Cumming, PT, MSPT, CLT, WCS Foundational Concepts Specialty Physical Therapy Kansas City, MO Objectives 1. Understand basic anatomy of pelvic floor bony and soft tissues structures. 2. Understand basic biomechanics of pelvic floor. 3. Understand how pelvic floor activates with running for support of thorax and maintenance of continence. 4. Understand how to coordinate pelvic floor with other supporting muscles of thorax with running Linea alba anatomy Note fascial envelope formed by obliques and TrA TrA fibers form the posterior section of the rectus sheath TrA pulls across rectus sheath EO and IO fibers form anterior section of rectus sheath. Highest compliance of linea alba is longitudinal Lowest compliance is in transverse plane Inferior to umbilicus compliance is smaller transversely compared to oblique direction Do no copy without permission 1

2 Prevalence of DRA 100% of women have DRA of 2.7 cm during 3 rd trimester Mota 2014 Many DRA do not close at 8 weeks and remain unchanged at 1 year post-partum Coldron et al 2008, Liaw et al 2011 DRA can change up to 4 months after discontinuation of breastfeeding 66% of women with DRA have pelvic floor dysfunction (UI, POP, pain) Spitznagle et al 2007 Some women have diastasis of other fascial planes as well Correlation of width and load transfer failure Some women with DRA are able to produce enough force closure of lumbar and pelvis to have functional load transference with DRA Other women with same inter-recti distance (IRD) fail to regain ability to transfer forces for lumbar and pelvic stability Factor of difference is not width of linea alba but tension that can be generated across linea alba to left and right recuts abdominus mm As long as forces are sufficient to stabilize the lumbar, pelvis and thoracic spine, patient demonstrate good load transfer regardless of width of linea alba Diaphragmatic assistance with trunk control Contributes to trunk control Resting tone increased prior to peripheral movements Tonically active with sustained activity Modulates activity with respiration during peripheral activities Diaphragm attachments Xyphoid process Internal surfaces of lower 6 ribs Lumbar spine Arcuate ligament arch over psoas and quadratus lumborum Diaphragm Note how far into the thoracic cavity the diaphragm goes. The core really starts in mid-thoracic range and runs to pelvic floor. Do no copy without permission 2

3 Coordination of diaphragm and TrA TrA and diaphragm activity linked with opposing patterns TrA activity increases with expiration while diaphragm activity decreases TrA activity decreases with inspiration while diaphragm activity increases Diaphragm restrictions Hypertonicity of EO, IO, RA or ES often restrict movement of lower ribs and prevent proper diaphragmatic excursion Minimal expansion of rib cage will occur during inspiration with EO, IO, RA or ES hypertonicity With decreased diaphragmatic excursion, inspiration will occur primarily in upper anterior chest Bony Structures of Pelvic Girdle Innominates Lumbar spine Sacrum Coccyx Hip joints Stability of the SIJ Force Closure Achieved through neuromuscular control TrA, Multifidus, pelvic floor and diaphragm Anticipates movement Single leg stance, ASLR good ways to test this Form Closure Achieved through wedge shape/design of joint and weight bearing forces Sacro-iliac joint function Absorb vertical forces from the spine and transmit them to the pelvis and lower extremities Crossfitforglory.com Do no copy without permission 3

4 Long dorsal ligament Sacrotuberous ligament Runs in mediolateral direction off of PSIS Increases in tension with sacral counternutation Can be a pain generator Runs from ILA to ischial tuberosity. Increases in tension with sacral nutation Ligament is an extension of hamstring tendon Symphysis Pubis joint Sacrospinous ligament Ligament has sensory fibers and be source of pain after vaginal prolapse repairs Originates at ILA of sacrum and inserts onto ischial spine Cartilaginous joint Moves very little 1-2 mm Can move in relationship to the sacroiliac joint What is the Pelvic Floor? Group of muscles at the base of the pelvis Works alongside the abdominal and spinal muscles Coordinates with the diaphragm to control intraabdominal pressure Pelvic Floor Muscles (PFM) 1 Layer 1: Bulbocavernosus, Ischiocavernosus, superficial transverse perineal Layer 2: Deep transverse perineal, urethral sphincter, compressor urethrae Layer 3: Levator ani (Iliococcygeus, puborectalis, pubococcygeus), coccygeus, Obturator internus Do no copy without permission 4

