A Literature Review

How the Stability of the Pelvic Floor Complex Affects the Lumbar Spine

By: Abigail Scheer

Faculty Advisor: Dr. Brett Winchester

18 October 2013

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ABSTRACT

This literature review explores the connection between the pelvic floor muscle complex

and the stability of the lumbo-pelvic region of the spine. The research analyzed depicts the role

of the pelvic floor musculature in the function ability of a person’s core, and how acute low back

pain can be diminished and controlled, with a reduction in the likelihood of recurring episodes, if

proper stabilization exercises and rehabilitation training are instituted. Weakness of the pelvic

floor can result from a myriad of triggers, which can be addressed by studying the operation

tactics of a person’s underlying muscle groups, and finding the correct method of improving

them.

Key Words:

pelvic floor muscles, PFM, low back pain, lumbo-pelvic instability, core stability, incontinence

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INTRODUCTION

Pain centered on the lower back is a common phenomenon in the world. It is a condition

that appears episodically and with no definite solution in sight. Eventually those thwarted with

this ailment surrender to the pain and inconvenience, feeling that even if they win the battle of

one flair-up, another incident is just around the corner. Low back pain has become a frequent and

costly diagnosis that plagues roughly 38% of the population at some point during a lifetime. It is

one of the top injuries to cause professional athletes to be benched during a match. As much as

30% of the professional athletic population has reported holding onto a low back complaint for

multiple years.1 This complaint has become so engrained in the norm of everyday culture that a

common turn of phrase when a situation goes awry or a person commits an unforgivable faux pas

is to relate it to a “pain in the butt (or lumbo-pelvic region).”

While low back pain is such a common diagnosis to be gifted, it is also one of the most

mysterious when it comes to solving the case as to what the root cause is. The lumbar spine’s lot

in life circulates around stability and mobility. This may appear to be a double edged sword of

contradictory parts. However, these roles, while they seem to be polar opposites, are actually

interdependent on one another for proper function.

Intrinsic muscle stiffness managed by the neuromuscular system and the proper function

ability of the reflex response are key players in modulating the needed joint stiffness to create

stability of the lumbar spine and sacroiliac joints.2-4

There are three sub-systems that combine to

create the stability needed for proper spine maintenance. Spinal ligaments, vertebral discs, and

osseous structures together create the passive sub-system of stability. An active sub-system is

designated by the recruitment of muscles, which is responsible for intrinsic muscle stiffness.

Finally, a neural feedback sub-system is comprised of responses that are both reflexive and

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voluntary.4 Therefore, proper muscle function and co-contraction is critical for sufficient

stiffness to adequately stabilize the spine.

The transversus abdominus and multifidus muscles are the local muscles of the lumbar

segments of the spine. These muscles that are deeply rooted to the spine co-activate with the

diaphragm and pelvic floor muscles to control spinal stability.5 Deficits in the motor function of

these core muscles, which cause a stall in the feed-forward contraction mechanism of the local

muscles, have been found to be present in patients suffering from low back pain.5

Core stability is a popular trend in the world of physical fitness. The goal of abdominal

muscles that resemble a six pack is at the top of many wish lists. However, the abdominal

muscles are but a single component of the human core. Thinking of the core as a box, the top

would be the diaphragm, the walls would be the superficial and deep abdominal muscles, and the

bottom would be the pelvic floor complex.1 These muscle groups must interact in a synergistic

relationship to develop optimal core stabilization, and in turn appropriate balance of the lumbar

spine.

For years, studies have been conducted to research the significant role pelvic floor

muscles play in the maintenance of continence. However, only in recent years have researchers

begun to conduct studies to answer questions regarding the many hats of function the pelvic floor

muscle complex wears, and the team members it must interact with to complete its tasks. Proper

diaphragmatic breathing and the ability to engage the transversus abdominus and internal

obliques all contribute to the feed-forward mechanism of the pelvic floor muscles. The complex

of muscles creating the pelvic floor serve as controllers of continence and monitors of intra-

abdominal pressure, but growing research and explorations in rehabilitation have determined that

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these muscles also stabilize the lumbo-pelvic spine and provide adequate stiffness for the

sacroiliac joints when acting in accordance with one another.6

This review of current literature explores in particular the role of pelvic floor musculature

in the stability of the lumbar spine. However, in order to accomplish this task, one must also

investigate the reliance of the pelvic floor muscles on diaphragmatic breathing and ideal

engagement of the superficial and deep abdominal muscles. Through the study of the ideal

function of this complex, what can go wrong when weaknesses strike, and how to repair the

vulnerabilities that act as both instigators and results of damage, this review will encompass the

character of the pelvic floor.

