PELVIC FLOOR AND PREGNANCY

What is your pelvic floor?

Your pelvic floor is a ‘sling’ of muscles that attach from your pubic bone in front to the tail bone of the spine. The urethra, vagina and anus all pass through the pelvic floor.

What does your pelvic floor do?

Your pelvic floor helps to support your abdominal contents, as well as control your bladder and bowel functions. It also helps to increase sexual awareness for both yourself and your partner during sexual intercourse. They work in sync with the core abdominal muscles to support your back.

Why do I need to improve my pelvic floor strength?

Strengthening your pelvic floor can help you to

• avoid losing urine, gas or faeces when you exert yourself with activities such as coughing, sneezing, jumping or lifting (stress incontinence)
• Reduce the risk or improve the symptoms of prolapse
• Improve recovery after childbirth and surgery for bladder prolapse, hysterectomy
• Increase sexual sensation and awareness to improve orgasmic potential
• Increase confidence and quality of life

What happens to the pelvic floor during and after pregnancy?

During pregnancy, the weight of the baby can put excess pressure on the pelvic floor, making it need to work harder in order to support your abdomen. Pregnancy related hormones can also weaken the pelvic floor muscles. During a vaginal delivery, the baby passes through the pelvic floor, stretching and often tearing the muscles. During a cesarean section, the core abdominal muscles are cut, which makes it difficult for them to work in conjunction with the pelvic floor to support your back.

How do I improve my pelvic floor strength?

It is important to work with a qualified professional such as a physioFIX Holland Park physiotherapist to isolate and improve your pelvic floor strength. Especially after childbirth or surgery, it can be easy to contract incorrect muscles which can put excess pressure on the pelvic floor. A physiotherapist will be able to check that you are contracting the muscles correctly and identify a suitable exercise program for you to help you get back to your everyday functions as well as sport.

It is never too late to start doing pelvic floor strengthening exercises. Research shows that the pelvic floor responds very well to exercise, and most women are able to overcome their incontinence problems with the correct advice.

Practice your pelvic floor exercises during pregnancy and continue them after childbirth. Even women having a cesarean childbirth will benefit from pelvic floor strengthening.

How do I contract my pelvic floor muscles?

 

1. Pretend that you are going to the toilet and you have to stop half way. You should feel your pelvic floor lift as you pretend to stop the flow of urine. You may also feel your lower abdomen draw in.
2. Breathe normally and hold the muscle contraction for 4-8 seconds. Repeat 4-8 times.

You should not experience any pain or worsening of your symptoms from performing these exercises. If you are having any difficulties with these exercises, or your feel your symptoms are not improving, contact your physioFIX physiotherapist for an assessment.

ANKLE SPRAINS

What is a sprained ankle?

A sprained ankle occurs when the medial (inside) or lateral (outside) ligaments that support the ankle are overstretched or torn. This usually happens through activities such as running, jumping, sharp direction changes, stepping on uneven ground or falling down.

A ligament is a strong band of connective tissue which attaches from bone to bone. It supports the ankle and prevents excessive movement. Ankle sprains usually occur on the lateral side of the ankle. There are three ligaments that provide stability to the lateral ankle. They are:

• Anterior talo-fibular ligament (ATFL) - goes from the talus to the fibula. This is the most commonly injured ligament.

• Calcaneo-fibular ligament (CFL) - goes from the calcaneus to the fibula

• Posterior talo-fibular ligament (PTFL) - goes from the talus to the fibula

The soft tissues and even the bones around the ankle can also become damaged when you sprain your ankle. Afterwards, muscle weakness and tightness, joint stiffness and poor proprioception can complicate the healing process and predispose you to future ankle sprains. Therefore it is important to seek appropriate treatment from your physiotherapist

What are the signs and symptoms of a sprained ankle?

• audible tear or snap at the time of injury
• pain and swelling
• bruising
• stiffness and reduced range of motion
• inability to put weight through injured leg

What can you do to help?

