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Editor: Leon Chaitow

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Journal of Bodywork and Movement Therapies (2007) 11, 327–339

Bodywork and

Journal of

Movement Therapies

REVIEW

Chronic pelvic pain: Pelvic floor problems, sacro-iliac dysfunction and the trigger point connection

Leon Chaitow, N.D., D.O.�

Marylebone Health Centre, Marylebone Rd, London NW1 5LT, UK

Received 23 April 2007; received in revised form 1 May 2007; accepted 6 May 2007

KEYWORDSChronic pelvic pain;High-tone pelvicfloor;Trigger points;Sacro-iliac;Breathing disorders;Interstitial cystitis;Stress incontinence;Prostatitis

Summary The incidence of chronic pelvic pain (CPP) is widespread, with multiplepotential aetiological features. There is evidence that CPP is relatively poorlyunderstood, even by specialists in genitourinary dysfunction and disease, andcertainly by the wider health care community. Recent research has suggestedconnections between chronic sacro-iliac restrictions/instability and a wide range ofpelvic floor related problems, as well as breathing pattern dysfunction. In additionmyofascial trigger points are reported to be commonly actively involved in the painaspects of problems associated with these structures. Studies have also indicatedthat in many instances CPP is amenable to manual therapeutic approaches.

It has been hypothesized that inadequate force closure may be a commonaetiological feature, affecting both urethral and sacroiliac instability. This paperattempts to outline current research-based concepts linking these mechanismsand influences with pelvic pain and dysfunction, including variously interstitialcystitis, stress incontinence, dyspareunia, vulvodynia, prostatitis, prostatodynia,penile pain, sacroiliac dysfunction, myofascial trigger point activity, and respiratorydisorders such as hyperventilation. Evidence-based therapeutic approaches suitablefor application by physiotherapists, osteopaths and other manual practitioners andtherapists are discussed.& 2007 Elsevier Ltd. All rights reserved.

Introduction

Chronic pelvic pain (CPP) is a widespread anddistressing condition that accounts for between10% and 15% of all gynaecological referrals, 25–35%

of laparoscopies and 10–15% of hysterectomies(Reiter, 1998). Zondervan et al. (2001) reportthat the estimated lifetime occurrence of CPPis 33%, affecting primarily, but not exclusively,females.

Associated conditions (to CPP) may include:

� Stress urinary incontinence (SUI)—difficulty incontrolling urination.

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1360-8592/$ - see front matter & 2007 Elsevier Ltd. All rights reserved.doi:10.1016/j.jbmt.2007.05.002

�Corresponding author at: 144 Harley Street, London W1G7LE,UK.

E-mail address: [email protected]

Foreword

The Journal of Bodywork and Movement Therapies (JBMT) has unique and targeted aims and scope. The journal attracts submissions from both researchers and practioners from around the world, reporting on their observations and findings.

The journal provides a source of user-friendly and clinically relevant articles for those involved in health care (prevention and treatment) who use manual, physical and movement modalities, therapeutically. Types of articles featured include original research, review, case studies, hypothesis etc. The journal bridges the divisions between health care professionals, from different backgrounds, as they identify communal ground, based on evidence.

JBMT has always been a source of information on the evolution of different models that have expanded all our horizons – for example the initial articles by Tom Myers that became Anatomy Trains, as well as a series of articles by James Oschman that became Energy Medicine (two extraordinarily important books) started their lives in JBMT. A variety of equally important papers and series have been, and continue to be, published in JBMT.

An invaluable regular feature of the journal has been the rehabilitation section authored by world renowned practitioner Craig Liebenson DC. His series offers ‘free to photocopy’ pages of illustrated rehabilitation and prevention guidelines usually accompanied by background research evidence for clinicians.

Our publication standards are high. All submitted articles are subject to a thorough blind review process. Where appropriate a dedicated evaluation of methodology and statistical analysis is conducted however, sufficient elasticity is built in to allow for speculation and hypothesis.

Along with my Associate Editors and Advisory Board members, I invite you to browse through the selection of papers from past JBMT issues in this brochure in order to get a flavour of what’s in store for you when you subscribe.

Leon Chaitow, Editor.

