Manual Therapy and the Pelvic Floor: Q and A

Recently my old friend Dr. Erson Religioso interviewed me for his popular blog targeted at an audience of manual therapy pros. I wanted to share an excerpt that reflects a few related questions that I get A LOT! Specifically where does manual therapy fit into my approach to patient care and how does the Diaphragm/Pelvic Floor Piston apply to other populations beyond women’s health. Check it out:

Julie Wiebe and I go waaaaay back! Flash back to over 3 years ago when there was no #SolvePT, #BizPT, and about 20 or so of us on social media. I reached out to her and others like Ben Fung who were on twitter at that time. Since then I have learned quite a bit from her posts and videos as well as her webinars. Read below how the pelvic floor is more than just for pelvic pain or incontinence.


2. You have told me in the past you do not use much if any manual therapy techniques any more, why is that and what has replaced them?

I think that the best way to answer this is to talk about it in terms of when I apply manual therapy. What I have learned along the way about how our foundation functions has led me a systems model for creating central stability. This involves working towards a balance of the brain, the neuromuscular, musculoskeletal, structural, postural, and sensory systems. I start at the center for all my patients, reorganizing that foundation through an integration of those systems and build movement and sport specific patterns from there. In other words, I work from the inside-out and love the integrative principle “If they fire together, they wire together” (Hebb’s Law).

Once we have re-estabilished and optimized that foundation, then I see what is left to handle with my manual skills. In many cases, there is not much left to work out. IMHO that tight muscle, stuck joint or whatever we see or feel that we want to address with our manual skills got that way somehow. So I try to figure out how it got that way first, before I apply my manual skills. Otherwise, I can manual therapy it ‘til I am blue in the face, but it will likely come back because I have never addressed the reason it got that way in the first place. I just like to begin with seeing what the body and brain can do for itself first, my job is to create the right environment to allow that. A practitioner that attended one of my courses, summarized that thought beautifully:

“Trust that the body is a self righting organism. Our job is to guide the process.” Norene Christesen, PT, DSc, CLT, OCS, President Wyoming Chapter APTA

This is also great for home carryover, I didn’t make them better, they made changes in how they thought about, used or moved their body and saw results. That’s pretty powerful. And it is great for my hands! Having said all that…I still think manual therapy has an important place so don’t misinterpret this as anti-manual therapy. I just watch and guide before I intervene with my hands.

3. Why is the diaphragm and pelvic floor important for not only women’s health but all populations?

What we have come to understand as research has evolved is that all four muscles of the deep core, diaphragm, TA, pelvic floor and multifidus, work together as a team to provide the muscular support and regulate the intra-abdominal pressure that contribute to setting up a sturdy center (not just the TA and multifidus). They actually interact like a Piston. On inhale the diaphragm lowers, and the TA and pelvic floor need to give, or open to allow this to happen. This builds IAP, which gives us inhalation stability and elastically loads the TA and pelvic floor. On exhale when the diaphragm rises, and the pressure is relieved, the TA and pelvic floor use that elastic loading and recoil up and in to more actively contribute to central stability. It is a dynamic interplay between these moving parts that gives stability that is also dynamic and responsive to the demands of function. This is a great study that demonstrates that relationship: . For a visual, I demonstrate their Pistoning interrelationship here . So our stability system actually runs off the breath cycle, how cool is that! And the pelvic floor is parallel in its action to the diaphragm, they work together, so it is important that clinicians know how to integrate them along with the TA and multifidus into their programming for stability, strengthening, balance, etc.

Let’s bring this home in another way, and link my thoughts from question 2 to these ideas. Here is an interesting study ( ) that created an asymmetrical activation of the pelvic floor and noted significant displacements of bony landmarks, with the largest displacements being of the femoral head, the innominate and coccyx on the same side. Applying that clinically, a patient may be utilizing their PF asymmetrically leading to what we might assess as a pelvic obliquity or stiff hip  for example. Instead of addressing it with our hands first, we can teach the patient to optimize recruitment of the PF in a proper relationship with the diaphragm and restore a more balanced recruitment pattern. Building movement patterns on that improved recruitment, will help with carry over and reinforce the balance. Then we see what is left to address with our hands. And the flip side of that, is if we have imposed some increased movement or alignment with our hands, then the pelvic floor is uniquely positioned to help maintain it if we can teach our patients to access it and use it with it’s functional partners. The pelvic floor is a very powerful (and currently underestimated) ally in our care of musculoskeletal issues.

Click here to read the full interview  and here to learn more about Dr. E! 

Feel free to shoot me some questions (below) about pelvic floor integration into manual therapy, rehab and conditioning programs. Everyone’s got one!


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