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The Orthopedic Physical Therapist's Guide to Pelvic Floor
Screening, Evaluating, Treating, and Referring
Kim McCole Durant PT, DPT, OCS, FAAOMPT
Meghan Musick PT, DPT, OCS, OMPT, PHC
Objectives:
1. Define the current evidence and established link between pelvic floor dysfunction and low back and hip pain
2. Gain an understanding of internal and external anatomy, and the relationship between lumbar spine, diaphragm, hip complex, and pelvic
floor structures.
3. Review appropriate screening outcome measures and history questions to rule in/rule out pelvic floor dysfunction for patient with main
complaint of hip and low back pain
4. Demonstrate muscle assessment including observation and external
palpation appropriate for low complexity pelvic floor dysfunctions.
5. Demonstrate techniques to integrate pelvic floor into a core
coordination retraining program
Schedule:
8:15-8:45 am - Literature Review
8:45-9:05 am - Anatomy and physiology review
9:05-9:35 am – How to screen
9:35-10:05 am - External examination
10:05-10:35 am - External treatment
10:35-10:40 am - When to refer, know your limitations!
10:40-11:05 am - Case studies
11:05-11:15 am - Closing remarks / Q&A
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Bridge Needed:
Over the next 30 years chronic health problems associated with pelvic floor
dysfunction are projected to increase by 50%due to increasing number of women reaching the age of 651.
Women who are forced to modify or cease exercise due to their PF symptoms are at an
increased risk of physical inactivity, associated chronic health conditions and social isolation2-
3.
Remove the bias towards pelvic floor
When we first start thinking
about treating patients with
pelvic floor dysfunction….
Women, geriatrics,
pregnancy, postpartum
Who we should be thinking
about when treating patients
with pelvic floor dysfunction…
EVERYONE!
Literature Review
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PT Journal - 2017 -> observational, cross-sectional study
125,645 sample size
Strong relationship of UI and back problems
UI more than doubles the risk of also experiencing low back problems
In men and women!4.
Are you asking your patients with low back pain about bladder health?
Cross-sectional analysis from Kentucky Women’s Health Registry
2,341 women
Chronic back pain significantly more likely to have SUI
Odds of SUI increased by 44% for women with CBP compared with those not reporting CBP
Important for all trunk muscles, including the pelvic floor muscles to function in coordination with one another5.
Scary Statistics
95.3% of participants with LBP had some form of pelvic floor dysfunction6.
200 women with primary complaints of LBP – 78% reported urinary
incontinence7.
Out of 1636 women with low back pain/pelvic girdle pain, 57% had pelvic
floor complaints6.
43% of females reported symptoms of UI pre THA; 3 months post-op
symptoms improved in 64% but persisted or worsened in 36%8.
311 female triathletes responded to a survey - 1 in 5 women reported pelvic
girdle pain9.
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Postpartum population
UI affects exercise participation in 1 in 2 symptomatic women; with some completely stopping exercise or modifying their participation10.
Of the women who experienced PF symptoms while participating in high-impact sports/exercise,
42% stopped their exercise participation secondary to symptoms10.
3,763 women postpartum followed over 12 years
Prevalence of persistent UI was 37.9%
Among those who reported UI at 3 months, 76.4% reported it at 12 years11.
Urinary incontinence does not resolve on its own!
Established Link
Low back pain and pelvic floor dysfunction
Lots of evidence
Pelvic floor dysfunction can occur in:
Men AND women, athletes, patients post op THA…EVERYONE!
Urinary incontinence does not resolve on its own
Not enough pelvic PTs to treat everyone with pelvic floor involvement
Anatomy Review
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Beyond the Pelvis Pelvic floor muscles work in conjunction
with other spinal stabilizers:
Diaphragm
Psoas
Transverse Abdominus
Internal oblique
External oblique
Rectus abdominus
Multifidus
Thoracolumbar fascia
Canister Example:
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A case example of a female runner
• 45 y/o female distance runner referred to outpatient PT with a diagnosis of ‘proximal L hamstring strain’
• C/C of hamstring, gluteal and ischial tuberosity pain
• Initial onset 4 months ago during a trail run, sensation of “pulling a muscle” while attempting to avoid a fall
• Significant exacerbation of symptoms 6 weeks later after sitting on a hard surface for several hours
• Pt no longer able to run due to pain, unable to sit for > 15 min12.