In the first 48 - 72 hours:

• RICE- Rest, Ice, Compression, Elevation. Use crutches and anti-inflammatory medications if necessary

Avoid activities that aggravate your ankle, ie. Increases pain or swelling 

• During the activity
• Upon rest after activity, or
• Increases the morning after activity

What can a physio do to help?

A physiotherapist will usually be able to diagnose a sprained ankle. Sometimes X-rays, MRIs or CT scans can confirm diagnosis and rule out other injuries such as fractures. Treatment may include:

• soft tissue massage
• joint mobilization
• anti-inflammatory advice and education
• ankle taping or bracing
• exercises to help improve flexibilty, strength and balance
• electrotherapy (eg. ultrasound)
• biomechanical correction
• a gradual return to activity program

Residual ankle instability - Occasionally the ligaments may not heal completely and become weaker or looser than pre-injury levels. This causes the joint to become more unstable, which puts you at a higher risk of re-spraining your ankle. The more frequently you sprain your ankle, the greater chance you have of re-spraining it yet again. Therefore, physiotherapy treatment for sprained ankles is important in order to reduce the chance of further sprains.

EXERCISES FOR SPRAINED ANKLES

Plantarflexion/Dorsiflexion (Foot pumps)

• Point your foot up and down as far as possible without causing pain

Progress: add Theraband for resistance

Inversion/Eversion

• point your foot inwards and outwards as far as possible without causing pain

Progress: add Theraband for resistance

Calf strengthening

• stand in front of a steady table or wall

• do a heel raise onto your toes

• hold for 5 seconds and slowly come down

Progress: do this on the stairs, holding on to the rail. Have half your foot on the step so that you can bring your heel below your toes and stretch your calf

Calf stretches

Lunge stretch

• lunge facing the wall, with your front leg bent and back leg straight

• keep your back heel down, and gently lunge forward until you feel a stretch in the back leg and knee

Knee to wall

• lunge facing the wall with the front leg bent and slightly away from the wall

• keeping your front heel down, lunge forward until the front knee touches the wall. You should feel a stretch in the lower calf of the front leg

Balance

• Heel raises
• Single leg stance
• Single leg stance plus heel raise

Advanced training

• Step ups/downs
• Hopping
• Figure 8s, zig zags
• Running

Perform 10-20 repetitions of each prescribed exercise,and repeat 3 times a day. These exercises should not cause or increase pain. Please contact your physioFIX physiotherapist if you have any questions regarding this information.

CORE STABILITY TRAINING

What are my core muscles?

Your core muscles include your Transversus Abdominis (TA), pelvic floor, multifidus and diaphragm muscles. They form a corset like structure around your lower back and hips to stabilize each spinal segment and pelvic bone during any activity eg. Walking, lifting, bending.

In particular, your TA is a muscle underneath your six-pack that wraps around your stomach to your lumbar spine and hips. Lower back pain can inhibit and weaken these muscles until they cannot support your back effectively.

How do I contract my TA muscle?

1. Lie on your back with a neutral lumbar spine, knees bent up 
2. Place your fingers 1 inch inside and down from your hip bone in front 
3. Gently breathe in and out, and relax your tummy completely 
4. Slowly draw in your lower abdomen (the area below your belly button) towards your back 
  

• you may feel your pelvic floor drawing up
• you may feel your lower abdominal muscles growing wider

 
5. Breathe normally and hold the muscle contraction for 5-10 seconds. Repeat 5-10 times, and do this 3-5 times a day 
6. Ensure that

• your stomach should be relaxed. You should not feel muscles bulging out
• you keep breathing - do not hold your breath

How do I contract my Pelvic Floor muscles?

• Lie on your back with a neutral lumbar spine, knees bent up

• Pretend that you are going to the toilet and you have to stop half way. You should feel your pelvic floor lift as you pretend to stop the flow of urine you may feel your lower abdomen draw in 
• Breathe normally and hold the muscle contraction for 5-10 seconds. Repeat 5-10 times and do this 3-5 times a day.

Check that you are doing the right exercise by?

