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HARNESSING THE DIAPHRAGM/PELVIC FLOOR PISTON FOR REHAB AND FITNESS Julie Wiebe, BSC, MPT www. HARNESSING THE DIAPHRAGM/PELVIC FLOOR PISTON FOR REHAB AND FITNESS Julie Wiebe, BSC, MPT www. juliewiebept. com

Pre and Post • • Photo of your partner Assess alignment Assess breathing pattern Pre and Post • • Photo of your partner Assess alignment Assess breathing pattern Rate your knowledge/skills in training core stability in your clients from 1 – 5 (5 is the highest)

Where We’re Headed Where We’re Headed

Foundation of Our Physical House Foundation of Our Physical House

The Unstable House • • • Local Remote Poor posture Agility/Performance Incontinence/Prolapse The Unstable House • • • Local Remote Poor posture Agility/Performance Incontinence/Prolapse

Zoe 101 Zoe 101

Anticipatory Core * • • Diaphragm Transversus Abdominis Pelvic Floor Multifidus Graphic courtesy of Anticipatory Core * • • Diaphragm Transversus Abdominis Pelvic Floor Multifidus Graphic courtesy of Lee 2001, www. discoverphysio. ca

Drafty Window or Reno Project? Drafty Window or Reno Project?

Pelvic Foundation: Tug O’ War Anchor = Pelvic Foundation: Tug O’ War Anchor =

Webinar Extras: Tug O’ War Demo For a visual demonstration of the Tug O’ Webinar Extras: Tug O’ War Demo For a visual demonstration of the Tug O’ War concept please pause the webinar and visit http: //youtu. be/h. AXvw. TI 02 qo

Integration * Stability that is responsive to the demands of function § § § Integration * Stability that is responsive to the demands of function § § § Teamwork Alignment Preparation Graphic courtesy of Lee 2001, www. discoverphysio. ca

Integration * Stability that is responsive to the demands of function § Teamwork Graphic Integration * Stability that is responsive to the demands of function § Teamwork Graphic courtesy of Lee 2001, www. discoverphysio. ca

Teamwork The Core Machine • • Machine only works if all gears work together. Teamwork The Core Machine • • Machine only works if all gears work together. Gears must move or the machine will fail.

Webinar Extras: Gear Demo Webinar Extras: Gear Demo

Teamwork • • • Postural and Respiratory Functions of the PFM Hodges, Sapsford, Pengel Teamwork • • • Postural and Respiratory Functions of the PFM Hodges, Sapsford, Pengel (2007) PFM followed respiratory cycle (ant, not post) PFM expiratory activity more associated with abs (low-level tonic activity w/bursts at mov’t frequency) PISTON

Webinar Extras: Piston Demo Webinar Extras: Piston Demo

Teamwork • • Contraction of the PFM During Abdominal Maneuvers Sapsford and Hodges (2001) Teamwork • • Contraction of the PFM During Abdominal Maneuvers Sapsford and Hodges (2001) 3 levels of Ab contraction Consistent inc in PFM before Ab pressure (PF inc w/Ab force)

Teamwork Changes in IAP during Postural and Respiratory Activation of the Human Diaphragm Hodges Teamwork Changes in IAP during Postural and Respiratory Activation of the Human Diaphragm Hodges et al (2000):

Teamwork Teamwork

Webinar Extras: Question Participant Question: How does a Hysterectomy impact the ability to generate Webinar Extras: Question Participant Question: How does a Hysterectomy impact the ability to generate Intra-abdominal pressure (IAP)?

Integration * Stability that is responsive to the demands of function § § Teamwork Integration * Stability that is responsive to the demands of function § § Teamwork Alignment Graphic courtesy of Lee 2001, www. discoverphysio. ca

Alignment The Core Machine only works if all gears line up. Alignment The Core Machine only works if all gears line up.

Alignment • • • Muscles are strongest at the midpoint of available ROM. Muscles Alignment • • • Muscles are strongest at the midpoint of available ROM. Muscles are weakest when long or short. Neutral Pelvis and Ribcage alignment (ribcage over pelvis) puts the Core in midrange positioning.

Alignment Different Ways to Balance the Spine Claus et al (2009): • Flat, Long Alignment Different Ways to Balance the Spine Claus et al (2009): • Flat, Long Lordosis, Short Lordosis, Slump • Short Lordosis best activity for TA and Multifidus • Flat-Least***

Webinar Extras: Question Participant Question: Can you demonstrate the difference between slump and flat? Webinar Extras: Question Participant Question: Can you demonstrate the difference between slump and flat?

