Combined Treatment for the Low Back and Pelvic Floor

By: Sarah Ellis Duvall, PT, DPT, CPT, Core Exercise Solutions LLC

What happens when a patient comes in with back pain from repeated forward bending but they also have a pelvic floor issue? This is more common than we realize since so many women think leaking is normal and fail to even admit to it when asked. I often have to ask more than once.

So, what then?

After you diagnose and treat the back, you need to prevent it from happening again and to do this you have to be able to generate and sustain intra-abdominal pressure to keep a spine healthy. That’s low back treatment 101 (thank you, McGill).  But, what if intra-abdominal pressure makes their pelvic floor worse? What if the pelvic floor treatment that worked for them was decreasing all intra-abdominal pressure? How do we mix that with creating spinal stability to make the entire system happy?

First we need to understand that not all pressure is bad, we just need to teach the pelvic floor how to handle it and find some middle ground between pelvic floor PT and the ortho world before we confuse all our patients with all or nothing thinking. So, let’s take a closer look at a progression with a patient that has mild urinary incontinence with pressure (coughing or sneezing) and a suspected herniated disc. This is an incredibly common scenario because postpartum moms are picking up heavy car seats and bending awkwardly over changing tables and cribs and they tend to be the highest subset with pelvic floor issues. It’s a great combo of postpartum ligament laxity and poor postural movement habits.

Here is a step by step breakdown of treatment:

#1. Get her diaphragm working. This will naturally help turn on the pelvic floor as well as provide a dynamic stabilization system to the spine. Not just deep belly breathing, but make sure you are getting a 360 expansion of her diaphragm. This will provide some spinal traction as well.

#2. Make sure her pelvic floor is coordinating with her diaphragm. This step might take a a bit of work and ability to feel. (Pelvic floor PT that uses biofeedback is incredibly helpful for this.) I will also have the patient palpate themselves if they can’t “mentally feel” in the comfort of their own home. Usually, they can physically feel if they take a large enough breath. Deep squatting also helps with mental feeling. Just make sure you instruct the patient to direct the pressure from a breath down but not bare down on their pelvic floor during the inhale.
Inhale: diaphragm goes down, pelvic floor relaxes
Exhale: diaphragm goes up, pelvic floor contracts

Deep Squat Exercise for 360 Diaphragm Expansion:

#3. Now it’s time to teach her to brace - even if she has to hold her breath a little in the beginning. Yep, I said it, create intra-abdominal pressure. BUT, you must make sure that the pelvic floor is coordinating. If not, you will make a pelvic floor issue worse! If a patient is having a hard time figuring out how to brace, just have them cough and hold it. Then move on conscious control from there. Now, if the pelvic floor is coordinating, this isn’t an issue, a cough (forced exhale) should cause a recoil up of the pelvic floor, effectively managing pressure in the trunk to stabilize the spine.

#4. Teach her to brace, breathe and move. This is hard one but absolutely possible through great exercises like McGill’s Bird Dog and Side Planks. You may need to start with a classic deadbug before advancing to these. Getting back body diaphragm expansion while holding a side plank will change your patient’s world.
Start with sideplanks from an elevated surface, then advance to the floor, then finally add a balloon.

Advanced sideplanks:

Make sure her diaphragm is coordinating with her pelvic floor. Absolutely no breath holding during this. Learning to manage spinal stability while breathing is the goal!

#5. Teach a hip hinge. This is a must but extremely hard to teach unless you have some core stability first. If a patient can’t stabilize their spine, then eccentric glute loading is virtually impossible. She will need this hip hinge for picking up that child a zillion times per day!

Learn how to hip hinge:

#6. Build a great squat with tons of eccentric glute loading. I also love to throw in the diaphragm for this one as well as the pelvic floor. The goal is to get all the parts moving and coordinating so it becomes second nature. Plus, great glutes = a safe back and a great pelvic floor!

Squat with pelvic floor timing:

#7. Both the low back and pelvic floor need hip rotation. If her hips don’t rotate properly, then her low back has to do more rotation. Not what we want from a back pain patient, especially one with a forward flexion injury. The pelvic floor also plays off the loading of the hips. So, building a dynamic reactive pelvic floor means you need hip rotation.

Start with a basic lunge, then work up to this rotation.

This exercise brings together core stability through transverse plane loading and hip rotation. Most patients will automatically feel their pelvic floor fire. The pelvic floor can’t help it; there is just too much stimulation from the deep core, deep hip rotators and adductors to resist firing in this exercise, which makes it such a great exercise for the pelvic floor.

