New Perspectives from The Integrated Systems Model for Women’s Health
Abstract provided for the 2014 IPPS meeting in Chicago for Diane Lee’s keynote presentation
Scientific research suggests that function of the pelvis is essential for the performance of almost every task (Vleeming et al 2012). It is particularly relevant for women suffering from pelvic girdle pain (PGP), incontinence, pelvic organ prolapse (POP), and/or sexual impairment; all possible symptoms of failed pelvic function. In addition, optimal structure and function of the pelvic floor muscles (PFMs) (e.g. anatomy, innervation, mobility, motor control, strength, endurance) is critical for these same conditions. Given the role the PFMs play in multiple tasks, it is not surprising that ‘muscle training’ is recommended as the first-line of treatment for women with these conditions (Bo & Hilde 2013, Dumoulin & Hay-Smith 2010, Fritel et al 2010, Morkved & Bo 2013).
In clinical practice, it is common to see complex patients with a combination of pain, incontinence, organ prolapse, and/or diastasis rectus abdominis (Smith et al 2008, Spitznagle et al 2007). A thorough evaluation often reveals many past injuries, thoughts/beliefs, and emotional states that have collectively led to changes in strategies for posture, movement, continence and pelvic organ support. Does the presence of pain, incontinence, or prolapse mean that the pelvis and specifically the PFMs require treatment? If not, how should a clinician determine where to intervene to effect the greatest improvement in function and reduction in symptoms?
There is little scientific evidence to guide clinicians for these complex, yet common, patients (Vleeming et al 2008). Clinical reasoning remains the recommended approach for determining best treatment for the individual patient (Jull 2012) and The Integrated Systems Model (ISM) is an example of such an approach.
The Integrated Systems Model for Disability & Pain
The Integrated Systems Model for Disability and Pain (ISM) (Lee L-J and Lee D 2011) is a framework to help clinicians organize knowledge and develop clinical reasoning to facilitate wise decisions for treatment. A key feature of this approach is Finding the Primary Driver (the best place to focus treatment). In short, this involves understanding the relationships between, and within, multiple regions of the body and how impairments in one region can impact the other. Specific tests are used to determine sites of non-optimal alignment, biomechanics and control (defined as failed load transfer (FLT)) during analysis of a task that is meaningful to their story/complaint (meaningful task analysis). Subsequently, the timing of FLT (which site fails first, second, third etc.), as well as the impact of manually correcting one site on another, is noted. Clinical reasoning of the various results determines the site of the primary driver, or the primary region of the body, that if corrected will have a significant impact on the function of the whole body/person.
Sometimes, two areas of the body require intervention (co-drivers) and sometimes one area requires most treatment (primary) while another requires some attention for the best outcome (secondary driver).
Further tests of specific systems (e.g. articular, neural, myofascial, visceral) then determine the underlying impairment causing the non-optimal alignment, biomechanics and/or control of the driver(s) for the specific task being assessed. Once the impaired system has been determined, specific techniques and training for release, alignment, control and integration into movement (including strength and conditioning) can be implemented to improve the function of the driver(s) and thus impact the function of the whole body/person.
New Perspectives from the ISM for Women’s Health
This keynote presentation will highlight through short case reports how the ISM can be used to identify when the pelvic floor should be specifically released and/or trained and when interventions should be focused elsewhere. All clinicians who assess the pelvic floor with internal techniques recognize the wide variety of asymmetric activation/release patterns of the PFMs (all three layers) across many different conditions. The most consistent finding in women with PGP, incontinence, and/or POP is inconsistency. In other words, the classification or diagnosis of a condition does not predict pain or PFM behavior.
Multiple mechanisms can drive asymmetric activation/relaxation of the PFMs and the ISM can help to identify when ‘twists in the skeletal pelvis’ are causing the asymmetric activation/relaxation or a result of it. An intra-pelvic torsion (twist in the pelvis) can be primary (i.e. the driver of the problem) or secondary (i.e. the victim of a problem elsewhere and thus compensatory). The primary problem may be as far away as the foot or the cranium, although the most common driver is in the thorax. Simple tests based on the ISM concept of ‘Finding the Primary Driver’ will quickly reveal when to treat the PFMs and when treatment should be directed elsewhere and thus impact the behavior of the PFMs.
Until we meet in Chicago next October have some fun with this test. With your patient supine and their hips and knees flexed, note the resting position of the left and right innominate. Is one side anteriorly rotated relative to the other (Chapter 8 in Lee D 2011). Assess the PFMs the way you usually do, paying particular attention to the presence of tender trigger points, ability to activate (grade of contraction), and ability to release/relax the all the various PFMs. Then neutralize the position of the left and right innominate (you can simply flex the hip on the side of the anteriorly rotated innominate in this test) and re-assess the resting tone (tenderness to palpation), activation and relaxation of the same muscles. Some will change and some will not, we will discuss what all this means next fall! Hint – stop trying to find the ‘best cue’ for PFM activation/release when this test changes the recruitment and/or relaxation pattern!
Bo K, Hilde G 2013 Does it work in the long term? A systematic review on pelvic floor muscle training for female stress urinary incontinence. Neurourol Urodyn 32:215-223
Dumoulin C, Hay-Smith J 2010 Pelvic floor muscle training versus no treatment, or inactive control treatments for urinary incontinence in women. Cochrane Database Syst Rev.
Fritel X et al 2010 Diagnosis and management of adult female stress urinary incontinence: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians. Eur J Obstet Gynecol and Reprod Biol 151(1):14-19
Jull G 2012 Management of cervical spine disorders: where to now? IFOMPT Quebec City, Canada
Lee L-J, Lee D 2011 Clinical Practice – The Reality for Clinicians. Chapter 7 in: 2011, The Pelvic Girdle, 4th edn. Elsevier, Edinburgh
Lee D 2011 The Pelvic Girdle, An Integration of Clinical Expertise and Research, Churchill Livingstone, Elsevier, Edinburgh
Morkved S, Bo K, Schei B, Salvesen K A 2003 Pelvic floor muscle training during pregnancy to prevent urinary incontinence: A single blind randomized controlled trial, Obstetrics and Gynecology101:313-319
Smith M D, Russell A, Hodges P W 2007c Is there a relationship between parity, pregnancy, back pain and incontinence? International Urogynecology Journal epub June
Spitznagle TM Leong FC Van Dillen 2007 Prevalence of diastasis recti abdominis in a urogynecological patient population. International Urogynecology Journal Pelvic Floor Dysfunction. 18(3):321
Vleeming A, Albert HB, Ostgaard HC, et al. (2008) European guidelines for the diagnosis and treatment of pelvic girdle pain. Eur Spine J 17, 794–819
Vleeming, A., Schuenke, M. D., Masi, A. T., Carreiro, J. E., Danneels, L., & Willard, F. H. (2012). The sacroiliac joint: an overview of its anatomy, function and potential clinical implications. Journal of Anatomy. doi:10.1111/j.1469-7580.2012.01564.x