Incorporating Pelvic Floor and
Diaphragm Training into Core
Programs
Margaret Bronson, PT, WCS, CAPP, COMT,CSCS
Parkview Outpatient Therapy
margaret.bronson@parkview.com
260-266-4080
Anatomy of the Pelvic Floor
“Pelvic Floor” refers to the compound structure which closes
the bony pelvic outlet
- bony pelvis
- pelvic floor muscles
- fascia and ligaments
-viscera
Anatomy of the Pelvic Floor

Bony pelvis
 Pubic
arch (pubic symphysis, inferior pubic rami, ischial
rami)
 Ischial
tuberosity
 Ischial
spine
 Coccyx
Anatomy of the Pelvic Floor

Pelvic floor muscles
 Pelvic
Diaphragm (levator ani)
 Pubococcygeus
 Iliococcygeus
 Coccygeus
 Puborectalis
 Associated
muscles
 Piriformis
 Obturator
Internus
Anatomy of the Pelvic Floor
Anatomy of the Pelvic Floor

Function of Pelvic floor muscles
 Pelvic diaphragm
 Supports bladder, bowel and uterus in a functional position and assists
the closure of the bladder and bowel outlet. It moves the
sacrum/coccyx on the pelvis.
 Stabilizes pelvic ring together with the diaphragm and transversus
abdominus to provide trunk and pelvic stability
 Obturator internus
 Laterally rotates the hip and lifts the bladder, bowel and uterus into a
functional position while assisting in closure of the urethra and anus
 Interacts with pelvic floor via arcuate tendon to stabilize hip (“rotator
cuff of pelvis”) while larger hip muscles move (eg. Squat)
 Piriformis
 Laterally rotates the hip. It moves the sacrum on the pelvis in
standing.
Anatomy of the Pelvic Floor

Pelvic ligaments
 Sacrotuberous
ligaments attach the ischial
tuberosity to sacrum
 Sacrospinous
ligaments attach spine to sacrum
Anatomy of the Pelvic Floor
Anatomy of the Pelvic Floor
Anatomy of the Pelvic Floor
Anatomy of the Pelvic Floor
Anatomy of the Pelvic Floor
 Facilitatory
muscles
 Adductors
 Gluteals
 Tranversus abdominus
 Obturator internus
 Synergistic
muscles
 Transversus abdominus
 Deep lumbar multifidus
 Respiratory diaphragm
Anatomy of the Diaphragm
Anatomy of the Diaphragm

Function of the diaphragm (Ron Hruska, Postural Restoration Institute):

Contraction during inhalation increases thoracic volume, drawing central tendon
down and dome descends and flattens using external intercostals

Relaxation of diaphragm to exhale requires opposition of strong transversus
abdominus and internal oblique muscles

Weakness of abdominals allow for excessive shortening of diaphragm, with
hyperactivity of lumbocostal ligaments, with eventual posterior orientation of
diaphragm at posterior linkage with quadratus lumborum and psoas mm

During normal inspiration and coughing, real-time MRI demonstrates parallel
cranio-caudal movement of the diaphragm and pelvic floor with synchronous
changes in abdominal wall diameter. Before inhalation, electrical activity can be
observed in the pelvic floor muscles as well as TrA and IO (Talasz, H et al, 2011)
Anatomy of the Diaphragm
Anatomy of the Diaphragm
Anatomy of the Diaphragm
Anatomy of the Diaphragm
Integrated function of PFM and
Diaphragm

Pelvic floor muscle activation highest in standing vs sitting, and in standing,
higher PFM activation in hypo-lordotic vs normal or hyperlordotic posture.
(Capson AC, 2011)

Hodges, et al (2007) noted that pelvic floor muscles contribute to postural
function of lumbar spine as well as respiratory function due to modulation of
intraabdominal pressure. The support of respiration by the pelvic floor
muscles is also outlined extensively by Bordoni and Zanier, 2013.

Julie Wiebe, PT (juliewiebept.com) had outlined a theory of the pelvic floor
piston, working in coordination with other muscles of the core: transversus
abdominus and obliques

The pelvic floor and diaphragm set up intraabdominal pressure for stability
during inspiration, and use of musclular function of TrA, IO and pelvic floor for
musculoskeletal lumbopelvic stability during expiration
Integrated function of PFM and
Diaphragm

It should also be noted that the female pelvic floor is a shaped like a dome, not a
basin (Hjartardottir, S. et al, 1997). This makes sense, given the wider female
pelvic with wider pelvic arch. Julie Wiebe makes the point that the broader shape
presents less ability to generate force, and plays a role in core deficiencies in
young females after puberty related to ACL disruption. She also states that the
male pelvic floor is shaped more like a cone, improving actin/myosin relationship.

Anterior weight shift facilitates anterior pelvic floor activation (Julie Wiebe)

Performing abdominal drawing in maneoevre during forward stepping increases
thickness of TrA and IO, resulting in increased lumbopelvic stability and thus, could
increase hip extension during gait (Madkoro, et al 2014)

Facilitation of adduction can improve pelvic floor function (extensive coverage
through Postural Restoration Institute: highly recommended!)

