Incorporating the Pelvic Floor into Ortho PT | Modern Manual Therapy Blog

Incorporating the Pelvic Floor into Ortho PT

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!

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