Building the Bridge
Initial treating diagnosis and POC:
Primary working hypothesis of hamstring syndrome
Re-examination: after 4 visits, pain levels improved from 7/10 to 3/10 with sitting, c/o a deep ache which the therapist was unable to palpate externally; referred for a PF examination
PF Exam (internal):
Symptom reproduction with palpation of obturator internus and levator ani muscles
Weak contraction of PF muscles (2/5 using Oxford grading scheme)
Poor PF muscle relaxation following contraction
Revised intervention:
Treatment added to address pelvic floor overactivity/hypertonicity including STM/mobilization, muscle energy techniques and EMG biofeedback
Outcome
7 more sessions over 2 months
Pt able to sit > 2 hours with pain no greater than a 1/10; 8 hours with use of wedge cushion
Pain-free SL hop, walking or running up to 15 miles
6 month f/u via phone: pt pain-free and running marathons without complaint12.
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Screening and History
Function of Pelvic Floor
The 5 ‘S’s
Sphincter control
Support
Stability
Sexual function
Sump pump
Common PF dysfunctions:
Urinary Incontinence
Stress
Urge
Mixed
Pelvic Organ Prolapse
Cystocele
Rectocele
Fecal incontinence
Pelvic Pain
Dyspareunia
Vaginismus
Vestibulodynia
Endometriosis
Pudendal Neuralgia
Constipation
DRA
Pelvic Floor Muscle Overactivity
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Incontinence:
Unwanted loss of urine at any time
Very common, but NOT normal
Lots of causes
Three types
Stress
With increased abdominal
pressure
Urge
Urge to void leading to leakage due to not making it there in time
Mixed
Urge and stress
Pelvic Organ Prolapse:
Lack of support of the connective tissues around the pelvic organs
causing one or more organs to be in a lower position
Sx:
Feeling of heaviness
Pelvic pain
Incomplete emptying of bowel and bladder
Back pain13.
Formal Screening Tools:
Cozean screening tool
https://backinmotionpt.com/files/pdf/CozeanPelvicDysfunctionScreeningProtocol.pdf
AAOMPT SIG screening tool
https://aaompt.org/Main/About_Us/SIGs/Pelvic_Health/Main/Education/Pelvic_Health_SIG.aspx
3 Incontinence Questions
https://www.racgp.org.au/getattachment/1bd242ff-e656-4fa3-8b36-b51f7cc57706/Appendix-13A.pdf.aspx
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Functional Outcome Measures
Pelvic Floor Disability Index (PFDI-20)
20 questions
Urinary Distress, Prolapse, Anal Distress
MCID – 13.5 points14.
Pelvic Floor Impact Questionnaire (PFIQ-7)
7 questions asking affect on bladder, bowel, and pelvis
MCID – 12%15.
Central Sensitization Inventory
associated with PFM tenderness/overactivity16.
Patient Specific Functional Scale
MCID – 2 points
Further history questions:
Urinary: Do you or have you experienced any urinary leakage (even just drops) with laughing, coughing, sneezing or physical activity? Will you sometimes feel a strong sense of urgency and have to rush to the bathroom? Do you experience any urinary leakage while rushing to the bathroom?
Bowel: Do you have a h/o constipation? How often do you have a BM? Do you ever have to strain to initiate or complete a BM?
Sexual Function: Do you experience any pain or discomfort with tampon insertion, gynecological exams or intercourse? Do you have difficulty achieving or maintaining an erection?
Supportive Function: known risk factors associated with levator ani tears
OB/GYN: How many pregnancies? How did you deliver? Hold old were you when you delivered? How long did you push for? Any complications with delivery Tearing? Instrument use? Episiotomy?
OB Hx Screen - PFM defect / avulsion
PFM defects during vaginal delivery are estimated at 10-36%
Pre delivery risk factors:
women’s age at her first delivery → likelihood of major PFM defect, is < 15% for mothers aged 20 yrs, compared to 50% or more among 40 yrs or older
Known delivery risk factors:
Prolonged 2nd stage labor
Use of forceps or vacuum
Episiotomy
Sphincter tears
Large fetal head17.