Lunge with Rotation:

#8. Assess overall alignment. Does the patient have a forward head? Do they stand with their knees locked? Posture is huge for both the treatment of the low back and pelvic floor. These are pieces of the puzzle that need to be addressed.

#9. Don’t forget about the top of the lumbar spine. Do they have thoracic spine stiffness? Same as with the hips, if the thoracic spine is not rotating and extending properly then the lumbar spine will take a beating. Not to mention the increased risk in pelvic floor issues from poor posture. Gaining 360 diaphragm expansion will really help with this.

#10. Last but not least, don’t forget about the feet. They are the foundation for the entire body. Weak arches + tight posterior chain = compensation up the chain.  Make sure she can engage her arches and has plenty of ankle dorsiflexion. If you want to get fancy, be sure to check for talus movement as well.  

This is a long list, but a comprehensive one. You probably won’t get repeat business from this patient because you will fix them so well, but you can guarantee they will tell everyone they know what an awesome PT you are! 

Want to learn more? Check out Sarah's 3hr CEU class on the Pelvic Floor [HERE]. This class takes a closer look at how the kinetic chain affects the pelvic floor. Take away effective new exercises to implement immediately into your program.

Sarah Ellis Duvall, PT, DPT, CPT

Sarah is a PT with passion. She has owned an out of pocket pay practice for a decade and enjoys treating both ortho and women’s health issues. Her passion lies in bringing together the big picture and treating the body as a whole. She is also a mom and adventure sports athlete.  

Find out more at

Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic...

Disruption- A radical change in an industry or business strategy, especially involving the introduction of a product or service that creates a new market. To cause disorder or turmoil in. To destroy, usually temporarily, the normal continuance or unity of 

Disruption. We see and hear that word a lot these days. We even have the #disruPT hashtag. Disrupting has become almost a buzz word not only in healthcare but in other industries as well. However, there is a fine line between disruption and simply improving upon an existing model, not that there's anything wrong with that. But true disruption makes the old business model obsolete. Following the obsolete model leads to irrelevance. And not being involved in the disruption can lead to destruction. 

History books are filled with stories of disruptors. The Wright Brothers were disruptors. Henry Ford was a disruptor. Steve Jobs and Apple were disruptors. Facebook and Twitter are disruptors. Napster in the late 90's and more recently, Netflix, were disruptors. Gary Vaynerchuk is a disruptor. Is Elon Musk a disruptor? It certainly seems like he could be with what he's doing with Tesla and Space-X, but ultimately time will tell.

We see that disruption can come in all shapes and sizes. What may appear now as only tiny ripples could very well become tidal waves of change in years to come. Yet, the question remains: is the PT profession ready for it? Is the general public truly ready for it? Was the music industry ready for iTunes? Bottom line, I don't think it matters if we're ready-- it's necessary and it's coming. What matters is if you're going to be a part of it or not. 

In the PT world,  I see direct access as the most significant disruption to the status quo. As far as individuals go, whether you like or agree with him or not, Dr. James Dunning is a disruptor. He is effecting the scope of practice not only within PT but also the chirporactic and acupuncture professions. I also think that John Childs with Evidence In Motion has the potential to be an enormous disruption with their new model of physical therapy education that could significantly alter advanced health care training in this country. 

Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has -- Margaret Mead

True disruption is often achieved by a few capable, persistent, fearless, and motivated individuals and groups. Which doesn't mean that everyone shouldn't strive for it. True disruptors are those that see a problem and work towards a solution to that problem, all the while keeping the confidence that what they are doing will be the right thing even in the face of public doubt, and uncertainty as to whether or not it will even work. 

I am not a disruptor, but I am a fan of the underdog, the little company taking on the big, bad corporation; a veritable "David vs. Goliath." (Although, if you read the Malcolm Gladwell book of the same title, you'll quickly realize that David was not quite the underdog that he was made out to be). I want the mom & pop shop to triumph despite a Wal-Mart opening up down the street. However, the challenge with disruption is that it can't just be new and innovative. It still has to be good.

With that in mind, here's a brief example: Over two years ago, I was eager to try out Dollar Shave Club after first hearing about it advertised on a podcast. Were they going to be to shaving what Netflix was for DVD rentals? Their commercials were funny. They were unabashedly confident and crass. After all, they were going after the icons of shaving, Gillette and Schick. I used them for a little over a year before facing the hard truth. Their blades were just not as good for me as Gillette's. There was no way around it. I switched back. I'm sure many people like DSC blades fine. After all, they're still in business. But I don't see the shaving industry being shaken up like the movie rental establishment.