METHODS

The research database available through the Logan College of Chiropractic Learning

Resources Center was employed for this literature review. Specific search engines utilized to find

appropriate articles included PubMed and Google Scholar. The search terms included when

hunting for suitable sources were as follows: pelvic floor muscles, PFM, low back pain, lumbo-

pelvic instability, core stability, and incontinence. This research was collected between the

months of March and July in the year of 2013.

DISCUSSION

Pelvic Floor Complex and Respiration:

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An average respiratory rate for an adult is 12 breaths per minute, totaling to roughly

17,000 breaths each day. The seemingly simplistic, yet vital, task of respiration is actually quite

complex, requiring the coordination of multiple muscle groups and a well-developed postural

structure to accomplish this chore. The act of inhalation causes the diaphragm to move inferiorly,

creating a negative pressure zone in the thorax. This, in turn, causes the ribs to rotate externally

and the lumbar spine to move anteriorly and superiorly.1

When coordination and structural balance are lacking, suboptimal respiratory patterns

result. Air is not drawn in as efficiently under sub-par breathing capabilities and the abdominal

muscles are forced into excessive relaxation during inspiration to create the necessary expansion

of the thorax. These short-comings result in shallow respiration that is concentrated in the upper

chest, rather than the thoraco-abdominal region.1 This less than ideal breathing pattern, if left

unchecked for a prolonged period of time, will result in shortening of the diaphragm,

hyperinflation of the lungs, and excessive use of accessory respiratory muscles.

Improper respiration and diaphragmatic function is noted with low back pain complaints.

According to research conducted by O’Sullivan et al, individuals with pain in the lower back

experience diminished movement of the diaphragm, dropping of the pelvic floor complex, and

increased respiratory rate when transferring their load through the lumbo-pelvic region while

breathing.7 Therefore, with education of the proper coordinated control of the diaphragm, pelvic

floor, and deep abdominal muscles, improvements in respiratory patterns as well as low back

pain can be seen.

Pelvic Floor Complex and Transversus Abdominis

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J. A. Hides et al. researched low back pain based on biomechanical instability in cricket

players.8 Cricketers with low back pain complaints were found to have a lesser capability to

effectively draw in the abdominal wall, a test that is primarily utilized to note the thickness and

strength of the transversus abdominis muscle. It was also determined that the anterior abdominal

fascia had a diminished amount of slide as compared with that of asymptomatic players.

Asymmetries of quadratus lumborum and internal oblique muscles were seen in symptomatic

cricket players as well.

The transversus abdominis muscle contributes to the stabilization of the lumbo-pelvic

area by aiding in the creation and harnessing of one’s intra-abdominal pressure. Tensions of

fascia are also affected by the transversus abdominis. Those with low back pain complaints tend

to have lumbo-pelvic muscles (particularly internal obliques and transversus abdominis) that are

over-zealous in contractibility. With stabilization training, a decrease in the amount of

contraction of the internal obliques and transversus abdominis muscles was seen during

abdominal bracing activities. This, in turn, allows for an increase in the amount of intra-

abdominal pressure that can be cultivated by the core musculature.8 Rehabilitation exercises that

focus firstly on the individual contraction of the transversus abdominis have been found to be

most effective in the beginning prior to the re-instatement of higher load exercises.8 Research

shows that the transversus abdominis does create a protective environment for the lumbar spine,

solo from the rest of the abdominal muscles.9, 11

The act of “drawing-in” or bracing the abdominal wall will engage the transversus

abdominis, along with the superficial abdominal muscles. This can be carried out in a four-point

kneeling position. To create a more specific exercise and zero in on the strengthening of the

transversus abdominis on a deeper level, one must also focus on the contraction of the pelvic

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floor muscles. This alteration to a simple exercise allows for a more selective contraction of

deeper abdominal musculature.