ISSN 1360-8592


Bodywork and

Journal of

Movement Therapies

REVIEW

Chronic pelvic pain: Pelvic floor problems, sacro-iliac dysfunction and the trigger point connection

Leon Chaitow, N.D., D.O.�

Marylebone Health Centre, Marylebone Rd, London NW1 5LT, UK

Received 23 April 2007; received in revised form 1 May 2007; accepted 6 May 2007

KEYWORDSChronic pelvic pain;High-tone pelvicfloor;Trigger points;Sacro-iliac;Breathing disorders;Interstitial cystitis;Stress incontinence;Prostatitis

Summary The incidence of chronic pelvic pain (CPP) is widespread, with multiplepotential aetiological features. There is evidence that CPP is relatively poorlyunderstood, even by specialists in genitourinary dysfunction and disease, andcertainly by the wider health care community. Recent research has suggestedconnections between chronic sacro-iliac restrictions/instability and a wide range ofpelvic floor related problems, as well as breathing pattern dysfunction. In additionmyofascial trigger points are reported to be commonly actively involved in the painaspects of problems associated with these structures. Studies have also indicatedthat in many instances CPP is amenable to manual therapeutic approaches.

It has been hypothesized that inadequate force closure may be a commonaetiological feature, affecting both urethral and sacroiliac instability. This paperattempts to outline current research-based concepts linking these mechanismsand influences with pelvic pain and dysfunction, including variously interstitialcystitis, stress incontinence, dyspareunia, vulvodynia, prostatitis, prostatodynia,penile pain, sacroiliac dysfunction, myofascial trigger point activity, and respiratorydisorders such as hyperventilation. Evidence-based therapeutic approaches suitablefor application by physiotherapists, osteopaths and other manual practitioners andtherapists are discussed.& 2007 Elsevier Ltd. All rights reserved.

Introduction

Chronic pelvic pain (CPP) is a widespread anddistressing condition that accounts for between10% and 15% of all gynaecological referrals, 25–35%

of laparoscopies and 10–15% of hysterectomies(Reiter, 1998). Zondervan et al. (2001) reportthat the estimated lifetime occurrence of CPPis 33%, affecting primarily, but not exclusively,females.

Associated conditions (to CPP) may include:

� Stress urinary incontinence (SUI)—difficulty incontrolling urination.

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�Corresponding author at: 144 Harley Street, London W1G7LE,UK.

E-mail address: [email protected]

� Interstitial cystitis (IC)—frequency, urgency,discomfort/pain on urination—non-bacterial.This is also described as Painful Bladder Syn-drome (PBS).

� Vestibulitis—essential Vulvodynia—with no ob-vious cause.

� Vulvar Vestibulitis Syndrome—a subset of urinaryand genital pain disorders or ‘‘painful bladder’’syndromes.

� Dyspareunia—painful intercourse.

A broad clinical definition of IC includes anypatient who complains of urinary urgency, fre-quency, and/or pelvic/perineal pain, in the ab-sence of any identifiable cause, such as bacterialinfection or carcinoma (Rovner et al., 2000).

Bo and Borgen (2001) found that 41% of elitefemale athletes experience SUI, a common featureof CPP. Nygaard et al. (1994) noted that in a studyof 144 nulliparous female athletes, ages 18–21years, 28% suffered from SUI.

Savidge and Slade (1997) observe that CPP ‘‘is apoorly understood condition’’.

This view is echoed by major researchers intoCPP in general, and IC in particular. For exampleRovner et al. (2000) state: ‘‘In the absence of agenerally accepted and effective therapy, a ‘‘trial-and-error’’ approach has emerged for the treat-ment of IC. Subsequent therapy is predicated onprior failures, and the patient’s and physician’swillingness to proceed with increasingly time-consuming, invasive, and/or costly treatments.’’

As discussed later in this paper, a strong associa-tion has been identified between chronic low backpain (LBP) and many of the CPP symptoms listedabove (Eliasson, 2006; Smith et al., 2006). Theseand other studies suggest that there may frequentlybe identifiable relationships between lumbo-pelvicdysfunction, and a variety of pelvic floor/organproblems.

A subgroup of individuals with CPP/IC/SUI, etc.,who appear to respond well to manual methods oftreatment, are the main focus of this paper.Common features, and manual treatment ap-proaches, are described below.

Trigger points, pelvic pain and associatedsymptoms

Recent studies, a number of which are summarizedbelow, suggest that a variety of chronic symptomsinvolving the pelvic organs, including the bladder,urethra, prostate and the lower bowel, can becaused, aggravated or maintained by the presence

of active myofascial trigger points (TrPt) in themuscles of the region, both external and internal.In many instances deactivation of these triggers hasbeen shown to improve or eliminate functionalsymptoms, as well as associated pain.