5 Pelvic Floor Superficial layers Share common attachments at perineal body Pelvic Floor Levator ani group Share tendinous attachments with obturator internus via the arcus tendinous of levator ani (ATLA) Attach at coccyx, ilium, ischium and pubis This structural support is important for the stability of the ilium, sacrum and coccyx in relationship to the pelvic floor Abdominal pressure is transmitted to the urethra via attachment of fascia that is laterally subvesicular to ATLA and PFM, thus impacting continence Role of Obturator Internus in PFM support Synergist: PFM, abdominal wall, and hips Increased activity with running Synergistic activation of PFM may help to tense pelvic fascial layers With connection to levator ani muscle the obturator internus (OI) contracts to assist in lifting the PFM Plays important role in pelvic organ support Tendons of piriformis and obturator internus join to form a conjoint tendon before inserting on to the proximal femur and hip capsule Dias, et al. 2017, Leitner et al. 2017, Solomon 2010 Role of facial layers in continence DeLancey Hammock theory: increased intra-abdominal pressure positively affects urethral closure pressure and contributes to continence Initial phase of increased intravaginal pressure during abdominal contraction is caused by pelvic floor muscle activation Abdominal pressure is transmitted to the urethra through lateral subvesicular attachment to ATLA and PFM Endopelvic fascial tissue structure stiffens during the reflex contraction of the PFM and forms a supportive layer against which the urethra is compressed. Leitner et al Do no copy without permission 5

6 Fascial tissue for pelvic support DeLancey levels of vaginal support: Level 1: Uterosacral/cardinal ligament Vertical fibers of paracolpium are continuation of ligaments and insert into vagina and cervix Loss of Level 1 support contributes to apical prolapse Level 2: Paravaginal attachments along length of vagina Attach to superior fascia of levator ani mm and ATLA Loss of Level 2 support contributes to anterior prolapse. Level 3: Perineal body, perineal membrane, and superficial and deep perineal muscles Support distal 1/3 of vagina Anteriorly, loss of level 3 support contributes to urethral hypermobility Posteriorly, loss of level 3 support contributes to posterior wall prolapse or perineal descent Ship model of pelvic support Diaphragm to psoas to obturator internus to levator ani fascial plane Fascial plane and muscle fiber interdigitation between diaphragm and iliopsoas into obturator internus and into levator ani musculature Physiology of the pelvic floor Muscle fibers are intertwined and act as a functional unit At rest the pelvic floor has an active resting tone to maintain continence Pelvic floor muscles (PFM): are made up of 70% slow twitch, and 30% fast twitch Slow twitch muscle fibers maintain base tone while fast twitch fibers are recruited for rapid contractions Lee, D 2016, Padoa, A, 2016 Functions of the Pelvic Floor Supportive: helps to support organs and forms the bottom of the core Sphincteric: controls openings of urethra, rectum and vagina Sexual: orgasm, arousal and relaxation Stability: assists in stability of sacroiliac joint, pubic symphysis, lumbosacral, and hip joints Sump-pump: venous, lymphatic pump Herman and Wallace PF1 Pelvic floor function in breathing Inhale: burrelleducation.com Diaphragm actively contracts, and pulls down, expanding rib cage and abdomen Pelvic floor eccentrically lengthens Exhale: Diaphragm relaxes up, rib cage contracts, abdominals contract Pelvic floor contracts and lifts **It is important to note that while this an important concept to understand the pelvic floor can be trained and needs to be trained during inhale and exhale Do no copy without permission 6

7 Biomechanics of pelvic floor muscles Contraction Closes vaginal, urethral and anal openings Creates a lift of the perineum Ischial tuberosities move together Pubis and coccyx come toward each other Voluntary contraction of PFM causes elevation of PFM and abdominal viscera Elongation Opens vagina, urethral and anal openings Perineum descends Pelvis opens with widening of ischial tuberosities Coccyx and pubis move away from each other Lengthening of pelvic floor musculature eccentrically Incidence of Stress Urinary Incontinence (SUI) in female athletes Many women limit themselves from running due to SUI Prevalence: 41% in female elite athletes Highest prevalence is found in sports involving high impact activities Ground reaction forces between 1.6 and 2.5 times bodyweight have been found in running at moderate speed Assumed that those forces are also transmitted to the pelvic floor Leitner et al. 2017, Moser et al Timing of pelvic floor and running In incontinent women, the delay between heel strike and contraction of the PFM is prolonged Continent women have greater upward displacement of PFM and viscera with elevation Increases of PFM activity with higher speed can be explained by rising ground reaction forces and associated higher force demands for the PFMs PFM and Central Nervous System (CNS) role in trunk support Pelvic floor and transverse abdominus respond in a feedforward manner via CNS according to the reactive forces of trunk and increasing intra-abdominal pressure Gradual adaptation of PFM is an important factor in continence meaning as we have increased level of activity we have increased PFM and abdominal activation Luginbuehl et al 2016, Leitner et al 2017 Moser et al 2017 Gradual adaptation of PFM There is no significant change in PFM response during different intensities in women with SUI Gradual adaptation of PFM is an important factor in maintaining continence This gradual adaptation also evident with different running speeds (increased running speeds= increased PF adaptation) Luginbuehl et al. 2016, Leitner et al. 2017, Dias et al PFM reflex activity with running Reflex activity suggests stretch-shortening cycle which consists of preactivity, eccentric lengthening, and concentric contraction Eccentric lengthening is reactive and a stronger contraction can follow which allows for increased muscle strength in a shorter period of time Clinically, important to train not only PFM activation but also elongation for improved eccentric muscle control pending patient findings Luginbuehl et al Do no copy without permission 7

