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! ! ! ! ! Pilates and the Pelvic Floor: The Core of Women's Health! ! ! ! ! ! ! ! ! ! ! ! ! LeiLahni DiMeglio! BASI Comprehensive Teacher Training Course 2014! Costa Mesa, California! June 22, 2014! ! ! ! ! ! ABSTRACT! Pelvic floor dysfunction is one of the most common causes of pelvic pain. Yet for most, the condition goes unidentified and untreated. The condition of the pelvic floor is highly reliant on several muscle groups that work in coordination and balance to create trunk stability. For women, the stability and health of these muscle groups contribute to the optimal functioning of gynecological processes, continence and sexual intimacy. This paper will touch on aspects of pelvic floor dysfunction and the effect of the surrounding muscle groups. A specific Pilates program designed to regain and maintain pelvic floor stability and function for a woman diagnosed with pelvic floor dysfunction will be outlined.! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 2 ! ! ! ! Table of Contents! ! ! ! ! ABSTRACT! 2! Anatomical Overview! 4! Introduction! 5! Pelvic Floor Dysfunction! 6! Trauma! 7! Muscle Imbalance! 8! Case Study! 11! Conclusion! 14! Bibliography! 15 3 Anatomical Overview! ! The Pelvis or Pelvic Girdle (PG) is located in the center of the body and is com- prised of three fused bones (ilium, ischium and pubic bone) creating the pelvis or hip bone, along with the sacrum and the coccyx. (Figure 1)! Pelvic Girdle FIGURE 1 Laying inside the PG is the pelvic floor (PF) which is comprised of a set of interwoven muscles. These muscles are divided into three layers. ! Superficial—bulbospongiosus, ischiocavernosus and superficial transverse perinei muscles and the external anal sphincter.! Intermediate—intrinsic urethral sphincter, deep transverse perinei, and in females, compressor urethrae and the urethrovaginal sphincter.! Deep—levator ani comprimised of the illiococcygeus and pubococcygeus and the coccygeus. (Sapsford, 2004) (Figure 2)! Superior View: Deep Female Pelvic Floor FIGURE 2 4 Introduction! ! The central location of the pelvis or pelvic girdle (PG) serves as a “bridge” be- tween the lower and upper half of the body. Inside the PG, the pelvic floor (PF) - the muscles supporting the inside of the pelvis, is the only transverse load bearing muscle group in the body. The PF muscles cradle the lower internal organs, much like a hammock holds a person. In women, it encompasses and supports three important pathways: the bladder, vagina and rectum while helping the uterus and pelvic organs function. ! Pelvic floor dysfunction (PFD) is one of the most common causes of pelvic pain. The direct causes of PFD are unknown and but are likely attributed to multiple factors. The most common factors are muscle imbalance or trauma to the pelvic area. Trauma can be due to an accident, vaginal childbirth, radiation treatments and/or surgery.! Muscle imbalance and/or weakness is lack of coordination and correct firing of the of the abdominals and back extensors, in accordance with the diaphragm. These are highly dependent on PF functionality and health. All the abdominal muscles in conjunction with the back extensors contribute to stabilization of the trunk and pelvis. There is also a functional relation between the diaphragm and the PF. ! Understanding how muscle groups relate and function in a complex orchestration is key to identifying ways to prevent and rehabilitate pelvic floor dysfunction (PFD). A Pilates program designed for a female with PFD will focus on rehabilitation of these muscle groups supporting the pelvis and PF without causing additional trauma to these already vulnerable muscles and organs.! ! ! ! 5 Pelvic Floor Dysfunction! ! Pelvic floor dysfunction (PFD) can affect both men and women. It is a general term used to describe a number of conditions that may affect the urinary, reproductive, digestive, sexual and stability systems in the pelvis. It can indicate a misfire in the muscles of and around the pelvis, caused by muscular imbalance or trauma. As such, PFD may present with a wide array of symptoms and impairments. ! •! Urinary or bowel incontinence! ! •! Difficulty controlling urinary or bowel urges! ! •! Painful urination or bowel movements! ! •! Vaginal or rectal pressure! ! •! Pain with intercourse or sexual stimulation! ! •! Frequent infections (yeast, urinary tract)! ! •! Urinary urge! ! •! Constant