The research conducted by Duncan Critchley with the Division of Physiotherapy at

King’s College in London found that the transversus abdominis muscle thickness increased

49.71% with abdominal bracing alone. If the pelvic floor muscles were engaged during this

“drawing-in” movement, the muscle group was found to increase in thickness by 65.81%.9 Those

with low back pain have been found to have a decreased thickening of the transversus abdominis

during low load isometric activities than those without low back pain.5 This can be attributed to

the lack of strength and stability of the pelvic floor muscles, the transversus abdominis’ partner

in contraction. Even when particular muscle groups are seen as lone rangers in the face of their

function ability and contributions to the overall operations of the core, interactions between sub-

groups are still needed for optimal performance.

Role of Pelvic Floor Complex in the Core

The musculoskeletal core is located centrally in the body so as to allow for optimal

stabilization of all mechanical segments of the being. Stability is present in the proximal most

parts of the body, in order to provide mobility and controlled force to the more distal parts.10

This set-up, known as the kinetic chain, acts much like any well-contrived plan from an athletic

team’s play book. For instance, just as a soccer player squares up his torso to create the ideal

point of contact and line of drive for a corner kick, the core’s main players of strength,

equilibrium, and kinesis allow for optimal placement of the distal segment in order to yield peak

results.10

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It is proven that a person’s core must utilize active structures in order to provide proper

stiffness and stability for the spine and evade injury.11

Any leakage of energy or control can

cause a previously stable system to falter leaving a gap for damage. When heavy loads are

quickly taken on hand, the core must be able to contain all energy and divvy it out in the proper

biomechanical manner.

Research published in 2004 by Morten Essendrop and Bente Schibye followed men and

women working as nurses in Denmark.11

This study focused on the degree of intra-abdominal

pressure engaged when one is placed in a position to lift a heavy item in a fast-paced scenario. It

was found that when a heavy load, such as a fallen patient, needs to be lifted quickly, the amount

of intra-abdominal pressure developed is higher than when lifting a smaller load. Along with this

surge in intra-abdominal pressure, comes an increase in extension torque.11

This study went as far as to separate the participants into categories, comparing the

capabilities of men versus women. It was found that while both genders increased intra-

abdominal pressure and extension torques when met with a heavy-load, men noted a higher rate

of intra-abdominal pressure growth. The women in the study were unable to activate their

abdominal muscles to the same degree as men during the Valsalva maneuver. It was also

determined that due to a woman’s build, which often includes a smaller reach than a man, she

must flex forward more than a man in order to reach her load. This decreases the extensor torque

in women. It was also hypothesized, that a woman’s pelvic floor musculature may be a limitation

to creating intra-abdominal pressure to the same extent as a man. This was found to be the case

in women who had birthed children and those who had not.11

Incontinence via Poor Control of the Pelvic Floor Muscles

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Weakness of the pelvic floor complex can be attributed to faulty posture and a loss of

neuromuscular control of the core musculature.1 These ailments have been found in those with

sacro-iliac joint pain and low back pain. These short-comings, when allowed to endure

indefinitely also have oppositional effects on respiration.1 Loss of stability in the pelvic floor

reaches beyond the bounds of musculoskeletal aches and alterations. Incontinence, pelvic girdle

pain, and prolapse are other known, yet unwelcome, consequences.

Research has proven that the pelvic floor complex is not an independent unit that stands

alone and works alone. It teams up with other deep muscle groups to bring stability and

coordination of bodily functions. However, this strategically active muscle group is often left

forgotten causing vital routines of the body to become uncoordinated and sub-par. A study

published in 2012, investigated the relationship between pelvic floor operations and

dysfunctional voiding.12

43 patients between the ages of five and 13 years old were selected to

participate in this research, and 24 of them experienced urinary incontinence. It was identified

that these neurologically normal children had a history of over activating the external urinary

sphincter with the goal of blocking the detrusor reflex.12

In other words, they were “trying to

hold it” too often. Over time, these behaviors created over activation of the pelvic floor muscles

and the abdominal wall that was difficult to relax, yielding non-ideal voiding situations,

obstructed defecation, and even pain in the perineal and perianal regions.12

Relaxation for these young people was the key. Diaphragmatic breathing exercises and

pelvic floor exercises were introduced into the kids’ daily routines, with the goal of consciously

turning on all core muscles and educating the participants on body awareness.12

After one year of

these exercises, 20 of the 24 children who entered the study with dysfunctional voiding, no

longer had that complaint.12

By properly engaging the abdominal wall and pelvic floor complex,

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the children were able to take control of muscle relaxation when it came time to void the bladder.