• Stopping mid stream

• During urination, try to slow or stop the flow mid-stream by pulling your pelvic floor up. Only do this once a week as a test

• Feeling for lift - place your hand firmly under your perineum as you sit in a chair. As you draw up the pelvic floor muscles, you should feel a gentle lift up from your hand if you feel a sense of bulging down, stop the exercise and consult a physiotherapist

Contract these muscles before you walk, lift, get out of the car, or do strenuous activity. These exercises should not cause or increase pain. Please contact your physioFIX physiotherapist if you have any questions regarding this information.

SCIATICA

Sciatica is a symptom caused by irritation, compression or damage to the sciatic nerve. The sciatic nerve is a nerve that starts from your lower back and then runs through the buttock muscles and down through your lower back to your foot. It provides sensation to the leg and controls the leg muscles.

Sciatica - Symptoms

Sciatica commonly refers to pain, tingling, pins and needles, numbness, burning or weakness typically going down one leg. In severe cases, the sciatica symptoms can be present in both legs. It can cause pain so severe that walking may be difficult.

Sciatica - Causes

It is important to know that sciatica is a symptom rather than the problem itself. Common causes of sciatica include:

• Disc bulge
• Disc degenerative disease
• Spinal stenosis- where the spinal canal narrows, and may compress the sciatic nerve or spinal cord
• Irritation of the nerve root as it exits the spine
• Piriformis syndrome- tightness in the buttock muscles that the sciatic nerve runs through
• Damage to the sciatic nerve
• Spinal or pelvic fractures
• Less commonly, tumours

Sciatica - Diagnosis

If you have any of these symptoms, you should seek the advice of your doctor or physiotherapist immediately. A physioFIX physiotherapist can help diagnose a lumbar disc bulge based on your history, symptoms and presentation. Investigations such as X-rays, CT scans or MRI scans can sometimes be used to supplement a physiotherapy assessment.

Sciatica - Treatment

Physiotherapy treatment for sciatica may include:

• Mobilizations of your lumbar spine
• Soft tissue work in your lower back and buttocks to reduce muscle spasm
• Stretches
• Core stability exercises including Pilates
• Acupuncture
• Electrotherapy
• Hydrotherapy
• Postural taping
• Postural and activity advice

Whilst you are recovering, it is important to avoid postures or activities that can aggravate the nerve. This commonly includes forward bending positions or lifting your leg up with your knee straight and hips bent. 

Sometimes gentle stretching can help relieve your symptoms, other times even this may aggravate your pain. This is why it is important to see your physioFIX physiotherapist to get a program tailored to your specific condition.

LOW BACK PAIN - DISC BULGES

(Herniated disc, prolapsed disc, ruptured disc, disc protrusion, disc disease, disc degeneration, degenerative disc disease)

Disc bulges are a common cause of back pain in the adult population. This can be caused by an acute traumatic incident or wear and tear on the disc over time. An intervertebral disc sits between each vertebrae of the spine. The disc is made of an outer strong fibrous ring (annulus fibrosis) and an inner softer core (nucleus pulposes). The core changes shape during movement to absorb shock forces. If the outer layer becomes torn, the jelly-like core can protrude outside, causing a disc bulge.

As the lower levels of the spine carry a heavier load than the upper ones, they undergo more stress. Hence the lowest disc of the spine (L5/S1) is most commonly affected with the disc above (L4/L5) the second most common.

Causes of a lumbar disc bulge

A traumatic incident such as a motor vehicle accident or lifting a heavy object may forcefully cause a disc bulge. However, most disc bulges are an accumulation of repetitive, forceful or prolonged stressors over time causing delayed inflammatory disc pathologies. These stressors include

• Bending forward
• Prolonged sitting in a poor posture 
• Lifting and/or twisting

Interestingly, some patients can get a disc bulge following a minor movement such as bending to pick up a piece of paper or sneezing. In these instances, the disc has normally been subject to repetitive or prolonged bending, sitting or lifting forces leading up to the incident.