Instead of waiting for the world to impose the need for change, visionary companies are likely to be earlier adopters than the comparison companies-- Jim Collins (Built To Last)

I see many physical therapists out there striving to make significant change and buck the status quo. People like Mike Eisenhart, Jeff Moore, Jerry Durham, Gene Shirokobrod, Ben Fung, and Kelly Starrett come to mind. We have new grad PTs like Ryan Smith opening up cash-based practices fresh out of school. We are also seeing improvements in technology and customer connection from groups like WebPT, Medbridge, Strive Labs, Therapy Partners, and Dave Kittle's Vinitial app. In the volunteering sector Justin Dunaway's Stand for Haiti stands out, no pun intended.

But for those of us who may not be the innovators, or even out in front leading a charge, it doesn't mean we can't do our part. Celebrate the disruptors. Support the movements. Leaders aren't leaders without followers. Innovation isn't innovation unless other people "buying in" and helping make a change. As Jerry Durham said to me in a conversation, "we need to be open to change and new ideas....and ask a lot of questions."  

And speaking of Jerry, stay tuned for exciting announcements regarding the launch of the new "Heathcare DisruPTion Podcast" (formerly, "Business, Baseball and Bourbon") from UpDoc Media with your host, yours truly, and Jerry Durham. 

Having trouble disrupting an industry, a community, or even within your own clinic? How about disrupting yourself?  What steps can you take that can make the change to help you achieve the things you've always wanted? As Scott Halford says in Activate Your Brain, "start small, but start now." The disruption is happening. You don't necessarily have to be out in front, but get on the train. 

As always, thanks for reading.


While contemplating your own disruption, if you're looking for some actionable ways to get involved or help make a change in your profession, clinic, and community, here's a few ideas to get you started:

On Twitter and not following anyone I mentioned in the post? Here's how you can:


Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic...

Nxt Gen PT and Modern Manual Therapy Present the long awaited first fully professionally shot, edited MMT course is now available for purchase. It will be live July 1st, and if you act now, you can save $40 off of the normal $139.99 price.

This course features
  • live cases
  • pain science education
  • functional mobilizations
  • upper quarter Clinical Practice Patterns and simple movement screening
  • how to treat and educate cervical pain, cervicogenic headaches, TMD and more

Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic...

In Louis Gifford’s Aches and Pains book Graded Exposure Section 4, he shares thoughts about what he termed his ‘Shopping Basket’ approach to care. He details all the different compartments to consider in one’s care for an individual in pain (Biomedical, Psychosocial, Disability/functional restrictions, Impairments, General health, and Pain). I have stretched this metaphor into my interventions to use when planning a treatment for a person with persistent pain. During our Therapeutic Neuroscience Education course we go through the various changes in the output systems (immune, endocrine, sympathetic, sleep, etc.) of an individual in pain and look at what interventions can we use to work on improving each of those outputs. When we get done we are left with a list of 20 some different treatment intervention options. So where do we begin?

Thinking of the shopping basket metaphor, I like to think of going to the grocery store and getting the right ingredients for a wonderful meal. First things first, I need to know what I’m cooking up. And the type of meal is more dependent on my guest diner (the patient) then it is on me the chef. I need to remember each of the interventions need to be about my guest not me. Just because I like to make certain meals (using treatment interventions that I’m use to), I need to be like Bobby Flay in “Beat Bobby Flay” and cook what the other person’s specialty is. If someone likes yoga, then a little yoga it is. If they are into meditation, then let’s work some meditation and diaphragmatic breathing. If I don’t have the specialty in a specific treatment then I might need to refer that out, while I continue with the rest.

Next is getting the ingredients needed. The grocery store has more things then I need, so I don’t need to buy everything. Just as the patient doesn’t have to do every intervention on the list of interventions we can come up with. As I try to instill in my students here at USD, more is not better. More is just more – better is better and many times simpler is better. Pain is complex and when we can move through to the simple side of that complexity it often times goes better. Also we need to consider that some of the items the person may have at home already. Often times they are doing some of the treatments on the list. We just need to check to make sure they are up to date and they know how to use the ingredient properly and not for an inaccurate reason. (Core stabilization exercises may be okay exercises to do, but not necessarily because the person’s core is to weak and causing their pain). Another potential is that maybe they are using an intervention and don’t really like it, but they are fearful if they don’t use they won’t get better. Then we can either show them some appropriate substitutes to use and see if they like them better or educate them that they can get rid of some ingredients and the end recipe will still be fabulous. Using ingredients (interventions) they already have and enjoy can be important when it comes to compliance. We tend to do what we like and enjoy. The best meal in the world that doesn’t get eaten is of little use. Just as the best intervention program that is not performed by the patient is of little use. You will get better results with a bad program that is used by the patient then a great program that is never used (obviously a great program that is used is best).