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Consider Patient A…
32 y/o female USPS clerk presenting to outpatient PT with a CC of LBP
Achy, throbbing, burning pain over LB and sacrum; NRPS 5/10 (best) to 10/10 (worst) “feels like my back is going to give way”
Initial Onset 2 years ago during pregnancy with no other known MOI
Recent CT non-significant
Previous therapies: Underwent PT at another facility within 1 year PP with no improvement in symptoms
More to the story…
OB hx: 1 abortion, 2 live births delivered via C-section
Bladder function: stress UI worsening after most recent pregnancy
Bowel Function/GI: h/o constipation, abdominal bloating, frequent straining needed to initiate and complete a BM
Supportive Function: denies symptoms of abdominal or vaginal heaviness, splinting
Sexual Function: (+) dyspareunia for initial and deep penetration, worsening after most recent pregnancy
How might this new info influence your original plan/hypothesis?
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Screening recap:
5 functions of the pelvic floor
3 screening tools
Cozean, AAOMPT Decision Tree, 3IQ
FOM
PFDI-20, PFIQ, PSFS, CSI
OB PFD risk factors
Moving beyond the generic bowel and bladder history question
Let’s practice asking the hard
questions!
Zoom breakouts
Objective: External Examination
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Objective: Observation
Posture
Ankle DF associated with anterior rotated pelvis and greater PFM activation compared to neutral and ankle PF18
Women with pelvic floor dysfunction had:
Increased thoracic kyphosis
Decreased lumbar lordosis
Knee varus
Foot pronation19
Continent vs incontinent women
Continent women maintained a greater lumbar lordosis in sitting20
Objective: Observation
Standing posture
Where is their ribcage in relation to their pelvis?
Where is the weight on their feet?
How are they breathing?
Functional testing:
https://blogs.bmj.com/bjsm/2019/05/20/ready-steadygo-ensuring-
postnatal-women-are-run-ready/
Load transfer
Squat
Hinge
SLS
Step down
Lifting
Carrying
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Objective: Abdominal Wall
Soft tissue appearance
Scar mobility
Diastasis check
Abdominal wall strength and
load transfer
Blow up balloon
ASLR
Diastasis Rectus Abdominus (DRA)
• How to measure in clinic:
• Assessing for depth, tension, and tissue quality
• Fair interrater reliability and good intrarater reliability
Two fingers perpendicular to linea alba
Patient performs head-lift
Assess above, at level, and below umbilicus
(+) if > 2 finger widths or 2.5 cm21.
DRA
Postpartum
6 weeks -> 60%
6 months -> 45.4%
12 months -> 32.6%21.
No agreement on definition and cut-off values for DRA or normal DRA
Evidence is shifting to focus on tissue ability to generate tension
Head lift, Curl-ups, curl-ups with rotation close the IRD
Pre-activation of TrA and PF led better tensioning of the tissue22.
Evidence is mixed
Link between IRD and lumbopelvic pain is uncertain23.
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Objective: Special Tests
Forced FABER
LBP studies
Pelvic Girdle Pain cluster
Active Straight Leg Raise Test (ASLR)
ASLR with lateral compression
Posterior Pelvic Pain Provocation Test
Forced FABER test24.
Pelvic Floor Considerations:
Educate on intent and expectations.
Obtain informed consent.
Use clear, respectful, and professional terminology.
If the patient has used other terms to describe their anatomy, use your patient’s language
Respect patient privacy and comfort.
External Pelvic Floor Assessment
Patient self assessment Coccyx Motion Palpation (CMP)
Position hand over sacrum and middle finger over the coccyx
Ask the patient to perform a PFM contraction
Assess if there was movement in the coccyx indicating proper contraction25.
Therapist assessment
Contract
Relax
Bear down
Symmetry? Difficulty? Delayed? Unable?
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External Pelvic Floor Assessment
Palpate medial to ischial tuberosities (stickers)
Assess for compensation strategy (breath holding,
glutes, adductors)
Assess for any pelvic pain
Assess for movement
during cough
Examination:
Observation
Posture
Breathing pattern
Functional movement patterns
Special tests
Active Straight Leg Raise
Forced FABER
Abdominal screen
DRA
External pelvic floor palpation
Thoracic rotation mobility
AROM/PROM hip abduction,
internal rotation, and external rotation
Core coordination assessment
PRACTICE on Monday ☺
Treatment Incorporating the pelvic floor
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What the literature has shown us:
PF and diaphragm work with the abdominals acting as part of the
anticipatory postural control system26-27.
Consistent increase in PF activation prior to inc abdominal pressure -->PF activation
matched abdominal force28.