Other causes of disc bulges include:

• Poor core stability to support the lumbar spine
• A sedentary lifestyle causing muscle weakness and tightness
• Being overweight
• Poor lifting technique
• Poor posture

Signs and symptoms of a lumbar disc bulge

Acute disc bulge patients commonly complain of:

• Sudden onset of severe back or leg pain
• Very limited back movement
• Pain with coughing, sneezing, sitting to standing
• Occasionally, listing their posture to one side

 Delayed inflammatory onset disc bulge patients commonly complain of:

• Gradual or delayed onset of diffuse back or leg pain- generally the day after the aggravating activity
• Limited back movement
• Pain in the morning

 Both patients can complain of sciatica symptoms, especially if the disc is compressing on the nerves that exit at the vertebrae and go down the legs. These symptoms include pain, pins and needles, numbness or weakness typically going down one leg. In severe cases the sciatica symptoms can be present in both legs.

Diagnosis

A physioFIX physiotherapist can help diagnose a lumbar disc bulge based on your history, symptoms and presentation. Investigations such as x-rays, CT scans or MRI scans can sometimes be used to supplement a physiotherapy assessment.

Treatment for a lumbar disc bulge

The majority of lumbar disc bulge patients make a quick full recovery with appropriate physiotherapy and do not require surgery.

Firstly it is important to avoid any activities that aggravate your back pain, such as sitting, bending forwards and lifting. You should avoid sitting for more than 15 minutes at a time. If you do need to sit, sit with a good posture (see Tips for Healthy Computer Use). Typically, lying down with your back straight, small periods of standing and walking, and back stretches will help with your pain. Consult your doctor or pharmacist about pain relief medications if necessary. You can use a heat pack to help reduce muscle spasm. All these activities will help your body recovery and minimize further protrusion of the disc.

The following physiotherapy techniques can help with disc bulge:

• Gentle mobilizations of the lumbar spine
• Massage to reduce muscle spasm
• Stretches (commonly into back extension)
• Gentle mobilization exercises- knee rocking, knee to chest
• Electrotherapy
• Acupuncture
• Core stability strengthening including Pilates
• Hydrotherapy
• Postural taping
• Postural and activity advice

With appropriate physiotherapy, symptoms typically take 2-3 weeks to start to settle. However, it takes approximately 6 weeks for the damaged tissue to heal to about 80% of its original strength.

Other interventions for a Lumbar Disc Bulge

Despite appropriate physiotherapy management, some disc bulges fail to improve and may require other investigations and treatment. Generally it is advisable to attend at least 6 weeks of physiotherapy treatment before seeking specialist advice. However, if you experience constant prolonged or worsening severe pain symptoms limiting movement, loose bladder or bowel control, or have paraesthesia in your private areas due to your disc bulge, you may require emergency surgery.

STRETCHES TO RELIEVE MUSCLE TIGHTNESS

Upper Trapezius stretch

1. Sit up tall and tuck your hands underneath your thigh

2. Bring your left ear to your left shoulder, until you feel a mild to    moderate pain-free stretch in your right side neck and shoulder.
3. Progress: Keep your left ear to your left shoulder, and look down and into the right armpit
4. Hold for 10-20 seconds, and repeat on the other side

Levator Scapula stretch

1. Sit up tall and tuck your hands underneath your thigh
2. Bring your left ear to your left shoulder, and look down and into your left armpit
3. Hold for 10-20 seconds, and repeat on the other side

Foam Roller Thoracic Extension stretch

Stage 1

1. Lie on your back and place the foam roller down the length of your spine breathe normally and keep your back and neck relaxed
2. Lie for 5-10minutes. It should feel slightly uncomfortable but not painful

Stage 2

1. Lie on your back and place the foam roller across the back
2. Keep your hands by your side on the ground breathe normally, keeping your back and neck relaxed. Use a pillow if necessary
3. Hold for 30 seconds- 1 minute. It should feel slightly uncomfortable but not painful move the roller up or down a few centimetres and repeat along the length of your upper back

Stage 3

1. Repeat stage 2, and move the roller continually up and down the spine
2. Repeat stage 2, and raise your hands above your head and rest them on the ground

This advice should not cause or increase pain. Please contact your physioFIX physiotherapist if you have any questions regarding this information