or frequent irritation and/or pain at the vaginal opening! ! •! Genital pain! ! •! Deep pelvic pain! Most people with PFD will merely just cope with their symptoms, despite the impact on their quality of life. Others will seek help from a variety of doctors, often trying pain medications and antibiotics which do not provide any lasting relief.! Some doctors and physical therapists have begun to diagnose women with these symptoms as having PFD, concluding that their symptoms are due to problems with the muscles of the pelvic floor. (Figure 3, Healthy vs Weakened PF) Because not all health professionals recognize PFD as a condition, it is a somewhat controversial diagnosis. As a result, awareness of PFD among healthcare professionals and patients is low.! ! 6 Healthy VS. Weak Pelvic Floor FIGURE 3 Treatment solutions are dependent on which type (or the cause) of the PFD. It is important to realize that there are many different rehabilitation modalities for PFD such as bio-feedback, muscle rehabilitation, acupuncture, and pelvic physical therapy. Consulting a doctor or specialist is always advised especially when PFD is caused by trauma.! ! Trauma! Studies of Pelvic Floor Disfunction (PFD) have generally been in women as it is predominantly a female problem; trauma to the PF is most commonly attributed (but not limited) to childbirth. During a vaginal delivery, stretching of the connective tissues can cause weakening and nerve damage that leads to PFD. Other childbirth-related traumas are episiotomy, prolonged second stage labor (over an hour in second stage) or extremely heavy babies. These events can cause the nerves to stretch well past their typical abilities. Over-stretching, cutting, or ripping of the pelvic floor muscles can also cause nerve damage. ! Women having a caesarean section are at lower risk of PFD in the short term, but are still vulnerable in the long term. In these women PFD symptoms usually do not surface until peri-menopause (time before menopause) when natural estrogen levels begin to slow down. Once these levels drop, the ability to keep muscle tone is inhibited.! 7 Non birth-related traumas are injuries due to accidents, radiation treatment, infections (usually undiagnosed) or any pelvic surgery which can cause a weakening in the PF. ! ! Muscle Imbalance! Having a muscle imbalance is common in most people. It can result from several factors and everyday activities including postural adaptations, overuse due to repetitive motion or as a response to pain or injury. Correct muscle activation and the relationship between muscle groups are important in identifying imbalances and ways to correct them.! It is impossible for a single muscle or muscle group to work independently. The health of the PF is reliant and greatly effected by the strength and stability of muscles in the torso. There is a balance and coordination of the muscles that create and maintain intra-abdominal pressure for stability. They include: the pelvic floor muscles (PF), transvers abdominis (TA), multifidi (M) and the diaphragm (D). (Figure 4) ! The Pelvic Floor FIGURE 4 8 How do these muscle groups work together? An examination of correct breathing shows the inner relationship. During exhalation and inhalation continual diaphragmatic engagement is essential to the initiation of the abdominals. ! During deep exhalation, the D relaxes and lifts to ignite the deep TA. This action maintains intra-abdominal pressure on the PF while air is leaving allowing the M to remain efficiently active helping abdominal muscle engagement during exercise. (Figure 5)! Trunk Pressure: Breathing vs. Holding Breath FIGURE 5 During inhalation, the dome shaped diaphragm contracts, dropping down into the abdomen and lowering abdominal pressure so that air can be sucked into the lungs. The intercostals work to lightly stiffen the ribcage so that the air pulls down. A weak D or holding one’s breath during exertion can cause a disruption in intra-abdominal pressure as well as a lack of oxygen, which results in both muscular and emotional stress.! The back extensor muscles (including the M) are working all of the time to keep the trunk erect. These tonic muscles need to be strengthened to work efficiently in order to angle the vertebrae into optimal positions. Without actively engaging and 9 strengthening, back muscles will become rigid, weak and shorten due to overuse. If shortening occurs, the abdominals will