PF activation precedes leg
movements29.
The pelvic floor, diaphragm and abdominal wall coordinate together during breathing and coughing in healthy women30.
Synchronous phase locked parallel movement of diaphragm and PF during quiet and forceful
breathing and coughing30.
IAP increases with inhale; TA and
PF responded to diaphragm26-27.
Core Coordination - start with the breath
Supine hands on lower ribs
“open and close umbrella”
“breathe into your hands”
Supine hand on chest, hand on belly
”try to get both hands to move together”
Progressing into sitting -> standing
Use towel as feedback
Core coordination – whole canister
Layering in the rest of the team
Cue in PF and TA with exhale
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Core coordination – whole canister
Standing forward lean
Progressing into lunge/step
with breathing pattern
Exhale during step
Core coordination – whole canister
Core integration exercises:
Band pull
Resisted push/pull
Squats / sit<>stands
Wall burners
Deadlift progression
Static lunge with lat pull
Core coordination – whole canister
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Pelvic Floor Lengthening Strategies
Most people tend to have difficulty lengthening their PF
Pain
Urgency and frequency
Constipation
The need to ‘strain’ when voiding
Anxiety
Over-active PFM’s can still present as ‘weak’
Women with incontinence demonstrated increased PF EMG compared to continent women both prior to and during postural perturbations31.
95% of women with LBP demonstrated PFM tenderness and/or impaired coordination on internal exam6.
Downtraining
Happy baby
Thoracic rotations
Butterfly stretch
Childs pose
Standing horizontal forward fold
Deep squat
Downtraining
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Virtual Lab Breakout!
Core coordination :
Qped belly drops with diaphragm, TrA, and PF
Resisted push/pull
Band pulls
Down training:
Happy baby
Standing horizontal forward fold
Child’s pose
When to refer for internal pelvic floor assessment…
Referral:
Suspected pelvic organ prolapse
At least one symptom of PFD combined with failure to progress with
traditional PT
Pain with intercourse
Unresolved coccyx pain
Extensive pelvic pain history
If you perform external PFM assessment and are not sure of your findings
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How to refer – resources
• APTA: https://aptaapps.apta.org//APTAPTDirectory/FindAPTDirectory.aspx
• Herman and Wallace: https://pelvicrehab.com/
• Global Pelvic Health Alliance: https://pelvicguru.com/directory/
• International Pelvic Pain Society:
https://www.pelvicpain.org/IPPS/Patients/Find_A_Provider/IPPS/Content/Professional/Find_A_Provider.aspx?hkey=ac3c51ec-0939-499f-a6a0-c72d0aa2f427
Case studies
Consider Patient B…
You are treating a 38 yo female patient with chronic R proximal, posterior hip pain.
3 month history
MRI (-) for hamstring pathology
Denies B/B problems on intake
4 children
Yoga instructor
Pain with resisted hip extension
Limited active hip IR
Limited, painful, and fearful of active trunk flexion
MMT: R hip ER (4-/5), IR (4/5), extension (3+/5)
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More to the story…
6 pregnancies
4 children
One miscarriage
One abortion
Went on bed rest for the 1st pregnancy after the 5th month due to increased BP
Postpartum depression after each pregnancy
Urinary leakage present after increased activity (jogging or jumping) which
she rarely does
Pain is worse during menstrual cycle
Treatment
Internal assessment:
Pain reproduced with palpation of R obturator internus and levator ani
Weak with endurance holds of pelvic floor
Treatment:
Soft tissue lengthening of R obturator internus internally with active hip abduction and adduction
Strengthening of pelvic floor
Graded exposure to fearful positions (bridging and forward folds)
Consider Patient C:
58 yo female referred following L2-S1 spinal decompression
Subjective History:
LBP beginning 25 years ago
R posterior thigh and lateral calf soreness and tingling
Main complaints:
Impaired sleep
Difficulty sitting > 1 hour
Difficulty standing > 1 hour
Difficulty walking > half a mile
Lumbar AROM:
Limited with extension and with R side bending
Sensory Intact to light touch
Reflexes Normal
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More to the story:
Pelvic floor dysfunction for 12 years including rectocele repair, pelvic floor lift, and hysterectomy that resulted in major complications
Splinting with BM
Urgency with urination
Urgency with BM
Perimenopause
Treatment:
Mixed of internal and external interventions
Internal -> PF lengthening then strengthening
External -> core coordination with hip/glute strengthening
In closing:
Start screening for these patients
Screening tools
Asking the hard questions in your history
Or use your intake forms
Moving away from the generic B/B question
Assessing pelvic floor externally
When in doubt – refer to an internal PF therapist
Incorporating the whole canister with core coordination
Breathing pattern
Question and Answer?!
