Dufour, S., Forget, M., Vandyken, B., Vandyken, C. (2018). Musculoskeletal Science and Practice, 34, 47-53.
Abstracted by: Samantha Bennett SPT, Missouri State University, Springfield, Missouri
Low back pain a common and debilitating injury that is the number one reason for visiting a primary health care provider (Beaudet et al., 2013). Low back pain is frequently treated without consideration of the pelvic floor to be included in the whole care of the patient. There is a great deal of anecdotal evidence that supports pelvic floor physical therapy involvement in the treatment of lumbosacral pain in females, but there is limited research evidence that supports specific causation between low back pain (LBP) and pelvic floor dysfunction (PFD).
The aim of this study is to investigate the association between lumbopelvic pain and PFD in women. The study analyzed a group of 85 non-pregnant adult females who presented to an orthopedic physiotherapy clinic for low back pain and consented to being included in the study knowing that there would be a digital pelvic floor exam. Participants were excluded if they demonstrated narcotic use, high levels of catastrophization (via Pain Catastrophization Scale), radiculopathy symptoms, and lack of consent to an internal exam of the pelvic floor.
Participants were assessed via four different examination procedures. Participants were assessed for pelvic organ prolapse (POP) for the purpose of determining the status of the connective tissues in the pelvic floor. The patients were evaluated for cystocele, rectocele, and procidentia (uterine prolapse). Pelvic floor muscle (PFM) strength was assessed for the purpose of identifying weakness or non-recruitment of PFM. PFM tenderness was assessed to note muscular tenderness and myofascial pain. In order to assess pain in the joints of the pelvic girdle or hip, a Forced FABER Test was performed in which a positive result was pain in the position of the leg being flexed, abducted, and externally rotated while in supine.
The study concluded that of the 85 participants, 62.4% reported urinary incontinence, 41.2% were found to have POP, and 95.3% were found to have objective pelvic floor dysfunction. The study is not blinded and there is a lot of potential for sampling bias since the participants are volunteers and have to consent to an internal exam. Additionally, the study is observational rather than experimental. Although there are many flaws with this study, it seems clear that there is a strong relationship between pelvic floor dysfunction and low back pain.
Personal Commentary:
I went to a pelvic floor physical therapy course this past weekend and became very interested in the overlap between low back pain patients and pelvic floor dysfunction due to the interaction of musculoskeletal structures between the pelvis and the low back. There is much anecdotal evidence for the link between the two, but it wasn’t the focus of the course. I have never considered pelvic floor relationships for my low back patients in clinical internships, but I’m starting to wonder if some of those patients could have benefited from seeing a pelvic floor physical therapist to add in that final component to their treatment and resolve their back pain.
Many women encounter PFD at some point in their lives and could potentially benefit from addressing these issues, but there is an unfortunate stigma associated with the pelvic floor for both men and women. As demonstration of the discomfort and shame associated with this part of the body, one of reasons that many women were excluded from this study is because they were not willing to have a pelvic floor assessment (Dufour, 2018). This is why it is important to assess for bowel, bladder, and sexual health in the subjective interview to get a clearer picture of the patient’s pathology. I plan to work in pelvic health where people are more willing to share this part of their medical history when asked, but I intend to watch carefully for signs of PFD in future non-pelvic orthopedic patients while sensitively addressing these issues.
References:
Beaudet, N., Courteau, J., Sarret, P., Vanasse, A., 2013. Prevalence of claims-based recurrent low back pain in a Canadian population: a secondary analysis of an administrative database. BMC Musculoskelet. Disord. 14 (1).