With balanced and strengthened musculature comes the even more important ability of control.

Pelvic Girdle Pain and its Relationship with the Pelvic Floor Muscles

The human body was designed to operate at an optimal level. Each component of the

structure has a purpose and is a vital player in the chain of activity required for maintained

conditioning. However, hiccups and alterations to biomechanics create weaknesses, energy leaks,

and breaks in the links of performance. Pelvic girdle pain affects 45% of pregnant women and

20-25% of those shortly after giving birth.13

Anatomical structures falling within the normal

range of function in the pre-parous woman morph and adapt with the changes that come along

with pregnancy. However, there is not a 100% guarantee rate on returns in the post-partum

world.

With the progression of trimesters and an ever-growing abdomen, the pregnant female

will experience a stretching of the linea alba, or the connective tissue linking the abdominal

muscles.13

This stretch will recede in the direction of normalcy in the year following pregnancy.

The excessive residual stretch remaining after that year is known as Postpartum Diastasis Rectus

Abdominis. 66% of the women dealing with this loss of stability have a dysfunctional pelvic

floor complex, resulting in urinary incontinence, fecal incontinence, and/ or pelvic organ

prolapse.13

Low back pain has been found to go hand in hand with these afore mentioned

shortcomings. In Iran, 84% of women who have been pregnant have a lifetime occurrence of low

back pain.14

There are two compensation patterns that these women typically use to generate stability.

One approach is affectionately termed the “butt-gripper.” This includes posterior tilting of the

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pelvis, and a loss of the lower lumbar lordosis.13

This is accompanied by the inferior

compression of the sacroiliac joints. Holding this position for a prolonged period of time creates

fatigue and eventually leads to a reduction of the support provided by the pubic bone. As a result

of this, the pelvic floor muscle complex becomes more tightly contracted to make up for a loss of

support.

The second scheme taken on by women who hope to regain their previous level of

stability is “chest-gripping.” To accomplish this approach, superficial muscles are overly utilized

and the deeper muscles are left lax and underutilized. In this case, the external oblique muscles

are contracted to make up for the lack of activation of the transversus abdominis muscle.13

This

increases the pressure in the lower abdomen and also creates a bulging appearance of the lower

abdomen, placing higher burdens on the soft tissue and internal organs of that area.

Both of these gripping methods create asymmetries in the muscle complex of the core,

ultimately modifying the natural abilities of the pelvic floor complex; however, not for the better.

Even those women, who are able to recover the apparent function ability of their core muscles

and recoup their continence capabilities, will become incontinent by five to seven years later in

31% of the cases recorded.13

The lagging revisiting of this condition is attributed to the eventual

fatigue of the core muscles and the delayed setting in of the neuromuscular re-education.

The loss of the balance of deep stabilizing muscles is thought to contribute to

lumbo-pelvic instability.6 Pelvic floor muscles aid in the maintenance of intra-abdominal

pressure and sacroiliac joint stiffness. An ideally functioning pelvic floor complex lifts the pelvic

organs and allows for form closure of the sacroiliac joints. Research shows that women with low

back pain complaints often end up lowering the pelvic floor muscles.6 This creates increased

vaginal resting pressure and increased activity of the pelvic floor muscles themselves in the hope

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of protecting against pelvic girdle pain.6 The coccygeus and levator ani muscles of the pelvic

floor complex utilize increased intra-abdominal pressure to resist downward movement of the

complex in the ideal situation.15

Increases in intra-abdominal pressure intensify spinal stiffness.15

The over stimulation of the pelvic floor muscles creates counter nutation of the sacroiliac joints,

a reduction in force closure, and ultimately, the maintenance of discomfort in those with pelvic

girdle pain and low back complaints.6

The active straight leg raise can be utilized to test the load transfer through the pelvis.16