Untrained pregnant and postpartum women were unable to simultaneously
contract TrA/IO and PFM when asked to contract PFM or TrA/IO (Pereira, et al
2013)
Integrated function of PFM and
Diaphragm

Prevalence of diastasis recti abdominus in urogynecological population was
52%, with older age, higher gravity and parity, and weaker pelvic floor
muscles than those without diastasis rectus abdominus, and 66% of patients
with DRA had at least one support-related pelvic floor dysfunction (SUI, FI or
POP).
Pelvic Floor Dysfunction
-Underactive
or overactive pelvic floor muscles with probable
incoordination of pelvic floor/diaphragm/TrA/IO/glutes system
resulting in urinary or fecal incontinence, pelvic organ prolapse
or constipation/ pelvic pain
-Schettino, et al (2014) studied 105 female athletes and found
>65% with SUI and/or urgency, with 70% reporting nocturia, 55%
with incomplete bladder emptying and 52% with pelvic pain. Bo
et al (2010) looked at 331 former elite athletes and 640
controls and found both former athletes and controls reported
SUI at 36%, but that of those athletes that had incontinence
during competing in sport (10%), more had UI after competing
that those that did not.
Integrated function of PFM and
Diaphragm
http://well.blogs.nytimes.com/2013/09/05/think-like-a-doctor-the-gymnastsbig-belly/
http://well.blogs.nytimes.com/2013/09/06/think-like-a-doctor-the-gymnastsbig-belly-solved/
Physical Therapy for Pelvic Floor
Dysfunction

Comprehensive history taking and evaluation of pelvic
floor musculature and associated musculature

Review of bladder diary/ fluid intake/ voiding

Assessment of strength, endurance and coordination of
PFM

Development of individualized plan of care
Physical Therapy for Pelvic Floor
Dysfunction
 PFM
strengthening for endurance and coordination
 Education regarding behavioral strategies to improve
continence
 Urge suppression techniques
 Timed voiding
 Toileting strategies
 Bladder irritants discussed
 Flexibility and strengthening of associated musculature
 Postural and functional retraining for activities causing
dysfunction (sport, sitting, intercourse)
 Modalities as needed: biofeedback, electrical stimulation
Integrating Pelvic Floor, Diaphragm and
Core in Your Athletes/Patients

DISCLAIMER: The following exercises are suggestions
based on the common muscle imbalances found in active
female patients with pelvic floor dysfunction. These are
not meant to substitute for a comprehensive and
individualized evaluation by a pelvic physical therapist.
Integrating Pelvic Floor, Diaphragm and
Core in Your Athletes/Patients
Integrating Pelvic Floor, Diaphragm and
Core in Your Athletes/Patients
Integrating Pelvic Floor, Diaphragm and
Core in Your Athletes/Patients
Boyle, K. et al, The Value of Blowing Up a Balloon, North American
Journal of Sports Physical Therapy. 2010; 5(3): 179-188
Integrating Pelvic Floor, Diaphragm and
Core in Your Athletes/Patients
Integrating Pelvic Floor, Diaphragm and
Core in Your Athletes/Patients
Integrating Pelvic Floor, Diaphragm and
Core in Your Athletes/Patients
Integrating Pelvic Floor, Diaphragm and
Core in Your Athletes/Patients
Integrating Pelvic Floor, Diaphragm and
Core in Your Athletes/Patients
Integrating Pelvic Floor, Diaphragm and
Core in Your Athletes/Patients
Integrating Pelvic Floor, Diaphragm and
Core in Your Athletes/Patients
Integrated function of PFM and
Diaphragm

Special Populations: Paradoxical Vocal-Cord Dysfunction in Athletes

These athletes may present with dyspnea or shortness of breath during exercise,
and may not be responding to current asthma medications (or they may present
worse than respiratory function tests would deem)

Difficulty completing fitness drills

Increased emotional stress/ high achiever

May have stridor, wheezing, hoarseness, hiccups or other vocal changes

Coexisting medical conditions may include exercise-induced asthma,
gastroesophageal reflux disease, pharyngeal erythema (secondary to postnasal drip),
habitual coughing or throat clearing, and may also present with muscle imbalances
and pelvic pain

These athletes would benefit from multidisciplinary assessment from speechlanguage pathologist and possibly pelvic floor therapist
Applying Concepts to Practice Tomorrow

ASK your female athletes about urinary incontinence! It is a dysfunction that indicates
muscle dysfunction that can impact their performance today and their quality of life
tomorrow. Address what you can based on this presentation, and refer on to pelvic
physical therapy when in doubt. If you feel comfortable, ask or use screening form to
assess pelvic pain (ability to use tampon, have pelvic gynecological exam or intercourse
without pain).

Look at posture: pelvic floor, TrA and IO work best with a neutral spine; ensure optimal
positioning of trunk during dynamic activities such as running, jumping, squatting.

Assess diaphragm function through posture and respiration: do they have stiff thoracic
spine inhibiting contraction/descent of diaphragm? Are abdominal muscles able to
contract to elevate diaphragm? Can they blow a balloon? Do they hold breath during
exertion portions of sport? Do they have other signs of diaphragmatic/ vocal-cord
dysfunction such as voice hoarseness, stridor, soft voice, or hiccups? Refer to or contact
speech-language pathologist for further evaluation.

Don’t be afraid to stop offending activity for short time while working on muscle
imbalances: try substituting uphill walking for running to improve pelvic floor
coordination with TrA/IO

Look, listen, feel…
Integrating Pelvic Floor, Diaphragm and
Core in Your Athletes/Patients

Any Questions???
Integrating Pelvic Floor, Diaphragm and
Core in Your Athletes/Patients

Thank you for listening and participating in this Breakout Session!

Margaret.bronson@parkview.com if you have any other questions regarding
your patients/clients