Additional finding in some of these studies (seebelow) indicate that sacroiliac dysfunction may attimes also be a part of the complex of overlappinginfluences (Anderson et al., 2005; Weiss, 2001;Holzberg et al., 2001; Lukban et al., 2001; Glazer,2000; Oyama et al., 2004; Riot et al., 2005; Mckayet al., 2001; Ling and Slocumb, 1993). Bernsteinet al. (1992) observed that patients, with theurgency-frequency syndrome, commonly demon-strated a high tonic level in the pelvic floormuscles, associated with a poor ability to relax ortense these muscles, often leading to inadequatevoluntary control of urinary flow.

Weiss (2001) echoes this observation, noting thatin his experience the majority of patients with ICreport an early history that resulted in pelvic floormuscle dysfunction, suggestive of increased pelvicfloor tension. Weiss reports that he has found thatan integral part of the treatment regimen, in suchpatients, involves normalization of these musclesvia manual deactivation of TrPts, while alsoreducing the pelvic floor hypertonicity by meansof stretching and strengthening exercises.

Weiss’s (2001) study (described below), viapublication in a major peer-review journal, was alandmark in drawing attention to the efficacy ofthese approaches. It has been followed by numer-ous good quality studies, all of which confirm thevalidity of the link between major, often debilitat-ing, pelvic symptoms, and the presence of high-tone pelvic floor musculature containing activetrigger points. These are usually capable of beingmanually deactivated with marked symptomaticimprovement following (Figs. 1–3, Box 1).

Box 1

Brief glossary

The following definitions/explanations shouldhelp with unfamiliar terms:

Diastasis recti: separation at the midline ofrectus abdominis left and right, pre-venting normal pelvic floor function.

Force closure: how musculo-ligamentousforces control translation betweentwo joint or soft tissue surfaces, whenunder load.

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L. Chaitow328

High tone: excessively sustained tone or‘tension’ in muscular or fascial struc-tures.

Thiele massage: a form of internal soft tissuemanipulation of pelvic floor musclesdeveloped in the 1930s by a Germanphysician G.H. Thiele.

Paradoxical breathing: a paradox occurs whenreality conflicts with expectation. Inrespiration the diaphragm shouldmove caudally on inhalation, however,in paradoxical respiration it movescephalad instead.

Examples of clinical studies

1. Using trigger point deactivation methods, de-scribed below, Weiss (2001) has reported thesuccessful amelioration of symptoms in (mainlyfemale) patients with IC, using myofascial releasetechniques. Forty-five women and 7 men, including10 with IC and 42 with the urgency-frequencysyndrome, underwent manual physical therapy tothe pelvic floor once or twice weekly for 8–12

weeks. Results were determined by patient-com-pleted symptom score sheets. These indicated therate of improvement according to outcome para-meters, with 25–50% improvement rated as mild,51–75% rated as moderate, 76–99% rated asmarked, and 100% rated as complete resolution.In 10 cases these subjective results were confirmedby measuring resting pelvic floor tension byelectromyography, before and after the treatmentcourse.

Of the 42 patients with the urgency-frequencysyndrome, with or without pain, 35 (83%) hadmoderate to marked improvement, or completeresolution, while 7 of the 10 (70%) with IC reportedmoderate to marked improvement. The meanduration of symptoms before treatment, in thosewith IC and the urgency-frequency syndrome, was14 years (median 12) and 6 years (median 2.5),respectively. In patients with no symptoms, orbrief, low-intensity flares, mean follow-up was 1.5years. In 10 patients who underwent electromyo-graphy mean resting pelvic floor tension showed a65% improvement, decreasing from 9.73 to 3.61mV.

Noting that it is well established that dysfunc-tional pelvic floor muscles contribute significantlyto the symptoms of IC, and what has been calledthe urethral syndrome (urgency-frequency with or

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Figure 1 The pelvic diaphragm (from Gray’s Anatomy for Students p. 393, Fig. 5.34).

Chronic pelvic pain 329

without chronic pelvic pain), Weiss suggests that itis also possible that these muscles act not only as asource of symptoms, but also as contributing factorfor the evolution of neurogenic inflammation of the

bladder wall, which is itself a source of urothelialpermeability, characteristic of IC.