A

woman with over contraction of the pelvic floor muscles will have a loss of stability of the pelvic

ring, which will reduce the capability of load to transfer through the pelvis. Post-partum women

that test positive in the active straight leg raise test have been found to have underperforming

diaphragmatic and pelvic floor muscles.17

Altered breathing patterns will be noted in those with a

positive active straight leg raise test.18

Manual compression, the utilization of a sacro-iliac

support belt or abdominal belt for instance, can help to reverse this muscle re-education as a

result of low back pain.17

The pelvic floor muscles are meant to automatically accommodate changes in intra-

abdominal pressure, shorten its length, and narrow the levator hiatus.16

Research has shown that

the levator hiatus is found to be larger in women who are plagued with urinary incontinence due

to the loss of pelvic floor muscle control. In a study pusblished by Eliasson et al. in 2008, it was

determined that 78% of women who had low back pain also reported urinary incontinence.14

It is

a circle of reactions that are both causes and results of one another. Low back pain causes a

woman to over contract muscles in order to compensate for the pain and lack of stability,

resulting in overly contracted pelvic floor muscles. In turn, excessively contracting the pelvic

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floor muscles will eventually cause fatigue, and the compensations made to the myofascial

tissues will egg on the low back pain symptoms.

Relationship between Pelvic Organ Prolapse and Pelvic Floor Muscles

Research has relayed that roughly 50% of post-parous women acquire weakened pelvic

floor support, causing varying degrees of pelvic organ prolapse.19

This affliction greatly affects a

woman’s lifestyle and is accompanied by symptoms of vaginal bulging and a sense of heaviness.

Braekken et al. reported in research published in 2010 that women suffering from pelvic organ

prolapse symptoms make up 20% of the waiting list for those wanting gynecologic surgery.19

Of

those women that have a reparative procedure, more than half experience a relapse in

symptomatology, and nearly one-third of those women end up having a follow-up procedure.

As it has been illustrated multiple times in this paper, the strength of the pelvic floor

complex greatly affects the stability of the lumbar spine, and in turn the reliability of continence.

It is also known that the degree of solidity of the pelvic floor muscles aids in the reduction of

prolapse of the pelvic organs. The study conducted by Braekken et al. followed women with

varying degrees of prolapse for six months, leading pelvic floor muscle exercises on a regular

basis.19

At the end of the six month period, women who participated in the exercise program had

an elevation of both the bladder and rectum within the pelvis, as made visible by ultrasound

imaging.19

No adverse effects have been found in relation to such exercises, and 56% of the

women who had a prolapse below the hymen had successfully decreased their incidence of

prolapse by the end of the six month period, according to the research.19

Pelvic Floor Dysfunction in Men

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As noted previously, trauma and a lack of stability and control can greatly alter the

abilities of the pelvic floor complex. 80% of women delivering a baby vaginally will experience

denervation of the of the pubococcygeus muscle, a key player in the pelvic floor.20

Just as giving

birth can disrupt the response required to trigger a contraction of the pelvic floor, so can a

traumatic surgery like a prostatectomy. Sapsford’s research states that while the negative effect

of a neurological disturbance during a prostatectomy or a vaginal delivery, will settle after just

seven days, lasting damage can remain, and rehabilitation will be necessary.20

Pelvic Floor Muscle Activation Depends on Body Position

Today’s society has become very sedentary. While physical activity is worked into the

lives of a large percentage of people, a good portion of the day is also spent sitting. People get up

in the mornings, sit in the car to drive to the office or school, sit at a desk for work, sit during

their lunch break, sit in rush hour traffic on the trek home, sit down at the dinner table for the

evening meal, and then maybe they relax and lounge around to catch their favorite sitcom in the

living room before bed. The key word in all of these scenarios is “sitting.” Those who wish to

lead balanced lives and be physically fit often think about how much they sit throughout the day,

but a key point is missed in this line of thinking. An important question that should be addressed,

is not only how often one is sitting, rather in what position they are sitting. The study published

by Sapsford et al. addresses the different sitting postures one may adapt, and which position

tends to provide a greater activation of the pelvic floor complex, and even the abdominal muscles

in parous women.21

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Pelvic floor muscle contraction is at its highest in the standing position and at its lowest

when lying down. In a world where sitting is a position that rules over a large chunk of a

person’s day, how can it be utilized to create the highest possible level of instigation of the pelvic

floor? Sapsford and associates found that pelvic floor muscle activity increases the most when

sitting in a “tall unsupported” position.21

The pelvic floor complex is often found working with

the abdominal muscles, mainly the transversus abdominis. In order to gain maximal activation of

the pelvic floor complex, the abdominal muscles must also be turned on. In contrast, a person

sitting in an “unsupported slumped” position holds their posture and gains stability mainly from

the ligamentous components that surround the spine, rather than the pelvic floor and abdominal

muscles.21

The pelvic floor complex can be engaged throughout the day, even while sitting, with

the goal of furthering its enduring abilities to hold contracture for prolonged periods of time.

