yoga during pregnancy

Creating Central Stability - The Role of the Pelvic Floor and Deep Core Muscles

By: 
Erson Religioso III, DPT, FAAOMPT

“Trust that the body is a self-righting organism. Our job is to guide the process.” Norene Christesen, PT

The following interview with Julie Wiebe, PT is excerpted from a longer article first appearing on themanualtherapist.com.

Q. Tell us a little about yourself and how you transitioned from a sports PT to a women's health PT specializing in pelvic floor health?

I practiced in orthopedics and sports medicine with recreational and professional athletes until I had my first child almost 11 years ago. During the pregnancy I remember having the conscious, and very arrogant, thought that if anything went wrong with my body during the pregnancy or after I would just fix it. I was quickly humbled by the physical challenge of recovery and the sense that something just wasn’t right inside my body after I had my daughter. I recognized that if I was having trouble recovering with my professional background, the climb for other women had added challenge. 

So, I began to investigate what happens to a woman’s body during pregnancy and beyond. The “core” was just coming on the scene around then, and it was clear that the loss of connection with the deep core elements was a critical and underlying issue for many of the typical pregnancy and post-partum complaints. The pelvic floor is a part of that core system, so there was an existing, natural link between the women’s health and the “core crazy” sports medicine worlds. Bringing those two worlds together became my passion, and my clinical niche became helping women across the lifespan recover from injury and pregnancy and return to fitness and sport. What I have learned from helping women rebuild a solid central foundation, can be applied in multiple populations, because everyone needs a central stability for efficient, effective and powerful movement and fitness. (Please note: I don’t like to use the word “core” anymore…means too many different things to different people. So I use words now like foundation, central stability, postural control, and sturdy anchor.)

What I have learned along the way about how our foundation functions has led me to a systems model for creating central stability. This involves working towards a balance of the brain, the neuromuscular, musculoskeletal, structural, postural, and sensory systems. I start at the center for all my patients, reorganizing that foundation through an integration of those systems and build movement and sport specific patterns from there. In other words, I work from the inside-out and love the integrative principle “If they fire together, they wire together.”

Once we have re-established and optimized that foundation, then I see what is left to handle with my manual skills. In many cases, there is not much left to work out. IMHO that tight muscle, stuck joint or whatever we see or feel that we want to address with our manual skills got that way somehow. So I try to figure out how it got that way first, before I apply my manual skills. Otherwise, I can manual therapy it ‘til I am blue in the face, but it will likely come back because I have never addressed the reason it got that way in the first place. I just like to begin with seeing what the body and brain can do for itself first, my job is to create the right environment to allow that. A practitioner that attended one of my courses, summarized that thought beautifully: 

“Trust that the body is a self-righting organism. Our job is to guide the process.” Norene Christesen, PT, DSc, CLT, OCS, President Wyoming Chapter APTA

Q. Why is the diaphragm and pelvic floor important for not only women's health but all populations?

What we have come to understand as research has evolved is that all four muscles of the deep core, diaphragm, TA, pelvic floor and multifidus, work together as a team to provide the muscular support and regulate the intra-abdominal pressure that contribute to setting up a sturdy center (not just the TA and multifidus). They actually interact like a piston. On inhale the diaphragm lowers, and the TA and pelvic floor need to give, or open to allow this to happen. This builds IAP, which gives us inhalation stability and elastically loads the TA and pelvic floor. On exhale when the diaphragm rises, and the pressure is relieved, the TA and pelvic floor use that elastic loading and recoil up and in to more actively contribute to central stability. It is a dynamic interplay between these moving parts that gives stability that is also dynamic and responsive to the demands of function. This is a great study that demonstrates that relationship: http://1.usa.gov/1ibumrS . For a visual, I demonstrate their pistoning interrelationship here: http://bit.ly/1nlybxF . So our stability system actually runs off the breath cycle, how cool is that! And the pelvic floor is parallel in its action to the diaphragm, they work together, so it is important that clinicians know how to integrate them along with the TA and multifidus into their programming for stability, strengthening, balance, etc.

Let’s bring this home in another way, and link my thoughts from question 2 to these ideas. Here is an interesting study (http://1.usa.gov/MgTBOf ) that created an asymmetrical activation of the pelvic floor and noted significant displacements of bony landmarks, with the largest displacements being of the femoral head, the innominate and coccyx on the same side. Applying that clinically, a patient may be utilizing their PF asymmetrically leading to what we might assess as a pelvic obliquity for example. Instead of addressing it with our hands first, we can teach the patient to optimize recruitment of the PF in a proper relationship with the diaphragm and restore a more balanced recruitment pattern. Building movement patterns on that improved recruitment will help with carry over and reinforce the balance. Then we see what is left to address with our hands. And the flip side of that, is if we have imposed some increased movement or alignment with our hands, then the pelvic floor is uniquely positioned to help maintain it if we can teach our patients to access it and use it with it’s functional partners. The pelvic floor is a very powerful (and currently underestimated) ally in our care of musculoskeletal issues. 

Q. Closing thoughts?

As I re-read my answers, particularly the one about using the PF to address pelvic obliquity, likely many readers thought: I’ll use my manual acumen to get it organized and then send them out to a women’s health therapist for that pelvic floor stuff. I just wanted to let you know that I am not a classically trained women’s health therapist, I don’t do internal. I evaluate the participation and responsiveness of the pelvic floor externally, and so can you. The pelvic floor is part of the system we use to stabilize our centers and it is a part of every move that we make. As therapists it behooves us to understand this muscle group as just that, a muscle group. It isn’t scary or oogey. It is an ally. Please note, there are circumstances that absolutely require a referral to a women’s health specialist (I refer out too!). But I think we have too much evidence for the physical therapy community to continue to set the pelvic floor aside from all of our other strengthening, movement patterning, and training programs. Time to see the pelvic floor in a new light.

This article is excerpted from an interview that first appeared on  www.themanualtherapist.com