Low back pain and the pelvic floor

 
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Low back is seen as an epidemic with 90% of primary care visits being a result of this ⁸,⁹. It is currently the leading cause of disability. The prevalence of low back pain in adults is reported to be as high as 84%  ⁶,⁸.

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As a result of the ongoing issues with low back pain, research has been focussed on looking at risk factors, best evidence guidelines for assessment and management. Recently research has started to focus on the link between pelvic floor dysfunction and low back.

This seems to be a big leap, however if we consider anatomy it seems obvious.

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The core muscles – which is seen a common contributor to low back pain – is made up of the diaphragm, transverse abdominis, multifidus and pelvic floor.

The pelvic floor also contributes to the intra-abdominal pressure needed for movement and different physical tasks¹.

The pelvic floor itself is formed by the muscles and connective tissue attached to the bottom of the pelvis.

Its primary functions are the following:

  • Supporting the reproductive organs, bladder, vaginal and rectal walls.

  • Maintaining continence.

  • Optimizing sexual function for orgasm.

  • Improving venous and lymphatic return.

  • Stabilizing the pelvis.

 

Pelvic floor dysfunction can be identified by weakness, poor endurance, tension, stiffness or overactivity³.

Urinary incontinence, which is the involuntary leakage of urine, is the most common pelvic floor dysfunction and can affect up to 1 in 10 Canadians, and 1 in 5 women⁷.

Many people live with incontinence, but it can be managed successfully with physiotherapy, and has Grade A/ Level 1 evidence

Several studies have linked low back pain to pelvic floor dysfunction ¹,⁴. On study showed that 78% of women with low back pain also have urinary incontinence⁴.

Despite the relationship between pelvic floor dysfunction and low back pain, many health care professionals do not examine or consider these muscles in the management of low back pain³,⁸.

Urinary incontinence is not the only type of pelvic floor dysfunction and while weak pelvic floor muscles do frequently result in urinary leakage or pelvic organ prolapse (the descent of pelvic organs into the vaginal canal), tight pelvic floor muscles can also lead to different forms of incontinence, sexual dysfunction, constipation, and various pain syndromes of the pelvis.

Now that we can see the connection between pelvic floor dysfunction and low back pain, we know that those with low back pain would benefit from assessment of their pelvic floor muscles.

A recent study by Dufour et al. (2018) looked at the physical characteristics of the pelvic floor muscles in women who were referred to physiotherapy for lumbopelvic pain. If they wanted to participate in the study, they were examined by pelvic floor physiotherapists. The physiotherapists participating in the study were trained and experienced pelvic health clinicians and through an internal digital examination, they differentiated between pelvic floor weakness and pelvic floor tenderness which both constitute features of very different dysfunctions³. 95% of the women with lumbopelvic pain had signs of pelvic floor dysfunction (notably, tenderness, weakness or the presence of prolapse): 71% of participants had tenderness on internal palpation³; this finding indicates to therapists that an individual has over-activity in the muscle. As well, 66% of women had pelvic floor muscle weakness and 41% had a prolapse³. Functionally, overactive pelvic floors were more strongly associated with disability compared to pelvic floor weakness³.

Many health care professionals, which include doctors, fitness professionals and even physiotherapists, encourage women to do “Kegel-like” exercises to strengthen the pelvic floor muscles. However, if someone’s dysfunction is caused by tight muscles, not only will Kegels not help, but they can even make it worse. For instance, 25% of women who followed instructions for Kegel contractions actually performed a technique that could potentially promote incontinence²

 

*References:

  1. Arab, A. M., Behbahani, R. B., Lorestani, L., & Azari, A. (2010). Assessment of pelvic floor muscle function in women with and without low back pain using transabdominal ultrasound. Manual therapy, 15(3), 235-239. doi:10.1016/j.math.2009.12.005

  2. Bump, R. C., Hurt, W.G., J. Fantl, J.A., & Wyman, J.F. (1991). Assessment of Kegel pelvic muscle exercise performance after brief verbal instruction. American Journal of Obstetrics & Gynecology 165;2, 322-329. doi: https://doi.org/10.1016/0002-9378(91)90085-6

  3. Dufour, S., Vandyken, B., Forget, M. J., & Vandyken, C. (2018). Association between lumbopelvic pain and pelvic floor dysfunction in women: A cross sectional study. Musculoskeletal Science and Practice, 34, 47-53. doi: https://doi.org/10.1016/j.msksp.2017.12.001

  4. Eliasson, K., Elfving, B., Nordgren, B., & Mattsson, E. (2008). Urinary incontinence in women with low back pain. Manual therapy, 13(3), 206-212. doi: 1016/j.math.2006.12.006

  5. Faubion, S., Shuster, L., & Bharucha, A., (2012). Recognition and management of nonrelaxing pelvic floor dysfunction. Mayo Clinical Procedures, 87(2), 187–193. doi: 1016/j.mayocp.2011.09.004

  6. Gross, D.P., Ferrari, R., Russell, A.S., Battié., M.C., Schopflocher, D., Hu, R.W.,…Buchbinder, R. (2006). A population-based survey of back pain beliefs in Canada. Spine,31(18):2142-5. doi:1097/01.brs.0000231771.14965.e4

  7. The Canadian Continence Foundation. (2014). Incontinence: The Canadian Perspective. Retrieved fromhttp://www.canadiancontinence.ca/pdfs/en-incontinence-a-canadian-perspective-2014.pdf

  8. Toward Optimized Practice (TOP) Low Back Pain Working Group. (2015). Evidence-informed primary care management of low back pain: Clinical practice guideline. Edmonton, AB: Toward Optimized Practice. Retrieved from http://www.topalbertadoctors.org/cpgs/885801

  9. Vos, T., Barber, R.M., Bell, B., Bertozzi-Vill, A., et al. (2015). Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet, 386 (9995), 743–800. doi: https://doi.org/10.1016/S0140-6736(15)60692-4

  10. Dumoulin C, Cacciari LP, Hay‐Smith EJC. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database of Systematic Reviews 2018, Issue 10. Art. No.: CD005654. DOI: 10.1002/14651858.CD005654.pub4.

 
BlogNicola Robertson