suffer a decreased range of motion. ! Essential to trunk support is the co-contraction of back and abdominal muscles. A strong and well developed TA supports the front of the trunk and assists the M. When the TA is weak reaction signals from the D will lag, the back will become overworked and inter-abdominal pressure will not be sufficient for the PF to efficiently support pelvic organ function.! The PF works most optimally when gravity is pulling the abdomen down. If the PF is healthy, it will not matter what direction the pelvis is in to keep it stable and function properly. Weakness of the TA and M can cause PF instability and allow tipping of the pelvis. This instability combined with impact such as running, jumping or even sneezing can challenge the PF beyond its ability. A clear sign of this muscle imbalance is stress incontinence, the inability to hold urine during these activities. ! Pelvic floor muscles need to be flexible to work as part of the ‘core’, which means that they need to be able to relax as well as lift and hold. It is common for people to brace their ‘core’ muscles constantly during exercise in the belief they are supporting the spine, but constant bracing can lead to the muscles becoming excessively tight and stiff. ! Everyday tasks such as lifting, nose blowing, laughing, coughing, and sneezing recruit the D, TA, M and PF. These muscle patterns generate enough force for movement while maintaining stability and continence. If any of these muscle groups do not fire in the correct order or are without efficiently, than a multitude of troubles may occur, including incontinence. Conversely, barring any trauma when the TA, M and D are strong and coordinate, the PF will work well also.! ! 10 Case Study! ! Mary* is a 59 year old female living with incontinence for over 5 years. She like most people, was embarrassed about not being able to hold her urine. During phases of peri-menopause (the time before menopause), she started experiencing additional PFD symptoms, that prompted her to seek medical attention. Her physician recommended Pilates as a workout to “strengthen her pelvic floor”.! Mary’s is currently about 30 lbs over her ideal weight and reports lower back pain and tightness. She describes her current workout regime as “I do not like to sweat”. In her twenties she had two vaginal births with episiotomies. Childbirth, adnominal weakness and a tight M are contributors to her PFD. ! A progressive approach to muscle development using Pilates will be taken. Outlined below are sessions with goals to strengthen abdominals (TA) , back extensors (M), and PF muscles for improved bladder control and ease pelvic pain. Breath cueing and breathing is essential to increase diaphragmatic engagement and correct firing of the abdominals for optimal PF pressure and stability. This will be addressed in all sessions. Sessions 1-10 are designed to avoid abdominal overload and prevent additional weakening of the PF. The goal is to gradually build up to more abdominal engagement in Sessions 10-20. In Sessions 1-10, the focus for the M is first to lengthen then in Sessions 10-20, will correctly strengthen the M. Lastly, maintenance and strengthening will be done in Sessions 20+. 11 EXERCISE BLOCK SESSIONS 1-10! WORKOUT SESSIONS 10-20 ! WORKOUT SESSIONS 20+! WORKOUT WARM-UP! ! PELVIC CURL! SPINE TWIST SUPINE! CHEST LIFT! LEG LIFTS! LEG CHANGES MAT PELVIC CURL! SPINE TWIST SP.! CHEST LIFT ! CHEST LIFT W ROT. MAT PELVIC CURL! SPINE TWIST SP.! CHEST LIFT ! CHEST LIFT W ROT.! S. LEG STRETCH! D. LEG STRETCH FOOTWORK RFM! PARALLEL HEELS! PARALLEL TOES! V HEELS! OPEN V HEELS! CALF RAISES! PRANCES! S. LEG HEEL! S. LEG TOES RFM! PARALLEL HEELS! PARALLEL TOES! V HEELS! OPEN V HEELS! CALF RAISES! PRANCES! PREHENSILE! S. LEG HEEL! S. LEG TOES RFM! PARALLEL HEELS! PARALLEL TOES! V HEELS! OPEN V HEELS! CALF RAISES! PRANCES! PREHENSILE! S. LEG HEEL! S. LEG TOES ABDOMINALS MAT! !! ! 100 PREP! CHEST LIFT W CIRCLE! MAT! !! !! 100! D. LET STRETCH! S. LEG STRETCH! CRISS CROSS! ! 100! COORDINATION MAT! !! !! 100! CRISS CROSS! HAMSTRING PL 1! ! DD LEG STRETCH! DD LEG STRETCH W ROT MAT! RFM HIP WORK! !! MAT! RFM SPINAL ARTICULATION STRETCHES! !! ! 