2. Chronic prostatitis involving non-bacterialurinary difficulties, accompanied by chronic pelvicpain (involving the perineum, testicles and penis),has been shown in a 2005 study at StanfordUniversity Medical School by Anderson et al., tobe capable of being effectively treated usingtrigger point deactivation, together with relaxationtherapy. The researchers point out that 95% ofchronic cases of prostatitis are unrelated tobacterial infection, and that myofascial TrPs,associated with abnormal muscular tension in keypelvic muscles, are commonly responsible for thesymptoms. This 1-month study involved 138 men,and the results showed that there were markedimprovements in 72% of the cases, with 69%showing significant pain reduction and 80% animprovement in urinary symptoms. Andersonet al. (2005) note that the levator endopelvicfascia, lateral to the prostate, is the most commonlocation of trigger points in men with pelvic pain.The manual methods used involved the therapistapplying treatment with the patient lying prone orlateral. The therapist’s right hand was used toexamine and treat the left side of the pelvic floormusculature, while the left hand was used for theright side. When myofascial TrPs were identified,digital pressure was held for approximately 60 s[described as myofascial trigger point releasetechnique—MFRT]. In addition it was found to behelpful if the patient was periodically requested tovoluntarily contract the muscles being palpated/treated in a manner that induced ‘‘release/hold-relax/contract-relax/reciprocal inhibition’’ of the

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Figure 2 The pelvic floor muscles (from Gray’s Anatomy for Students, p. 369, Fig. 5.7).

Figure 3 Pelvic part of the urinary system (from Gray’sAnatomy for Students, p. 399, Fig. 5.39).

L. Chaitow330

tissues. Additionally mobilization of the pelvic floormuscles included ‘‘stripping, strumming, skin roll-ing and effleurage’’. Treatment in this study wasdelivered weekly for 4 weeks, and biweekly for afurther 8 weeks.

3. In a review of prostatitis and chronic pelvicpain, Anderson (2002), the lead author of the studyoutlined above, has described palpation and treat-ment protocols for locating myofascial TrPt asso-ciated with prostatitis symptoms, and something ofthe rationale associated with this approach:

The patient is examined in the dorsal lithotomyposition to provide better examination of thelower abdomen, genitalia, and rectal and inter-nal pelvic musculature. Inserting a finger in therectum yy the examiner evaluates the sphinc-ter ani circular muscles for tone and tenderness.Mapping of painful trigger points is performedwith special attention focused on the insertionof muscles and ligaments into the followingareas: rectus abdominus into pubic bone, in-guinal canal obliques, subpubic adductor longusinsertion, pubococcygeus insertion intersectingwith prostatic endopelvic fascia, and obturatorinternus muscle with accompanying Alcock’scanal (examined with and without externalrotation of the knee).

Anderson (2002) has also reflected on possibleaetiological features:

Predisposing factors for the formation of myo-fascial trigger points [in this region] includemechanical abnormalities in the hip and lowerextremities; chronic holding patterns, such asthose that occur in toilet training; sexual abuse;repetitive minor trauma in constipation; sportsthat create chronic pelvic stimulation; trauma;unusual sexual activity; recurrent infections;and surgery. Pelvic floor muscles are commonlytightened out of instinct under stress. Initiatingfactors that incite trigger points are oftenforgotten; they may not arise from a singleevent but are rather additive in nature. Thereseems to be a general association with theprocess of somatization.

Anderson notes that pelvic TrPt are painful oncompression, commonly giving rise to character-istic referred pain, tenderness, and autonomicphenomena. When pressure is applied the patientmay react with a spontaneous verbal expression orwithdrawal movement.

4. The effectiveness of transvaginal Theilemassage (see Note below) has been demonstratedon high-tone pelvic floor musculature in 90% ofpatients with interstitial (i.e. ‘unexplained’) cysti-

tis by Holzberg et al. (2001). Describing thetechnique the researchers observe: ‘‘Subjectsunderwent a total of 6 intravaginal massagesessions using the Theile ‘stripping’ technique.’’This technique encompasses a deep vaginal mas-sage via a ‘‘back and forth’’ motion over the levatorani, obturator internus, and piriformis muscles, aswell as a myofacial release technique. Where atrigger point is identified, pressure is held for 8–12 sand then released. As to the mechanisms involved,they report: ‘‘As a result of the close anatomicproximity of the bladder to its muscular support, itappears that internal vaginal massage can lead tosubjective improvement in symptoms of IC.’’

Note: Thiele massage was developed in the 1930s(Thiele, 1937) for treatment of coccygodynia. Thielsubsequently noted that in his experience pain inthis region was only due to trauma in approximately20% of cases and in the rest by pelvic muscles thatwere ‘in spasm’ (Thiele, 1963) (Fig. 4).

