Faculty member Ginger Garner PT, DPT, ATC/L is offering a new short course, The Voice and The Pelvic Floor. This course introduces foundational concepts needed to be able to use vocal techniques to treat the pelvic floor and core. Dr. Garner is a clinician, educator, and longtime advocate committed to making physical therapy services accessible, affordable, and equitable, especially for pelvic health.

When you think of pelvic health, what comes to mind? Obvious variables like the pelvic floor & girdle, abdominals and related synergists, mental health, and gut and respiratory health are probably at the top of your list. 

But how often do we consider the voice as a biomarker of pelvic health? It can impact all of the variables above and more. 

Historically, speech-language pathologists’ study of vocal health has stopped at the respiratory diaphragm, while physical and occupational therapists’ study of pelvic health has stopped, well, in the same place. Neither has traveled beyond that until recently. 

However, there is a third diaphragm beyond the respiratory and pelvic, the laryngeal diaphragm. It’s also known as the cervical, cervico-thoracic, vocal, and/or thoracic diaphragm. The three diaphragms include: 

• The Laryngeal Diaphragm - is responsible for neurological optimization of stress response and physiological control of swallowing and communication; but, it also influences vagal tone for cardiorespiratory functioning and respiratory and pelvic diaphragm functioning. It contains the muscles that are responsible for phonation, which includes intrinsic variables such as the arytenoids, but also extrinsic components which have a direct impact on the vocal fold health, such as the suprahyoid muscles.
  
  
• The Respiratory Diaphragm - is the connecting point between cephalad and caudad diaphragms and is the main muscle influencing pulmonary function. However, the respiratory diaphragm exacts a major influence on mind-body health, which goes far beyond pressure regulation of the vocal and pelvic diaphragms.
  
  
• The Pelvic Diaphragm - is the terminal end of the tri-diaphragmatic (3D) system, and can bear the brunt of trauma and impairment if dysfunction is present in the two upstream diaphragms. The pelvic diaphragm contains the levator ani, coccygeus, and related synergists, pelvic fascia, and neurovascular structures, which in turn can work with or against breathing and voicing tasks. 

The diaphragms are in constant movement and none work in isolation. Together, their intersectional action provides us with the key to both internal and external biopsychosocial stability and structure of the mind-body. 

The laryngeal diaphragm has a supradiaphragmatic vagal impact, while the pelvic diaphragm exacts subdiaphragmatic vagal health, chiefly through afferent and efferent input, respectively. The 10th cranial nerve lives up to its namesake, “the wandering,” as it touches each of the three diaphragms on its journey, harnessing the capacity to lessen pelvic and visceral pain, while also improving vocal quality and lung function, and changing pain, mood, and digestive function. 

The mind-body interface of the 3D system has been further defined in recent years, broken down into a voluntary motor system (the one we spend all our time studying and treating), and the “emotional motor system,”  and the implications are profound. Anatomists and researchers tell us that in order to generate speech, we need both motor systems to function. But specifically, our emotional motor system must first perceive safety before speech can be produced or produced well.  

To get a feel for your own emotional motor system health, try this brief exercise: 

1. Think about a recent incident that made you feel nervous, or anxious. 
2. How well could you breathe? 
3. Talk? 
4. Sing or hum? 
5. Engage in intimacy with someone? 

Not very well, right? This feeling is the fallout from your emotional motor system perceiving danger or threat. It’s what Dr. Stephen Porges means by the phrase, “neuroception.” Neuroception is the ability to detect risk - but it’s not just the ability to detect it - neuroception is the ability to accurately detect risk. 

Here lies the problem: 

If we cannot detect external risk or internal threat accurately, aka if our neuroception wiring is faulty, then we may move to 1 of 4 default modes for behavior: fight, flight, freeze, or fawn. If we are left in this state of reactivity, courtesy of the sympathetic nervous system, then polyvagal theory predicts we will enter into a dissociative state, termed a dorsal vagal response (DVR). The DVR drives self-preservation in severe trauma states, which can preserve life; but it is also to blame for bradycardia and left unchecked, death. Especially now post-COVID, it’s imperative that all therapists understand how to recognize, screen for, and help nurture healthy self-regulatory strategies via trauma-informed care.  

We must also learn how to create a therapeutic landscape conducive to healthy neuroception, one that appeals to the “safety switch” of the emotional motor system. Establishing this healthy therapeutic alliance with our patients and clients is critical in pelvic health because the same motor system that controls the creation of sound, dictates everything associated with pelvic health, including micturition, defecation, partuition, stress response, and sexual function.

Understanding the basis of “3D” neurophysiology makes targeting the voice a perfect alternate but necessary pathway for successful comprehensive pelvic health care. The ability to create sound literally determines how we interact with the world around us, and whether or not we can do so with empathy and safety. Additionally, the success of our intervention as pelvic health therapists is also determined by the degree to which we are using a biopsychosocial model, which has long been supported as the most effective and cost-effective way to manage pain and tackle chronic disease and impairment. 

What does including the voice look like in pelvic health? 

For starters, the first step is evaluating the orofacial and vocal health of the patient or client. Second, and perhaps surprising to some, is the evaluation of the therapist’s own voice as a therapeutic agent. These assessments work to identify red flags that place undue stress through the downstream diaphragms and stress response system. More complex assessment can include lumbopelvic ultrasound imaging as well, which provides a more comprehensive way to individualize therapy prescription. 

Assessment is essentially a 4-pronged process - The first two prongs consist of building on existing evaluation skills in respiratory, core, and pelvic floor and girdle assessment. The final two include an assessment of the physiological functioning of the orofacial area and voice and an evaluation of psychosocial determinants which would influence cranial nerve and vocal functioning. The voice is an incredible tool for improving pelvic health outcomes, if we learn how to harness its frequency and power. 

Join Dr. Ginger Garner for a virtual short course, The Voice and the Pelvic Floor scheduled for October 1, 2022, to learn more.

Sources 

1. HOLSTEGE, G., 2016. How the Emotional Motor System Controls the Pelvic Organs. Sexual Medicine Reviews, 4(4), pp. 303-328.
2. HOLSTEGE, G. and SUBRAMANIAN, H.H., 2016. Two different motor systems are needed to generate human speech. The Journal of comparative neurology, 524(8), pp. 1558-1577.
3. Speer LM, Mushkbar S, Erbele T. Chronic Pelvic Pain in Women. afp. 2016;93(5):380-387. 
4. Miciak M, Gross DP, Joyce A. A review of the psychotherapeutic “common factors” model and its application in physical therapy: the need to consider general effects in physical therapy practice. Scand J Caring Sci. 2012;26(2):394-403. doi:10.1111/j.1471-6712.2011.00923.x
5. Padoa A, McLean L, Morin M, Vandyken C. The Overactive Pelvic Floor (OPF) and Sexual Dysfunction. Part 2: Evaluation and Treatment of Sexual Dysfunction in OPF Patients. Sex Med Rev. 2021;9(1):76-92. doi:10.1016/j.sxmr.2020.04.002
6. Wijma AJ, van Wilgen CP, Meeus M, Nijs J. Clinical biopsychosocial physiotherapy assessment of patients with chronic pain: The first step in pain neuroscience education. Physiother Theory Pract. 2016;32(5):368-384. doi:10.1080/09593985.2016.1194651
7. Porges SW. The polyvagal perspective. BiolPsychol. 2007;74(2):116-143.