100 PREP !! ! BTM LIFT ! MAT! LEG CIRCLES! CORKSCREW! FROG ! CIRCLES DN/UP! OPENINGS! EXT. FROG! EXT. FROG RVS RFM FROG ! CIRCLES DN/UP! OPENINGS! EXT. FROG! EXT. FROG RVS !! !! ! MAT! RFM RFM !! ! LEG CIRCLES! CORKSCREW! FROG ! CIRCLES DN/UP! OPENINGS ! MAT! RFM SEAL PUPPY! OPEN LEG ROCK! ROLL UP! BTM LIFT! BTM LFT W EXT !! ! ! ROLL LIKE BALL! REST POSITION! MAT! ROLL LIKE BALL! REST POSITION! CAT STRETCH! HAMSTRING ST. RFM KNEELING LUNGE! SIDE SPLIT !! ! MAT! FRONT SUPPORT! RFM! SCOOTER! RFM- REFORMER EXERCISES RFM !! ! MAT! SEAL PUPPY! MAT! RFM ADD. SQEEZE! LEG CIRCLES! MAT! RFM FB INTERGRAITON F/I! ! !! ! !! ! !! !! ! ! RFM SEAL PUPPY! ROLL UP! OPEN LEG ROCK! TEASER PREP! BTM LIFT! BTM LFT W EXT! SHORT SPINE !! !! ! MAT! RFM ROLL LIKE BALL! REST POSITION! CAT STRETCH! KNEELING LUNGE! FULL LUNGE! SIDE SPLIT !! ! MAT! LEG PULL FRONT! BACK SUPPORT! MAT! LEG PULL FRONT! LEG PULL BACK! RFM ELEPHANT ! UP STRETCH 1 RFM! (knee stretc h) ROUND BACK ! FLAT BACK! RVS. KNEE STRETCH MAT- MAT EXERCISES 12 EXERCISE BLOCK ARM WORK! SESSIONS 1-10! WORKOUT MAT (magic circle)! !! ! RFM supine SESSIONS 10-20 ! WORKOUT SESSIONS 20+! WORKOUT BENT ARMS! STRAIGHT ARMS! ARMS OVERHEAD! S. ARM BICEP! S. ARM SIDE PRESS! MAT (magi c circle)! BENT ARMS! STRAIGHT ARMS! ARMS OVERHEAD! S. ARM BICEP! S. ARM SIDE PRESS! EXTENSION! ADDUCTION! CIRCLES UP/DN! TRICEPS RFM! (sit) CHEST EXPANSION! BICEPS! RHOMBOID! HUG A TREE! SALUTE MAT! (ankl e weigh ts)! SIDE LEG LIFT! FORWARD & LIFT! FORWARD DROPS! HIP ABDUCTION! HIP EXT. BENT! HIP EXT. STRT! MAT! (ankl e weigh ts)! SIDE LEG LIFT! FORWARD & LIFT! FORWARD DROPS! HIP ABDUCTION! HIP EXT. BENT! HIP EXT. STRT! RFM S. LEG SKATING RFM S. LEG SKATING! HAMSTRING CURL ! !! ! ! MAT (magi c circle)! BENT ARMS! STRAIGHT ARMS! ARMS OVERHEAD! S. ARM BICEP! S. ARM SIDE PRESS! !! ! RFM! (sit) CHEST EXPANSION! BICEPS! UP / DN CIRCLES! HUG A TREE! TRICEPS FB INTERGRAITON A/M! LEG WORK MAT! (magic circle)! !! ! RFM LATERAL FLEXTION/ ROTATION! BACK EXTENTION! !! MAT! RFM ! CIRCLE ANKLE! ANKLE BENT KNEE! ANKLE ST. KNEE! HAMSTRING PR.! !! ELEPHANT !! ! ! !! ! SIDE LIFTS! SIDE KICK MOD.! MAT! SIDE LIFTS ! SIDE KICK! TILT! MERMAID RFM MERMAID ! ! !! ! !! ! ! !! ! ! MAT! SIDE LIFTS ! SIDE KICK! SAW! RFM SIDE OVER (BOX) !! ! MAT! BACK EXTENSION! MAT! MAT! DD LEG KICK! S. LEG KICK! RFM BACK EXTENSION! SWIMMING! BREASTSTROKE PREP RFM BREASTSTROKE (LONG BOX) RFM PULLING STRAPS 1! PULLING STRAPS 2 ! ! ! RFM- REFORMER EXERCISES MAT- MAT EXERCISES 13 Conclusion! ! The hourglass shape of a woman’s body allows the pelvis to provide primary support for everything above it. The pelvis is the foundation upon which much of the body’s structure rests, and just as with any structure, it is crucial that this foundation be solid. When the floor of the female pelvis is compromised, either by imbalance or trauma, many things can go wrong — from painful intercourse to incontinence and PF pain. ! Mary has been very diligent about making her sessions two times per week for the last month. She takes both mat and reformer sessions designed to meet her specific needs. Though she has not reported any significant weight loss, she “feels better, stronger and lighter” with more urinary control. Her pain is less constant and she feels very encouraged by the results.! In some cases a progressive approach through Pilates rehabilitation can have great impact on the improvement of PF function and continence. Non-invasive management through the use of Pilates is a safe and effective way to overcome many pelvic floor complaints by correcting muscle imbalances. ! ! ! ! 14 Bibliography! !! ! ! BOOKS! BASI Study Guide – Comprehensive Course 2014, copyright 2000-2013 Body Arts and Science International! ! BASI Movement Analysis Workbook – Reformer, copyright 2000-2012 Body Arts and Science International! ! BASI Movement Analysis Workbook – Mat, copyright 2000-2012 Body Arts and Science International! ! Franklin, Eric. Pelvic Power. Hightstown, NJ: Eysian Editions, Princeton Book Co., 2003! ! Isacowitz, Rael, and Karen S. Clippinger. Pilates Anatomy. Champaign, IL: Human Kinetics, 2011. Print.! ! Isacowitz, Rael. Pilates. Champaign, IL: Human Kinetics, 2006. Print.! ! ! ! JOURNALS! University of Missouri-Columbia. "Comprehensive, nonsurgical treatment improves pelvic floor dysfunction in women." ScienceDaily. ScienceDaily, January 2014.! ! School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia. Manual Therapy. “Rehabilitation of pelvic floor muscles utilizing trunk stabilization.” Ruth Sapsford OB-GYN, August 2003! ! ! ! http://www.pelvicfloorfirst.org.au “The Pelvic Floor and Core” August 2013! ! ! ! All illustrations provided by Google Images! ! WEB! ILLUSTRATIONS! 15