8 Electromyography (EMG) with eccentric vs concentric muscle activation Muscles must be electrically active during elongation or stretch of the muscle Eccentric muscle actions produce less EMG activation vs concentric muscle contractions Luginbuehl et al Normal PFM patterns on EMG with vaginal sensor Voluntary concentric PFM contraction causes cranial displacement and backward rotation of the sensor Backward rotation interpreted as compression of the bladder against the PFM and vaginal wall Eccentric PFM contractions causes caudal displacement and forward rotation of the probe Leitner et al Assessment of PFM with vaginal sensor EMG prior to heel strike In preparation of heel strike, eccentric muscle activation cause caudal translation and forward rotation accompanied with increased muscle activity on EMG Pre-activity prior to heel strike prepares the tendonmuscle system for the absorption of impact forces Eccentric phase is not triggered by heel strike but precedes it Leitner et al Assessment of PFM with vaginal sensor EMG at heel strike Upon heel strike, voluntary concentric muscle contractions causes cranial translation and backward rotation showing lift of levator ani muscles and compression of urethra Heel strike terminated the caudal displacement of PFM Heel strike initiated a quick concentric contraction Maximum backward rotation occurs between ms after heel strike No difference between continent and incontinent women with PFM displacement and rotation Leitner et al PFM activation on EMG with running Static standing: 29.6 %EMG Prior to heel strike: Eccentric lengthen occurs; Running EMG pre-activity of 72 %EMG at 50 ms prior to heel strike during running at 8km/hr After heel strike: concentric contraction occurs Increased EMG activity to 124 %EMG within 214 ms During running: max PFM activation varied per person and speed activity varied from 98 to 238%EMG and pre-activity from 72 to 136% EMG PFM activity in women and SUI PFM can activate to level higher than MVC during impact activities. PFM can increase to 200%EMG in incontinent women during running. During impact activities, incontinent women had higher PFM activity than continent women Leitner et al. 2017, Moser et al Luginbuehl et al. 2016, Leitner et al. 2017, Moser et al Do no copy without permission 8

9 EMG with changes in running speed Values higher with faster running speeds vs slower running speeds. Higher PFM activity with faster running due to reflexive and reactive force generation with running Hypothesize during 11 km/hr speed, a fast monosynaptic reflex follows the impact of initial contact Luginbuehl et al 2017 Timing of abdominal wall and PFM muscles activation During impact activities, PFM contract before other trunk muscles in continent women In incontinent women, PFM contract after other trunk muscles Time from onset of PFM activity to the onset of intra-abdominal pressure, urethral, and posterior vaginal wall pressure increases contributes to continence. PFM activation and increased urethral pressure before the increase in intra-abdominal pressure assist in maintaining continence Leitner et al. 2017, Dias et al How do we apply this to our patients? What muscles are weak? What muscles are shortened? How does this impact the pelvic floor? How do we apply this to our patients? Forward flexed posture: What muscles are weak? What muscles are shortened? How does this impact the pelvic floor? How do we apply this to our patients? Increased lumbar lordosis What muscles are weak? What muscles are shortened? Treatment How does this impact the pelvic floor? Do no copy without permission 9