Alignment Sitting Postures Affects PFM Activity in Parous Women Sapsford et al (2006) • Alignment Sitting Postures Affects PFM Activity in Parous Women Sapsford et al (2006) • • Slump, Upright Unsupported, and Very Tall Unsupported (thoracic) Increased resting activation of PFM as alignment improved

Alignment Neutral Rib Cage and Pelvis § § Position of optimum Core recruitment Move Alignment Neutral Rib Cage and Pelvis § § Position of optimum Core recruitment Move toward neutral

Integration * Stability that is responsive to the demands of function § § § Integration * Stability that is responsive to the demands of function § § § Teamwork Alignment Preparation Graphic courtesy of Lee 2001, www. discoverphysio. ca

Preparation Neuromuscular Strategy: Preprogrammed motor control system, engaged through nervous system. The sensory system Preparation Neuromuscular Strategy: Preprogrammed motor control system, engaged through nervous system. The sensory system feeds information to create a graded response. Anticipatory vs. Reactive: Prepares for task vs. engaged based on demands of task

Preparation Transverse Abdominis is not Influenced by the Direction of Arm Movement Hodges et Preparation Transverse Abdominis is not Influenced by the Direction of Arm Movement Hodges et al (1997) • • TA EMG increased prior to deltoid regardless of UE direction EMG of superficial abdominals varied with movement direction

Preparation • • • Contraction of the Human Diaphragm During Rapid Postural Adjustments Hodges Preparation • • • Contraction of the Human Diaphragm During Rapid Postural Adjustments Hodges et al (1997): Same result for the Diaphragm Anticipatory contraction occurred regardless of phase of respiration Same result for elbow motions, not hand or digits

Preparation • • Postural and Respiratory Functions of the PFM Hodges et al (2007): Preparation • • Postural and Respiratory Functions of the PFM Hodges et al (2007): Same result for the pelvic floor Pelvic floor preceded the abdominals

Integration Build a clinical model that: • • • Teamwork: All gears moving Alignment: Integration Build a clinical model that: • • • Teamwork: All gears moving Alignment: Optimized Preparation: Strategy

Core Redefined CORE STRATEGY: NEUROMUSCULAR CORE EXERCISE: MUSCULOSKELETAL Core Redefined CORE STRATEGY: NEUROMUSCULAR CORE EXERCISE: MUSCULOSKELETAL

Core Strategy: Diaphragm/Pelvic Floor • • Sets up IAP for inspiratory stability Creates elastic Core Strategy: Diaphragm/Pelvic Floor • • Sets up IAP for inspiratory stability Creates elastic loading on PF and TA for expiratory stability Avoids overuse of superficial abs Umbrella breaths preserve alignment

Core Exercise: TA/Multifidus • • • Disrupts IAP Disrupts alignment Poor exercise form Leads Core Exercise: TA/Multifidus • • • Disrupts IAP Disrupts alignment Poor exercise form Leads to abdominal overuse, compensations, breath holding, etc. Dysfunctional timing of PF recruitment

Core Strategy Changes in IAP during Postural and Respiratory Activation of the Human Diaphragm Core Strategy Changes in IAP during Postural and Respiratory Activation of the Human Diaphragm Hodges et al (2000):

Core Strategy: Defined Core Strategy is a system that harnesses the neuromuscular relationship that Core Strategy: Defined Core Strategy is a system that harnesses the neuromuscular relationship that exists between the Anticipatory and Reactive Core. A cascade of force from the inside-out that provides both the stability and flexibility required to respond to the task at hand.

Questions? Questions?

Core Dysfunction Core Dysfunction

Core Dysfunction = PF Dysfunction • • • Central instability Alignment disorders Gait dysfunction Core Dysfunction = PF Dysfunction • • • Central instability Alignment disorders Gait dysfunction Balance deficits Upper and lower quarter musculoskeletal imbalances Gap to fill: Present as a LB, hip, neck, shoulder

PF Dysfunction = Core Dysfunction • • Incontinence Pelvic Organ Prolapse Post-prostatectomy Dyspareunia “Women’s PF Dysfunction = Core Dysfunction • • Incontinence Pelvic Organ Prolapse Post-prostatectomy Dyspareunia “Women’s Health” MSK co-morbidities Functional re-training

Pelvic Floor Dysfunction Redefined • • Women experience more pelvic floor issues than men Pelvic Floor Dysfunction Redefined • • Women experience more pelvic floor issues than men (Core component) Both can be impacted

