A Case Study in Breathing Mechanics and the Pelvic Floor

;Aparna Rajagopal, PT, MHS is the lead therapist at Henry Ford Macomb Hospital's pelvic dysfunction program, where she treats pelvic rehab patients and consults with the sports therapy team. Her interests in treating peripartum patients and athletes allowed her to recognize the role that breathing plays in pelvic dysfunction. She has co-authored the course, "Breathing and the Diaphragm: Pelvic and Orthopedic Therapists", which helps clinicians understand breathing mechanics and their relationship to the pelvic floor.

A few months ago a young woman with a diagnosis of dyspareunia was referred to me. She had been a gymnast through her teens and now worked out regularly. She reported being unable to use tampons throughout her life, experiencing difficulty with undergoing pelvic examinations, and inability to have intercourse with her partner all through her married years. She also had a history of long-standing constipation and urinary symptoms including increased voiding frequency and the feeling of incomplete emptying.

Her examination included significant overactivity of her abdominals. A very chest dominant pattern of breathing with very limited lower lateral costal expansion, limitations in thoracic mobility, a fairly rigid rib cage with a very narrow infra sternal angle, connective tissue restrictions of the abdominal, pelvic areas, decreased flexibility of her hamstrings, and weakness of her Glut Max muscles. There was significant guarding and an internal assessment of pelvic floor muscles was not performed initially due to associated discomfort.

Throughout the first few sessions, we worked on releasing her first rib, the scalenes, latissimus dorsi, and quadratus lumborum muscles, and worked on reducing the connective tissue restrictions in the abdominal and pelvic regions. We also spent time improving rib cage and thoracic spine mobility and reducing the chest dominant pattern of breathing; while trying to establish improved abdominal compliance and lateral costal expansion with inhalation. All this, along with techniques aimed at improving neuromuscular control of her Gluteus Maximus without excess compensatory pelvic floor muscular assistance led to enough improvement in a few sessions to allow for an internal pelvic floor muscle assessment to be performed.

The patient's job activities required constant vocalization and I found that she contracted her neck, her abdominal, and pelvic floor muscles very strongly with any vocalization and did not relax the muscles after she finished vocalization. The patient was educated on softening her vocalization, and on a more controlled release of air through the glottis with more gradual abdominal and pelvic floor contractions while performing glottal/vocalization exercises. The patient was very keen on continuing her fitness-related activities through all of her therapy. Manual internal pelvic floor muscle assessment performed with standing activities revealed that although she did not particularly find her workout routine very taxing she tended to exhale extremely forcefully with each repetition of the exercise. This forceful exhale was naturally accompanied by very strong recruitment of her abdominals and her pelvic floor muscles, and once again there was decreased relaxation after cessation of her exercises. The treatment process involved making the patient aware of breath patterns and her gripping, nonrelaxing quality of the contractions of the pelvic floor and the abdomen and how she could gain some relaxation by utilizing her breath.

In addition to continuing to receive pelvic therapy from me, the patient consulted with Leeann, a sports-trained therapist, for 2 sessions to set up a fitness program. Leeann set up a program for the patient to strengthen her core and gluteal muscles while monitoring the pelvic floor externally. The fitness program progressed with challenging exercises in non-weight bearing and quadruped positions which were then progressed to kneeling and then standing. An important focus during the development of this program was on monitoring the patient's strength of exhaling and ensuring pelvic floor relaxation with breathwork between repetitions ensuring that there was no reverting to the old habit of gripping.

The patient's complaints for which she initially sought pelvic therapy were completely resolved. The patient's pelvic pain symptoms were resolved with treatment directed at the thorax, the breath, vocalization and the glottis, and lower extremity muscle strength. Very little time was spent on conventional manual techniques applied directly to the pelvic floor musculature.

In the Herman and Wallace course, you will learn skills to effectively assess the thorax, the diaphragm, breathing patterns, thoracic mobility inclusive of joint mobility, and myofascial connections. Come and learn how postural changes can affect the biomechanics of how the body performs and in turn affect intra-abdominal pressure. Learn easy effective strategies that will help you in your care of patients with low back pain and pelvic floor dysfunction the very next day. Hope to see you in class!

;Aparna Rajagopal will be co-teaching Breathing and the Diaphragm: Pelvic and Orthopedic Therapists on May 15-16, 20201 with her colleague Leeann Taptich. This course instructs practitioners on breathing mechanics and their relationship to the pelvic floor.