julie w. wiebe, pt, mpt, bsc · o pelvic rocking o ribcage elevation/depression o teeth gritting...

2016

Property of Julie Wiebe, PT. 2016. All rights reserved. Duplica@on, transfer, and/or transmission of all course videos and materials is prohibited. 1

DIAPHRAGM/PELVIC FLOOR PISTON FOR ADULT POPULATIONS: ONLINE

Julie W. Wiebe, PT, MPT, BSc www.juliewiebept.com

Module One • Concepts • Evidence • Core Function/Dysfunction

Module Two • Alignment

Module Three • Diaphragm • Breathing Mechanics

Module Four • Pelvic Floor • Transversus Abdominis

Module Five • Synergists: POS

Module Six • Synergists: AOS/LS

Module Seven • Synergists: RS • Gait

MODULE FOUR: PELVIC FLOOR/TA Julie W. Wiebe, PT, MPT, BSc www.juliewiebept.com

2016


Module Four Preparation

¨  Full length mirror ¨  One or two each: Hand towel, bath towel ¨  Pillows (2 of different thickness, and size)

¨  Selfies: •  Your standing alignment (uncorrected or perfected, please)

both a front and side view. •  Have a fried or colleague video you while taking a deep

breath (from the front, and side). •  Have a friend or colleague video you while performing a

squat, a single leg squat (both LE), and single leg stance (both LE)

Core Components

CORE

Diaphragm Pelvic Floor

Rethink Pelvic Floor Dysfunction

Postural Response of the PF and Abdominal Muscles in Women With and Without Incontinence

Smith et al. (2007)

•  3 groups continent, mildly incontinent, severely incontinent

•  Incontinent had > PF and EO than continent

•  Consider muscular interaction

•  Continent demonstrated balance, efficient, and task appropriate system

Graphic courtesy of Lee 2001, www.discoverphysio.ca

2016


Pelvic Floor

Phase-locked Parallel Movement of Diaphragm and Pelvic Floor

During Breathing and Coughing—a Dynamic MRI Investigation in

Healthy Females

Talasz et al (2011) •  Pelvic floor excursion varied but

always cranial on excursion ¨  Quiet breathing: mean 2.1 mm

¨  Forceful breathing: mean 7.0mm

¨  Coughing: mean 3.8 mm

CORE

Pelvic Floor

Pelvic Floor: Anatomy 101

Ischiococcygeus

O: Ischial spine

I: Coccyx

Levator Ani:

•  Pubococcygeus

O: Pubic ramus

I: Lower sacrum/coccyx

•  Iliococcygeus

O: Reinforced fascial band

I: Interdigitates with Pubococcygeus

•  Puborectalis

O: Pubic symphysis

I: Sling behind rectum


Urogenital Diaphragm

Anatomy 101: •  Two muscular and connective tissue

layers inferior to Pelvic Floor

•  Origin/Insertion- Pubic Symphysis (PS), Pubic Rami, Perineal Body, Ischial Tuberosity (IT), (Coccyx)

•  Perineal Body –  Interdigitates with urethral and anal

sphincters thru Transverse Perineal Muscles (Deep and Superficial)

–  Anal sphincter interdigitates with Puborectalis

2016


Pelvic Floor

Anatomy 101: Action •  Anticipatory contraction to

stabilize lumbo-sacral, SI, pelvic-hip, and PS joints

•  Force couple with multifidus to control the sacrum

•  Synergist with TA (1˚ Anterior) •  Ebbs and flows with the

Diaphragm (1-7 mm) •  Supports pelvic viscera •  Pelvic floor (slow twitch) and

urogenital diaphragm (fast twitch)

•  S2,3 nerve roots for PF and foot intrinsics


Pelvic Floor: Function

Function: •  Needs to be integrated into

Core recruitment, and functional patterns

•  Anticipatory, balanced contraction between: •  anterior/posterior •  Right (R)/Left (L)

•  Concentric/Eccentric •  Creating a motor program,

strategy, and resting tone


Pelvic Floor: Dysfunction

Dysfunction: •  Bum gripping

•  No link to the rest of Core o  No TA

o  Breath holding

•  Movement

o  Hollowing

o  Pelvic rocking o  Ribcage elevation/depression

o  Teeth gritting


2016


Pelvic Floor: Tricks

Tricks: •  Ski Jump

•  Pursed lips/open mouth

•  Turn feet in/out

•  Lift your arches

Pelvic Floor: Assessment

Palpation (With Permission Always) •  Posterior Pelvic Floor Palpation with TA •  Landmark this on your self:

•  PF: West of IT, East of anus •  TA: Bulge/Brace vs TA tensioning on

exhale •  Qualitative assessment: does it lift?

Does it lower? Does it follow diaphragm? Involuntary/Voluntary?