After figuring a bit more about what meal might be appropriate and what ingredients they already have and want to keep, it is time to start filling up the shopping basket. I think as we look to add ingredients again it is important to ask if it is an ingredient that the patient might like or not. While the recipe might need some chopped greens we can vary what that is (maybe substitute kale for spinach). Also where does the patient want to start with the shopping of ingredients to add? Let them pick which interventions to start with. While we might be use to a specific order when we go through the grocery store, we may need to allow some flexibility based on what the patient is willing start with. We may think they need some spices early on, but we may need to get to those later once they are liking a taste of the recipe and ready to then “kick it up a notch”.

One thing we need to remember is that every meal has to have its staple ingredients. Based on my interpretation of the evidence and clinical experience there are four staples of interventions that need to be included for people with persistent pain: Pain Neuroscience Education, Exercise, Sleep, and Goal Setting.

Pain Neuroscience Education

Goal Setting



Pain Neuroscience Education: Obviously I may be a bit bias when it comes to PNE, but I think there is pretty good evidence that a person has to understand why they hurt and that pain is not always injury.

Exercise: When a Cochran Review gives you the “Gold” level of evidence stamp of approval, I think we should be using it. Which type of exercises, that gets a bit more debatable and in some cases may not matter, pick the chopped greens the person likes and dose it appropriately.

Sleep: Most people in persistent pain are not sleeping well (if they are then this staple is already at home and have them continue to use it). We need to address it and help them create better sleep hygiene to improve their sleep.

Goal setting: People with persistent pain need to have goals to work toward. Many of them have none or they are poorly defined. To improve motivation and self-efficacy we need to help them generate realistic objective goals based on their values and then achieve them. By helping them achieve these goals we can get them to move out of learned helplessness state and see that positive change is possible and that they can get their life back and provide a sense of hope so many of them are lacking. These goals need to be based specifically on the patient’s values (not ours) related to improved function, measurable, agreed upon, realistic and have some time base to them.
ter these staples are in the shopping basket we can continue gradually putting more things in or maybe that is all the recipe needs. That is what the diner (patient) and chef (PT) need to figure out together. Also remember as the chef, part of our job is to teach the diner how to eventually cook this meal on their own.

What say you? How do you fill your shopping basket for the person in persistent pain?

Via Dr. Kory Zimney, DPT

Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic...

In our 9th episode of Untold Physio Stories Jason shares how having a personal training background has benefited him as a physical therapist.

Make sure to follow Erson on facebook and instagram and Jason on facebook and

Untold Physio Stories is sponsored by the EDGE Mobility System, featuring the EDGE Mobility Tool for IASTM, EDGE Mobility Bands, webinars, ebooks, Pain Science Education products and more! Check it out at .  Be sure to also connect with Dr. Erson Religioso at Modern Manual Therapy and Jason Shane at Shane Physiotherapy.
One of the most common questions asked about running a cash-based practice is what kind of receipt do I provide my patients and what should be included so the patient will be reimbursed. 
Most insurance companies do allow for patients to submit the claims themselves and this process is fairly straightforward. I find that it is much easier of a process for the patient to do this than for the provider. Typically there is a 1-page form that needs to be completed for each visit and mailed in. Once the patient's out-of-network deductible is met, then the insurance company should provide a reimbursement payment to the patient for payments made greater than the co-pay amount.

Receipts for a Cash Practice

I provide all of my patients with a receipt or “super bill” that is customized using QuickBooks, so they can submit their charges for physical therapy to their insurance company. This "super bill" contains all of the information they need to submit their own claim to their insurance company. I include their ICD-9 diagnosis code(s) and CPT treatment codes along with all of my practice information, a signature and tax id number or EIN.

Click here for a Sample Super Bill or receipt that I use in my cash-based practice.

Instructions for Patients

I instruct my patients to be sure to let their insurance company know that they have already paid for the services and that the reimbursement should be sent directly to them.  Patients are directed to contact their insurance company to obtain the form which they should fill out to self submit.  Sometimes all the patient will need to do is send in the print out of the receipt I provide them.  I have also created a "Superbill" form that you can print, fill out and hand to your patients and it is included in The CashPT Toolkit.

People who have Health Savings Accounts or Flex Spending Accounts can pay with their HSA of FSA credit cards or check books. I let my patients know that I am happy to answer any of their questions and I will provide any documentation they need directly upon their insurance company's request.

How Much Do Patients Get Reimbursed in a Cash Practice?