Core Dysfunction Gender Neutral • • Pain Posture Core Dysfunction Gender Neutral • • Pain Posture

Core Dysfunction Gender Neutral • Pain Core Dysfunction Gender Neutral • Pain

Gender Neutral: Acute Pain Experimental Muscle Pain Changes in Feedforward Postural Responses of the Gender Neutral: Acute Pain Experimental Muscle Pain Changes in Feedforward Postural Responses of the Trunk Muscles Hodges et al (2003) • • TA had immediate delay and decrease in amplitude Variable response from the other trunk muscles (*lost their anchor)

Gender Neutral: Chronic Pain Why Do Some Patients Keep Hurting Their Back? Mac. Donald Gender Neutral: Chronic Pain Why Do Some Patients Keep Hurting Their Back? Mac. Donald et al (2009) • • • Short (SM) and long multifidus (LM) responses Controls and non-painful side of LBP demonstrated SM first Delay of SM on painful side of LBP group

Core Dysfunction Gender Neutral • • Pain Posture Core Dysfunction Gender Neutral • • Pain Posture

Gender Neutral: Posture • • PFM Activity in Diff. Sitting Postures in Continent and Gender Neutral: Posture • • PFM Activity in Diff. Sitting Postures in Continent and Incontinent Women Sapsford et al (2008): Upright unsupported vs Slump Both Incontinent and Continent had inc in PFM, IO, & TA in UU Continent had greater lumbar lordosis ”Prolapse greater kyphosis”

Core Dysfunction Venus vs Mars Core Dysfunction Venus vs Mars

Venus vs Mars Venus vs Mars

Venus vs Mars • • • Puberty: Distinct physical differences begin Girls: Bony pelvis Venus vs Mars • • • Puberty: Distinct physical differences begin Girls: Bony pelvis and pelvic floor broaden at puberty Boys retain conical shape and contractility

Venus • • Broader, more shallow pelvis Lower center of mass Shorter legs Quad Venus • • Broader, more shallow pelvis Lower center of mass Shorter legs Quad dominance Hamstring deficits Increased genu valgum Increased tibial torsion

Venus vs Mars • • • ACL non-contact tears Pregnancy/Postpartum Menopause Venus vs Mars • • • ACL non-contact tears Pregnancy/Postpartum Menopause

Venus vs Mars • ACL non-contact tears Venus vs Mars • ACL non-contact tears

Venus Hits Puberty Girls are 2 -4 x (5 -10 x) more likely to Venus Hits Puberty Girls are 2 -4 x (5 -10 x) more likely to experience an ACL non- contact injury than boys

Venus Hits Puberty “Progress in women’s sports will halt if this issue is not Venus Hits Puberty “Progress in women’s sports will halt if this issue is not aggressively confronted” Warrior Girls by Michael Sokolove

Venus Hits Puberty Deficits in Neuromuscular Control of Trunk Predict Knee Injury Risk Zazulak Venus Hits Puberty Deficits in Neuromuscular Control of Trunk Predict Knee Injury Risk Zazulak et al (2007) • • Trunk displacement, proprioceptive repositioning errors, and history of low back pain predictive in females Only history of low back pain predictive in males

Venus Hits Puberty • • • Girls lack a “neuromuscular spurt” at puberty-Hewitt Females Venus Hits Puberty • • • Girls lack a “neuromuscular spurt” at puberty-Hewitt Females have increased frontal plane motion and valgus torque ( hip internal rotation) at landing. Lephart Why?

Venus Hits Puberty Programs are now addressing mounting evidence of poor neuromuscular control • Venus Hits Puberty Programs are now addressing mounting evidence of poor neuromuscular control • LE neuromuscular control through balance, single leg stability, plyometrics, and sport specific agility drills • Hip strengthening, pronatory control (LE kinetic chain) •

Evidence to Consider • • • Pelvic floor changes at puberty diminish pelvic stability Evidence to Consider • • • Pelvic floor changes at puberty diminish pelvic stability Pelvic stability facilitates control of the pelvic-hipknee complex at landing Pelvic stability contributes to core/trunk stablity

Evidence to Consider • • • Breast development! Structural shift of rib cage to Evidence to Consider • • • Breast development! Structural shift of rib cage to accommodate breast growth Diminished diaphragm capacity to set up IAP stability system

Future Research Questions? • • Could alignment be predictive of knee injury risk? Could Future Research Questions? • • Could alignment be predictive of knee injury risk? Could Zazulak’s markers be predictive of incontinence? Could neuromuscular re-ed programs that integrated the pelvic floor successfully reduce knee injury risk? Incontinence in elite athletes?