Passive versus Active Stiffness of the Lumbar Spine

As mentioned previously in this review of the literature, a slumped seated posture is

maintained primarily by ligamentous structures, rather than muscle contracture. This creates a

passive trunk stiffness of the lumbar spine rather than stability set in by active stiffness. Passive

trunk stiffness is achieved in a manner that utilizes ligaments, yet lacks the control provided by

muscle contraction.3, 22

Therefore, while this type of stiffness may provide a sense of rigidity, it

is majorly lacking in the secure nature that comes with trunk stability. Active stiffness is

achieved via co-activation of antagonistic and agonistic muscle groups.3 In the region of the

lumbar spine, these roles are carried out by the abdominal muscles and extensors, respectively.

The abdominal muscles create a flexion moment arm, while the extensors aid in the extension of

the back, balancing out to maintain a neutral spine.3

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This active approach to stability requires the participation of the intrinsic muscle group as

well as the reflex response, as mentioned in the introduction of this paper.3 These necessities are

lacking in those with low back pain. In order to compensate for these great losses, low back pain

sufferers over-recruit antagonist and agonist muscle groups in order to maintain a level of

rigidity and make up for the loss of neuromuscular management.3

When looking to regain stiffness in the lumbar spine and relieve the symptoms of low

back pain, passive and active care provide different roads to travel. An option chosen by some is

the use of an abdominal belt. While some progressive results may be noted after its use, the

negatives and shortcomings far outdistance the known positives. There is no doubt about it, the

use of an abdominal belt does provide a solid firmness and unyielding rigidity that allows for a

sense of relief and a feeling of a strong hold on the lumbar spine in those suffering with low back

pain.

However, research has shown that the muscles that are designed to provide that sense of

stability, namely the spinal extensors and abdominal muscles, lower activity levels when

strapped in by the abdominal belt.23

There is a loss of co-activation of these muscles, and

prolonged use of the abdominal belt can cause a deficit in active muscle recruitment for spine

stability.23

When the abdominal belt is finally removed, the further instability of the already

weak stabilizing muscles can actually increase the risk of additional low back injury. This can be

attributed to the sudden loss of artificial stabilization provided by the abdominal belt. An active

approach to regaining spinal stability and stiffness in the lumbar spine would include

rehabilitation of the core musculature to increase intra-abdominal pressure through functional

exercises.23, 24

Sufficient intra-abdominal pressure is the essential component called for when

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working to regain stability of the lumbar spine through rehabilitated muscles and retrained

biomechanics.25

Gaining Control of the Pelvic Floor

Established weakness and an inability to control the contractions of the pelvic floor

muscle complex create the shortcomings of the lumbo-pelvic region of the spine, as relayed

throughout this paper. It has also been reported that while passive approaches to care may relieve

the symptoms of pain initially, the root of the pain and lack of function ability can only be

addressed from an active rehabilitation stand point. Without a functional approach dedicated to

the restoration of what is found to be lacking in the performance of the pelvic floor muscle

complex and its core teammates, there can be no reduction in the amount of relapse that is

otherwise eminent.

The pelvic floor is not a solo operator. It is a part of a team of muscles that come together

to comprise the core. Together these muscles aid in proper respiration, the gaining of maximal

intra-abdominal pressure, restoration of lumbar stability, the reinstitution of continence, and

proper maintenance of internal organ positions. These muscles work together to reach common

goals. While they may be able to complete the above tasks with a missing member or even on

their own, the results would be sub-par and require compensations that would eventually fatigue

and result in further damage.

Just as function ability relies on the participation of all muscle components of the core, so

does rehabilitation. Weakness of one muscle group leads to the weakness of all muscle groups.

Where one thrives, all thrive, and where one fails, all fail. There can be no MVP that holds the

key to carrying the rest of the team through their routines—at least not for long. Even the best

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athletes cannot face off against a slew of opponents without tripping up and wearing out after a

time.