The amount patients receive depends on their individual plan, benefits, deductible and co-pay. I do not know exactly what my patients receive; occasionally an EOB or explanation of benefits is also mailed to my office. I do know that most of my patients do not spend $1000 in my practice and many people have large co-pays. A typical patient with a $1000 or greater deductible may not receive a reimbursement, unless they have already had out of network therapy elsewhere. This will still allow the payments to count towards their deductible, which is important if they require additional therapy or interventions later in the year.

Insurance Questions

Most people do not understand or know what their insurance benefits really are. They may know what their co-pay is, but then have no idea what their deductible or other benefits are. For this reason I have an “insurance benefits worksheet” posted on my website and in my FAQ page, that can help prospective patients through the phone call they can make to their insurance company to verify their benefits and figure out how to file their claim.

Essential & "Secret" Info. to Include

A long time ago, when I was only a massage therapist and working in California where some people have massage therapy benefits on their plans, one insurance company wanted me to identify the ‘place of service’. I mean really? Did they not know it was at my business? 

After calling, waiting on hold and finally talking to someone, I asked her what this was.  She told me that is was a code for where the treatment was provided, but that she could not give me the specific information (the exact code) I needed as it was not her job.  

Anyway, I finally found it elsewhere and the place of service code is: “Office Code 11”, which is for a stand-alone outpatient facility, so I include that on all my receipts as well. If you travel to your patients home, use the 'place of service code' 12.

I also include a Bold Red line stating that “the patient has paid for the service provided in full and LeBauer Physical Therapy is NOT an insurance provider for this claim. Please provide payment directly to the patient.”  Occasionally, I will still receive a reimbursement check made out to my practice. 

Request for Medical Records

If a company (insurance, law firm, etc) requests patient records, I ask for a $50 administrative fee as a pre-payment.  Many requests have started to come in with this information already in the cover letter. Sometimes there is a standard fee that is determined by law that will pay per page. I learned this lesson the hard way by sending out notes before payment to a law firm, which did offer to pay for the notes. The payment took 3 months and 6 phone calls, to collect. I only persisted on principle.  

On another occasion I was asked to provide my treatment notes for a patient. When I called, I asked how they would like to pay for this ‘reasonable’ amount and the representative said they did not provide payment for treatment notes. I restated my request two more times and then asked for the manager. After speaking with the manager the representative of this insurance company told me that they would just reprocess the claim for my patient.

Documentation Standards

The beauty of a cash-based or out-of-network practice is that I do not need to meet the burdensome documentation requirements of private insurance and especially Medicare. However the patient evaluation, plan of care and daily notes still need to be completed with the same diligence and accuracy as a traditional practice since they may still be requested by insurance companies, law firms and other health-care providers offices.

The CashPT Checklist The Essential Steps to Start a Cash-Based Therapy Practice

Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic...

I was sent the Brace 2 Play by it's creator, Dr. Andrew Mirabella, DPT in return for an honest and fair review. As you know, I have a soft spot in my heart for PT Entrepreneurs, so I had to feature his great product on the blog.

Andrew told me he based the Brace 2 Play off of Mulligan concepts that worked very well for him in practice after learning them on an affiliation. While the mechanisms may be debated, the fact is that providing a novel stimulus of compression and perception of support will help many return to function sooner.

Brace 2 Play Review

The Brace 2 Play is now featured on EDGE Mobility System and there is currently a sale, I extended over the weekend for everyone who missed it. Coupon code summer20 gets you 20% off all products.

Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic...

It's that time of the year again! Like the best TV shows from the 80s and 90s, it's a flashback episode because content recycling is easier than new content (coming again next week - don't worry!)

These posts have been some of our most popular so far, and I only wrote one of them! Special thanks to the MMT Team for producing such amazing content.

  • a quick and novel variation on upper thoracic mobilization
  • done in WB and involves shoulder elevation and trunk rotation

  • by Dr. Dennis Truebig, DPT
  • just because the rotator cuff has been repaired, does not mean you shouldn't screen the cervical spine
  • same goes for the thoracic spine
  • stuck in phase 1? You still have plenty to treat!
  • by Dr. Christine Walker, DPT
  • how you can screen multiple areas in a novel and threat free way
  • via rising star Sian Smale, one of MMT's most popular contributors!
  • read this post for a great review on red flags, and what to look for in serious pathology, nerve root compression, spinal cord compromise, and more!

  • two posts in the top 5 for Dr. Dennis Truebig!
  • it was a close race between this and Red Flags, but E-stim is apparently several hundred more views popular!
  • this makes me think I should do a modalities blog and be 10 million times more popular

Thanks for reading as always, 2016 has been the biggest year for the blog so far, going multi-author, becoming Modern Manual Therapy Blog - but keeping the url for SEO reasons. 

Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic...