Lily is a 50-year-old mother of two who works as a receptionist at a local dentist office. Her day-to-day duties include answering patient phone calls, calling insurance, and scheduling appointments. This typically results in sitting for long periods of time until her lunch break, where she will try to squeeze in a quick walk. Lily is also dealing with a move from one house to another since she and her husband are now empty nesters. She has recently begun to experience some low back pain that has steadily crept in from her low back to her left glute to halfway down her left hamstring. After doing some research and trying a few stretches on her own with minimal pain reduction, Lily decides to make an appointment with her local physical therapist (PT). To her surprise, at the first appointment the PT starts asking if Lily has ever had any bladder or bowel leakage or urgency. Lily, being a mother of two, goes “oh of course I wet my underwear at least once a day, but it has been that way forever. Besides, it’s to be expected after giving birth”. Thankfully, Lily’s physical therapist is looking at the broader picture than just the low back and makes sure to educate Lily that this indicates pelvic floor muscles weakness and is associated with her low back pain.
Many of us think of the core as the abdominal muscles, spine, and back muscles which essentially make a cylinder. What many people don’t realize is that the core is also made up of the diaphragm, a dome shaped muscle at the bottom of the rib cage that helps to pull air into the lungs like an upside-down syringe, and the pelvic floor muscles that make up the sling at the bottom of the pelvis. The diaphragm is the top of the cylinder, the pelvic floor is the bottom, and the core muscles of the abdomen and back are the walls of the cylinder. They all function together and it is important to have good strength, endurance, and control over these muscles to decrease risk of back pain and pelvic concerns like urine leakage and pelvic prolapse. Unfortunately, the pelvic floor is often ignored during the rehabilitation of low back pain as many providers choose to emphasize abdominal strength only. However, studies have shown that there is a relationship between low back pain and pelvic floor dysfunction (weakness, lack of control, and/or pain).
For example, a study looked at 225 women in Saudi Arabia with an average age range of 39-54 years old that has low back pain. The majority (69%) had multiple spontaneous vaginal births. About half of the women with chronic low back pain suffered from neuropathic (nerve) pain which was found to be significantly associated with pelvic floor dysfuncton.1Another study of 108 women found that uncontrollable urinary urgency, central sensitization (increased sensitivity of the brain and spinal cord nerves), and lumbopelvic pain (pain in low back, hip, pelvis and gluteal region), were predictive of pelvic floor discomfort with internal examination. Central sensitization refers to increased sensitivity of the nervous system that is associated with persistent pain.2 Another study compared two groups; one received ultrasound, short-wave diathermy (heat-based therapy), and back strengthening exercises while the other received the same treatments plus pelvic floor strengthening 3 times per week over a 24 weeks time frame. Those who participated in pelvic floor exercises had significantly lower pain severity and disability scores than the other groups. Both groups demonstrated improvement in trunk muscle function, such as range of motion.
Let’s best honest - back pain is common. About 80% of people will have repeated episodes of back pain and 10-40% will develop chronic or persistent low back pain that occurs for 12 or more weeks. About one third of people will experience nervous system pain, or neuropathic pain during their life.1 In addition to addressing the pelvic floor, it is important to create a well-rounded approach to back pain. There is strong evidence to support the use of exercise to address trunk muscle strength, trunk muscle endurance, aerobic exercise, aquatic exercise, and general exercise. There is also strong evidence to use active treatments, such as physical therapy, yoga, stretching, Pilates, and strength training, as well as education for those with persistent low back pain. There is moderate evidence for the use of massage for pain relief, especially in acute onset low back pain.4 Passive treatment to calm pain such as chiropractic care, acupuncture, and massage therapy can all help reduce pain, but they will not provide increased tissue strength and long term pain reduction that allows for increased function of movement. Research shows that active treatment strategies, such as physical therapy, show the highest success for long term pain reduction and increased functional improvement to allow you to move and live life without flaring your pain every time. No one wants pain, but we also do not want to have to stop moving and living to avoid pain from kicking on. It is so important to decrease pain while also increasing strength to allow the body to move freely without pain!
Exercise can have multiple benefits aside from directly effecting the spine or pelvic floor. For instance, aerobic exercise has been recommended for the treatment of chronic low back pain to improve pain and disability. A study performed on 101 power plant workers (male and female) found that 10-15 minutes of aerobic warm up on a stationary bike at a moderate pace followed by aerobic exercise, such as treadmill walking, stair climbing, or biking) for 30-45 minutes at 3 days per week at a particular intensity (70-85% of maximal heart rate) over 12 weeks demonstrated significant improvement in pain and disability as compared to those who only received passive treatment (TENS, ultrasound, heat, and interferential current) for 3 days per week over 12 week. Aerobic exercise has additional benefits in regard to increased physical activity tolerance and improved mood, sleep, and relaxation, which are especially important during healing.
Remember, it is important to not only address the structural, or physical, components that are contributing to back pain. It is also vitally important that your physical therapist addresses your beliefs, emotions, and behavioral responses associated with the back pain and every-day life. If these additional factors are not addressed than there can be increased risk that an acute instance of back pain becomes chronic. Believe it or not, your ideas about pain, ability to heal and get better, anxiety, and depression can increase the risk of low back pain.
In summary, if you are suffering from low back pain make sure that your PT is acknowledging other areas of the body that may be contributing to your pain, such as your pelvic floor. He or she should also incorporate discussion of how you are feeling regarding your body and your healing. If you have been dealing with persistent low back pain please note that not all PT’s are skilled at addressing the pelvic floor so please do your research and try to find a skilled pelvic floor PT, as pelvic floor dysfunction could be an overlooked contributing factor to your pain!
Written by Jordan Schmidt, PT, DPT
Edited by Molly Hart, PT, DPT
Murtezani, A., Hundozi, H., Orovcanec, N., Sllamniku, S., & Osmani, T. (2011). A comparison of high intensity aerobic exercise and passive modalities for the treatment of workers with chronic low back pain: a randomized, controlled trial. European journal of physical and rehabilitation medicine, 47(3), 359–366.