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Meghan Musick
Kim M [email protected]
References:
1. Bonis M, Lormand J, Walsh C. Immediate Effects of Exercise and Behavioral Interventions for Pelvic Floor Dysfunction and Lumbopelvic Pain. J Women’s Health Phys Ther. 2020;44(2):54-62.
2. Moore, I. S., James, M. L., Brockwell, E., Perkins, J., Jones, A. L., & Donnelly, G. M. (2021). Multidisciplinary, biopsychosocial factors contributing to return to running and running related stress urinary incontinence in postpartum women. British Journal of Sports Medicine.
3. Dakic, J. G., Hay-Smith, J., Cook, J., Lin, K. Y., Calo, M., & Frawley, H. (2021). Effect of Pelvic Floor Symptoms on Women’s Participation in Exercise: A Mixed-Methods Systematic Review With Meta-Analysis. Journal of Orthopaedic& Sports Physical Therapy, (0), 1-54.
4. Cassidy T, Fortin A, Kaczmer S, Shumaker J, Szeto J, Madill SJ. Relationship Between Back Pain and Urinary Incontinence in the Canadian Population. Phys Ther. 2017;97(4):449-454.
5. Bush HM, Pagorek S, Kuperstein J, Guo J, Ballert KN, Crofford LJ. The Association of Chronic Back Pain and Stress Urinary Incontinence: A Cross-sectional Study. J Women’s Health Phys Ther. 2013;37(1):11-18.
6. Dufour S, Vandyken B, Forget MJ, Vandyken C. Association between lumbopelvic pain and pelvic floor dysfunction in women: A cross sectional study. Musculoskel Sci Pract. 2018;34:47-53.
7. Eliasson, K., Elfving, B., Nordgren, B., & Mattsson, E. (2008). Urinary incontinence in women with low back pain. Manual therapy, 13(3), 206-212.
References:
8. Tamaki, T., Oinuma, K., Shiratsuchi, H., Akita, K., & Iida, S. (2014). Hip dysfunction‐related urinary incontinence: A prospective analysis of 189 female patients undergoing total hip arthroplasty. International Journal of Urology, 21(7), 729-731.
9. Yi J, Tenfelde S, Tell D, Brincat C, Fitzgerald C. Triathlete Risk of Pelvic Floor Disorders, Pelvic Girdle Pain, and the Female Athlete Triad. Female Pelvic Med Reconstr Surg. 2016;22(5):373-376.
10. Dakic, J. G., Hay-Smith, J., Cook, J., Lin, K. Y., Calo, M., & Frawley, H. (2021). Effect of Pelvic Floor Symptoms on Women’s Participation in Exercise: A Mixed-Methods Systematic Review With Meta-Analysis. Journal of Orthopaedic& Sports Physical Therapy, (0), 1-54.
11. MacArthur, C., Wilson, D., Herbison, P., Lancashire, R. J., Hagen, S., Toozs‐Hobson, P., ... & Prolong Study Group. (2016). Urinary incontinence persisting after childbirth: extent, delivery history, and effects in a 12–year longitudinal cohort study. BJOG: An International Journal of Obstetrics & Gynaecology, 123(6), 1022-1029.
12. Podschun, L., Hanney, W. J., Kolber, M. J., Garcia, A., & Rothschild, C. E. (2013). Differential diagnosis of deep gluteal pain in a female runner with pelvic involvement: a case report. International journal of sports physical therapy, 8(4), 462.
13. Saunders, K. (2017). Recent advances in understanding pelvic-floor tissue of women with and without pelvic organ prolapse: considerations for physical therapists. Physical therapy, 97(4), 455-463.
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References:
14. Wiegersma M, Panman CM, Berger MY, De Vet HCW, Kollen BJ, Dekker JH. Minimal Important Change in the Pelvic Floor Distress Inventory-20 among Women Opting for Conservative Prolapse Treatment. Am J Obstet Gynecol. 2017;216:397.e1-7.