•  L vs. R Observation: •  Looking for appropriate motor

strategies and dysfunctional patterns •  Pelvic stability in function (single leg

squat) Documentation

Self-Palpation Demo

2016


Functional Tests: Squats

Functional Tests: Single Leg Squat

Functional Tests: Single Leg Stance

2016


Independent Pelvic Floor Standing Lab

¨  Play with the ski jump to feel how an alignment shift will elicit a response from the back half vs. front half of the pelvic floor

¨  Shift back to the middle to see if you can still maintain your connection with both halves

¨  Goal is access to both halves, use in a balance way ¨  Self-palpation ¨  Self-assess functional testing (Squat, Single Leg,

ASLR)

MODULE FOUR: FIND THE PISTON

Pelvic Floor Demo

2016


Independent Pelvic Floor Side Lying Lab

¨  Check in with alignment: Feet, Fanny and back of head aligned. Pillow between knees, and under head

¨  Gently open/melt anus to close on a red kidney bean, lift it 1cm into your body (back bean)

¨  Connect with breath cycle: Umbrella inhale, gentle belly rise, open anus, drop the bean

¨  Begin exhale through a straw: close on the bean and lift up & in 1 cm

¨  Follow this pattern as you add a 2nd bean lower and lift with vaginal opening (front bean)

¨  Inhale open, exhale close and lift = PISTONS

Independent Pelvic Floor Side Lying Lab

¨  Observe/feel for substitutions (bum grip, breath hold, abdominals)

¨  Ball squeeze to enhance closing on the beans (optional)

¨  Seated vs Side Lying may create added proprioception

Pelvic Floor: Tips

Tips 1.  Train with exhale to start. 2.  Use beans as conscious engagement,

goal is subconscious. 3.  Awareness/train the subconscious recoil;

can they feel it? (Blow before you go) 4.  Bean lift should match level of exertion,

pencil or couch? “Beans to your chin”. 5.  Cue asymmetrically if needed. “Lift

your right bean”. 6.  Eventually train on inhale as well. 7.  If you cannot palpate a PF

engagement, check alignment, check breath, or “hypervigilant”

Demo Sitting Piston Posture

2016


Core Components

CORE

Diaphragm

Pelvic Floor

TA

Transversus Abdominis

Anatomy 101:

Origin: •  Thoracodorsal fascia •  Lower 6 ribs •  Interdigitates with costal fibers

of the diaphragm

Insertion: •  Upper and middle fibers blend

with RA sheath reaching linea alba in midline

•  Inferior fibers blends with insertion of IO at pubic crest

Transversus Abdominis

Anatomy 101: Action

•  Anticipatory contraction to stabilize the spine

•  Expiratory muscle at the end of an extended exhale

•  Synergist with PF (anterior) •  Physical link between thoracic

cage-spine-pelvis •  Deepest abdominal: leverage •  Control fxn, not movement fxn •  Flattens abdomen •  Cinches waist •  Slow twitch, becomes fast twitch

in presence of dysfunction

2016


Transversus Abdominis: Function

Function

•  Preparatory contraction •  Slow tensioning •  Abdomen will flatten or

descend •  Concentric with expiration •  Eccentric with inspiration Dysfunction •  Quick bulge or bracing •  Breath holding

Independent Transversus Abdominis Lab

q  Repeat brace vs. tension q  Supine, Standing or All-Fours

q  Palpate medial to ASIS or superior to PS q  Monitor response of the TA on umbrella inhale q  Monitor response of the TA to extended exhale alone q  Monitor response to TA with Piston cycle q  Play with bean lifts (full, back, front, R and L) monitor

TA response, asymmetries q  Observe for compensation

Concept Synthesis

2016


SL Squat Wk 1 vs Wk 6

Module Summary

Pelvic Floor/TA

¨  TAP ¨  Blow before you go ¨  Integration vs Isolation ¨  Subconscious/Conscious ¨  Involuntary/Voluntary ¨  Alternative assessment/interventions ¨  TA as responder

2016


Questions?

Clinical Steps

Make it Quick 1.  Current alignment (symptoms)

2.  New Core= Piston

3.  “Piston Posture”

4.  Umbrella breath

5.  Exhale “Blow before you go!”

6.  Increase patient awareness of PF

7.  Teach in sitting

8.  Put it immediately into a functional activity (arm lift, squat, yoga pose)

Core Strategy: Defined

Remember: q We are building a Strategy. q  Strategy before strength. q  Do not strengthen a dysfunctional

strategy.

2016


Homework

What’s Next…..Module Five

¨  Recruitment order: inside-out ¨  Anticipatory to reactive core ¨  Supports new strategy, alignment ¨  Q and A ¨  Posterior Oblique Synergist (POS)

julie w. wiebe, pt, mpt, bsc · o pelvic rocking o ribcage elevation/depression o teeth gritting...

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