10 Biomechanics squat Pelvic ring moves as one, in all planes Ischial tuberosities come away from each other Pelvic floor is eccentrically loaded as are glutes, quads, gastroc, soleus Abdominal wall and multifidus contract to stabilize Weight distribution, trunk mechanics, knee and hip Biomechanics single leg squat Pelvic ring symmetrical for weight shift and squat Core contrast for stability Hip ER, QL stance side isotonic Hip extensors, knee extensors, plantar flexors eccentrically loaded Ankle inverters, everters isotonic Trunk mechanics, weight distribution Assessment: Functional Strength Active Straight Leg Raise (ASLR) Pt. lies supine and is asked to actively raise one leg and then the other about 1 foot off table. Pt. rates difficulty of each leg, examiner watches for stability through pelvis and spine (Mens et al) Single leg stance/squat Pt. stands, holding onto a stable object for balance, balances on one leg 5 sec, then the other. Examiner watches for hip drop indicating gluteal weakness. Also this is used as a pain provocation test for pubic symphysis joint. If pt. can perform this can have them try single leg squat, watching for hip drop, hip IR, knee pronation, foot pronation, trunk flexion as compensatory movements for gluteal weakness PFM assessment To maximize PFM activation for lift and closure of urethra, the PFM must also be able to eccentrically elongate prior to heel strike Important to assess ability to both concentrically and eccentrically activate PFM for best trunk control with running Can assess with EMG or digital vaginal assessment Strengthening PFM PFM activation with cues to Bring tailbone to pubic bone or Visualize stopping passing gas and urine PFM activation should occur in conjunction with transverse abdominus (TrA) for maximum trunk control Train PFM and TrA with functional activities for muscle strength and motor control High PFM tone considerations with SUI Women with SUI have increased PFM activity on EMG. PFM hypertonicity may be contributing to SUI This subset will not respond positively to PFM strengthening protocols due to poor ability to elongate and activate PFM Relaxation or down training of PFM using biofeedback or tactile cues Contract/relax to fatigue Diaphragmatic breathing Trigger point release/soft tissue mobilization Postural and body mechanics education Good referral to PFM PT for further assessment for appropriate treatment Do no copy without permission 10

11 Treatment Strategies for PFM with Running Assess PFM on EMG while running for PFM activation prior to heel strike and with heel strike Eccentric lengthening is occurring prior to heel strike Assess trunk muscle activation strategies with running, keeping in mind the importance of timing activation of abdominal wall and PFM Feed forward system Look at ability to activate PFM with different forces to adapt to different levels of abdominal pressure and GRF Look at running speed! PFM activation in women with SUI Incontinent women have higher PFM activity than continent women during impact activities. Suggests that although women with incontinence may have reduced muscle mass and maximal ability, the activity of their PFM is greater during postural perturbations Leitner et al. 2017, Moser et al High PFM tone considerations with SUI Women with SUI have increased PFM activity on EMG. PFM hypertonicity may be contributing to SUI This subset will not respond positively to PFM strengthening protocols due to poor ability to elongate and activate PFM Relaxation or down training of PFM using biofeedback or tactile cues Contract/relax to fatigue Diaphragmatic breathing Trigger point release/soft tissue mobilization Postural and body mechanics education Good referral to PFM PT for further assessment for appropriate treatment Using Running as Treatment Running should be considered for SUI treatment options to increase reflex activity of PFM Training protocols should include involuntary reflexive muscle activity Quick changes in direction Increasing and decreasing running speeds and incline Jumping and hopping activities Remember to look at the entire system! Moser et al 2017 References Bordoni, B, Zanier, E. Anatomic connections of the diaphragm: influence of respiration on the body system. J Multidiscip Healthc. 2013; 6: Dias N, Peng Y, Khavari R, Nakib NA, Sweet RM, Timm GW, Erman AG, Boone TB, Zhang Y. Pelvic floor dynamics during high-impact athletic activities: a computational modeling study. Clin Biomech. 2017(41); Faubion SS, Suster LT, Bharucha AE. Recognition and management of nonrelaxing pelvic floor dysfunction. Mayo Clin Proc. 2012(2); Lee D. The Pelvic Girdle: An Integration of Clinical Expertise and Research. Churchill Livingstone Luginbuehl H, Naeff R, Zahnd A, Baeyens JP, Kuhn A, Radlinger L. Pelvic floor muscle electromyography during different running speeds: an exploratory and reliability study. Arch Gynecol Obstet. 2016(1); Leitner M, Moser H, Eichelberger P, Kuhn A, Baeyens JP, Radlinger L. Evaluation of pelvic floor kinematics in continent and incontinent women during running: an exploratory study. Neurourology and Urodynamics. 2017; Marques A, Stothers L. The status of the pelvic floor muscle training for women. Can Urol Assoc J.2010: 4(6); Moser H, Leitner M, Baeyens JP, Radlinger L. Pelvic floor muscle activity during impact activities in continent and incontinent women: a systematic review. Int Urogynecol J.2017; Padoa A, Rosenbaum T. The overactive pelvic floor Solomon, LB, Lee YC, Allary SA et al. Anatomy of piriformis obturator internus obturator internus, obturator externus. J Bone Joint Surg 2010; 92-8; Jennifer Cumming, PT, MSPT, CLT, WCS jenn@foundationalconcepts.net Do no copy without permission 11