Rehabilitation of these muscles also calls for a strategy of where to start and what the

goal is at the finish. After all, even professional marathon runners must begin at the starting line

in order to be successful with their race. If they jump in at the 14th

mile, disqualification is

eminent, and they are labeled as a failure. Beginning rehabilitation with the wrong muscle group

will only yield the instigation of greater compensations, a worsening of the problem at hand, and

a loss in the end.

Breathing is the minimal requirement for life. The ability to function and thrive first

depends on this act before anything else. It makes sense then to begin rehabilitation with the

education of proper respiration, or diaphragmatic breathing.20

This requires 360 degrees of

inflation around the core, as well as minimal elevation of the rib cage, and little movement of the

chest with inspiration. All muscle components of the core should be activated during the act of

proper diaphragmatic respiration. Without mastering the basics, more complex activities cannot

be mastered.

In a patient with low back pain who lacks strength in the pelvic floor, it is also vital to

practice and master the endurance of the contractility of the pelvic floor muscles. This can be

done though extended muscle holds.20

As mentioned earlier in this paper, “tall upright” sitting is

a good position for this exercise.21

Progression can include moving into a standing position or

even walking while maintaining contraction of the pelvic floor along with co-contraction of the

trasnversus abdominis muscle. Just as coaches have always encouraged their players to practice

in order to brush even the possibility of perfection, repetition of these exercises is crucial.

Sapsford et al. deems the need for five repetitions of the exercise at least five times each day a

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necessity for success.21

The improvement of endurance in pelvic floor muscle contraction will

allow for better coordination of co-contraction of the transversus abdominis muscle with the

pelvic floor complex. Once this skill is mastered, strengthening becomes the next step of

rehabilitation.

The ability to actively recruit the core muscles in an all-inclusive fashion is beneficial for

those dealing with low back pain. By addressing the weaknesses and not just the symptoms of

the complaint, a rehabilitation regiment can be set into motion providing all of the ingredients

necessary to minimize the re-exacerbation of the pain.

CONCLUSION

The pelvic floor complex is jack of all trades. This muscle group is strategically placed

within the body to provide significant contributions to multiple functions of the body. These

include proper respiration, continence, maintenance of the proper positions of the organs residing

in the pelvis, and the stabilization of the lumbar spine. The last role listed for this muscle group

has only hit the scene on the research circuit in recent decades. The components of spinal

stabilization are still being researched, and the puzzle pieces are still being put together.

Unknowns and unanswered questions continue to drive the research in this particular topic.

The pelvic floor is also fundamental to the allowance of the transversus abdominis,

diaphragm, and internal oblique muscles to reach optimal biomechanical function. While these

muscles can carry out their roles in a solitary fashion temporarily, research has illustrated that the

end of the road on such a trip will always end at a road block. The muscles that are over

activated with the goal of making up for the deficit of an under activated muscle will fatigue,

leaving larger follies in its wake.

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Low back pain is one of the most common ailments to strike people in today’s world. It

eats up large quantities of personal time, capabilities, and medical budgets. Surgeries are often

sought out in the hope of finding a quick fix and a simplified route to get out of pain. However,

there are no such things as quick fixes or magic solutions. This paper illustrated that a chunk of

people, larger than one would ever wish to admit, continue to relapse into the painful and

debilitating situations that led them to surgery in the first place.

Research and growing knowledge to understand the kinetic chain and the biomechanics

of the body, have allowed for another option. By understanding the roles played by the anatomy

surrounding the lumbar spine, as well as the shortcomings that come along with muscle

weakness and lack of coordination, a conservative route of rehabilitation can be presented to the

patient as a first step before more extreme measures are taken.

The human body is well-oiled system with the ability to run smoothly with proper

functioning biomechanics. As people move from infancy to adulthood, the deep muscles of the

body tend to be forgotten due to postural changes and the shifting away from natural

biomechanics. Superficial muscles become over active in the hopes of compensating for the

stability lost with the weakening of the deep muscles. If people can be re-educated on how to

utilize all muscle groups in the way they were meant to, pain and shortcomings like mechanical

low back pain would become less of a phenomenon, and more of a rarity. The place to start with

this change is the pelvic floor.

Scheer, A. Page 22

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