Venus vs Mars • • ACL non-contact Pregnancy/Postpartum Venus vs Mars • • ACL non-contact Pregnancy/Postpartum

Venus Has A Baby Three out of four Core muscles are directly impacted by Venus Has A Baby Three out of four Core muscles are directly impacted by pregnancy (damage not only due to delivery!)

Venus Has A Baby • Respiratory Diaphragm: Descent compromised • Transversus Abdominis: Stretched out Venus Has A Baby • Respiratory Diaphragm: Descent compromised • Transversus Abdominis: Stretched out rubber band • Pelvic Floor: Lengthens to hold 14 -24# • Multifidus: Tends to be preserved

Venus Has A Baby • • Muscular changes Structural changes Soft tissue adaption Hormonal Venus Has A Baby • • Muscular changes Structural changes Soft tissue adaption Hormonal changes

Venus Has Back, Hip, Knee…. Pain • • • Core dysfunction Muscular length and Venus Has Back, Hip, Knee…. Pain • • • Core dysfunction Muscular length and strength changes Compensation patterns Poor recovery strategies Poor fitness strategies Injury vulnerability

Future Clinical Considerations • • • Pelvic floor dysfunction is rarely considered as a Future Clinical Considerations • • • Pelvic floor dysfunction is rarely considered as a contributing factor in knee, hip, shoulder, jaw, cervical, etc. pain A new clinical model of inclusion must emerge. Clinical Tip: Add to intake; red flags for referral

Venus vs Mars • • • ACL non-contact Pregnancy/Postpartum Menopause Venus vs Mars • • • ACL non-contact Pregnancy/Postpartum Menopause

Venus Has Hot Flashes Common Co-morbidities • • • Balance deficits Incontinence Common denominator: Venus Has Hot Flashes Common Co-morbidities • • • Balance deficits Incontinence Common denominator: Pelvic Floor dysfunction

Venus Has Hot Flashes Is Balance Different in Women with and without Stress Urinary Venus Has Hot Flashes Is Balance Different in Women with and without Stress Urinary Incontinence Smith et al (2008) • • Greater COP displacement in SUI group Both groups had greater COP displacement w/full bladder

Venus Has Hot Flashes Effectiveness of Multidimensional Exercises for the Treatment of SUI in Venus Has Hot Flashes Effectiveness of Multidimensional Exercises for the Treatment of SUI in Elderly Community-Dwelling Japanese Women: Kim et al (2011) • Treatment group: 44. 1% reduction of UI ( 39. 3% retained at 7 -mo f/u)

Venus Has Hot Flashes Integrated Balance: • • • Sensory Musculoskeletal Neuromuscular Venus Has Hot Flashes Integrated Balance: • • • Sensory Musculoskeletal Neuromuscular

Venus Has Hot Flashes Role of the Medullary Reticular Formation in Relaying Vestibular Signals Venus Has Hot Flashes Role of the Medullary Reticular Formation in Relaying Vestibular Signals to the Diaphragm and Abdominal Muscles Mori et al (2001) The Diaphragm receives input from the vestibular nuclei via the brain stem

Balance/Incontinence Win-Win Trunk Stability • Mainstay of balance programming • Applying IAP Piston/Core Strategy Balance/Incontinence Win-Win Trunk Stability • Mainstay of balance programming • Applying IAP Piston/Core Strategy will optimize central stability and pelvic floor function

Balance/Incontinence Win-Win Foot Intrinsic Weakness • Mainstay of balance programming • Share nerve roots Balance/Incontinence Win-Win Foot Intrinsic Weakness • Mainstay of balance programming • Share nerve roots (S 2, S 3) • Integrate these linked system to enhance responsiveness foot and trunk stabilizers in a balance chllenge

Lifespan Balance Dysfunction DIZZY MOMMY BOOT CAMP Lifespan Balance Dysfunction DIZZY MOMMY BOOT CAMP

Future Research Questions? Would a more supple, functional pelvic floor be more responsive to Future Research Questions? Would a more supple, functional pelvic floor be more responsive to medical/hormonal interventions, maintain elasticity, maintain continence, reduce falls, age related joint issues? • Imagine if we normalized the pelvic floor at puberty! •

Questions? Questions?