15. Barber MD, Walters MD, Bump RC. Short Forms of Two Condition-Specific Quality-of-Life Questionnaires for Women with Pelvic Floor Disorders (PFDI-20 and PFIQ-7). Am J of Obstet and Gynecol. 2005;193:103-113.
16. Keizer A, Vandyken B, Vandyken C, Yardley D, Macedo L, Kuspinar A, Fagahani N, Forget MJ, Dufour S. Predictors of Pelvic Floor Muscle Dysfunction Among Women with Lumbopelvic Pain. Phys Ther. 2019;99(12):1703-1711.
17. Saunders, K. (2017). Recent advances in understanding pelvic-floor tissue of women with and without pelvic organ prolapse: considerations for physical therapists. Physical therapy, 97(4), 455-463.
18. Lee, K. (2018). Activation of pelvic floor muscle during ankle posture change on the basis of a three-dimensional motion analysis system. Medical science monitor: international medical journal of experimental and clinical research, 24, 7223.
19. Zhoolideh, P., Ghaderi, F., Salahzadeh, Z., Adigozali, H., Azghani, M. R., Jafarabadi, M. A., & Seleme, M. R. (2021). The Relationship Between Static Standing Posture and Common Pelvic Floor Disorders. Muscles, Ligaments & Tendons Journal (MLTJ), 11(1).
20. Sapsford, R. R., Richardson, C. A., Maher, C. F., & Hodges, P. W. (2008). Pelvic floor muscle activity in different sitting postures in continent and incontinent women. Archives of physical medicine and rehabilitation, 89(9), 1741-1747.
References:
21. Sperstad, J. B., Tennfjord, M. K., Hilde, G., Ellström-Engh, M., & Bø, K. (2016). Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. British journal of sports medicine, 50(17), 1092-1096.
22. Gluppe, S. L., Hilde, G., Tennfjord, M. K., Engh, M. E., & Bø, K. (2018). Effect of a postpartum training program on the prevalence of diastasis recti abdominis in postpartum primiparous women: a randomized controlled trial. Physical therapy, 98(4), 260-268.
23. Crommert, M. E., Flink, I., & Gustavsson, C. (2021). Predictors of disability attributed to symptoms of increased interrecti distance in women after childbirth: an observational study. Physical Therapy.
24. Dufour S, Vandyken B, Forget MJ, Vandyken C. Association between lumbopelvic pain and pelvic floor dysfunction in women: A cross sectional study. Musculoskel Sci Pract. 2018;34:47-53.
25. Zhoolideh, P., Ghaderi, F., Salahzadeh, Z., Adigozali, H., Azghani, M. R., Jafarabadi, M. A., & Seleme, M. R. (2021). The Relationship Between Static Standing Posture and Common Pelvic Floor Disorders. Muscles, Ligaments & Tendons Journal (MLTJ), 11(1).
26. Hodges, P. W., Sapsford, R., & Pengel, L. H. M. (2007). Postural and respiratory functions of the pelvic floor muscles. Neurourology and urodynamics, 26(3), 362-371.
27. Hodges, P. W., Butler, J. E., McKenzie, D. K., & Gandevia, S. C. (1997). Contraction of the human diaphragm during rapid postural adjustments. The Journal of physiology, 505(2), 539-548.
References:
28. Sapsford, R. R., Hodges, P. W., Richardson, C. A., Cooper, D. H., Markwell, S. J., & Jull, G. A. (2001). Co‐activation of the abdominal and pelvic floor muscles during voluntary exercises. Neurourology and Urodynamics: Official Journal of the International Continence Society, 20(1), 31-42.
29. Sjödahl, J., Kvist, J., Gutke, A., & Öberg, B. (2009). The postural response of the pelvic floor muscles during limb movements: a methodological electromyography study in parous women without lumbopelvic pain. Clinical biomechanics, 24(2), 183-189.
30. Talasz, H., Kremser, C., Kofler, M., Kalchschmid, E., Lechleitner, M., & Rudisch, A. (2011). Phase-locked parallel movement of diaphragm and pelvic floor during breathing and coughing—a dynamic MRI investigation in healthy females. International urogynecology journal, 22(1), 61-68.
31. Smith, M. D., Coppieters, M. W., & Hodges, P. W. (2007). Postural response of the pelvic floor and abdominal muscles in women with and without incontinence. Neurourology and urodynamics, 26(3), 377-385.
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