5. Lukban et al. (2001) have noted a link betweenthe sort of symptoms described in the previousexamples, as well as painful intercourse (dyspar-eunia), together with sacro-iliac (SI) joint dysfunc-tion. Sixteen patients with IC were evaluated a/ forincreased pelvic tone and trigger point presence,and b/ for sacro-iliac dysfunction. The studyreports that in all 16 cases SI joint dysfunctionwas identified. Treatment comprised direct myo-fascial release, joint mobilization, muscle energytechniques, strengthening, stretching [as appropri-ate to findings], neuromuscular reeducation, andinstruction in an extensive home exercise pro-gramme. The outcome was that there was a 94%

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Figure 4 Diagrammatic view of the levator ani andischio-coccygeus, viewed from the pelvic surface (fromSapsford et al., 2001, with permission).


improvement in problems associated with urina-tion; 9 of the 16 patients were able to return topain-free intercourse. The greatest improvementseen related to frequency symptoms and suprapu-bic pain. There was a lesser improvement in urinaryurgency and nocturia. The researchers suggestthat: ‘‘Manual physical therapy may be a usefultherapeutic modality for patients diagnosedwith IC, high-tone pelvic floor dysfunction,and sacroiliac dysfunction. Intervention seems tobe most useful in patients with primary complaintsof urinary frequency, suprapubic pain, anddyspareunia.’’

6. Oyama et al. (2004) evaluated the effective-ness of transvaginal manual therapy of the pelvicfloor musculature (Thiele massage) in 21 sympto-matic female patients with IC and high-tonedysfunction of the pelvic floor. Thiele massagetreatment (including trigger point deactivation)was given twice weekly for 5 weeks. At long-termfollow-up symptoms of pain and urgency remained‘significantly improved’. They concluded that:‘‘Thiele massage appears to be very helpful inimproving irritative bladder symptoms in patientswith IC and high-tone pelvic floor dysfunction, inaddition to decreasing pelvic floor muscle tone.’’

7. A French osteopathic study by Riot et al.investigated a new approach to treatment ofirritable bowel syndrome (IBS), in which thetreatment offered involved a combination ofmassage of the coccygeus muscle, together withphysical treatment of frequently associated pelvicjoint disorders. One hundred and one patients (76female, 25 male, mean age: 54 years) with adiagnosis of Levator ani syndrome (LVAS) werestudied prospectively over 1 year following treat-ment. Internal massage, including trigger pointdeactivation) was given with the patient sidelyingon the left. Physical treatment of the pelvic jointswas applied at the end of each massage session.Forty-seven (46.5%) of the 101 patients, sufferedboth from LVAS and IBS. On average less than 2sessions of treatment were necessary to alleviatesymptoms. Sixty-nine per cent of the patientsremained free of LVAS symptoms 6 months later,while 10% still had symptoms, but were improved.At 12 months, 62% were still free of symptoms, witha further 10% improved. A similar improvementtrend was observed in the IBS-patient group (53%IBS free initially following treatment, 78% at 6months, 72% at 12 months). All IBS-free patientswere LVAS-free at 6 months. The conclusion wasthat the LVAS symptoms may be cured or alleviatedin 72% of the cases at 12 months, following one totwo treatment sessions. The researchers suggestthat since most of IBS patients benefited from this

treatment, it is reasonable to suspect a mutualaetiology, and to screen for LVAS in all IBS patients.

Observation

These studies (amongst many others) point totrigger point activity being a probable aetiologicalfeature of a number of different conditions invol-ving the pelvic organs, most notably urinaryincontinence (UI) and IC. A recurring feature inthese studies was an excessive degree of tone inthe pelvic floor muscles, particularly levator ani, aswell, commonly, as piriformis. A variety of nameshave been ascribed to the condition including‘levator ani spasm syndrome’ (Lilius and Valtonen,1973), ‘tension myalgia of the pelvic floor (Sinakiet al., 1977), and most recently ‘chronic pelvicfloor myofacial trigger point pain syndrome’(Baldry, 2005).

In addition to pelvic floor involvement, pre-viously cited researchers such as Lukban et al.(2001), Riot et al. (2005) as well as Anderson(2006), have all identified sacroiliac dysfunction asa frequently associated factor. Possible mechanismsfor this connection deserve some consideration.

It has been suggested that what are termedIdiopathic Pain Disorders (IPD)—which includepelvic disorders such as—IC and vulvar vestibulitis(VVS) (as well as non-pelvic related conditions suchas temporomandibular joint disorders (TMJD),fibromyalgia syndrome (FMS), IBS, chronic head-aches, chronic pelvic pain, chronic tinnitus andwhiplash-associated disorders), are mediated by anindividuals genetic variability, as well as byexposure to environmental events. The primarypathways of vulnerability that underlie the devel-opment of such conditions are seen to involve painamplification and psychological distress, modifiedby gender and ethnicity (Diatchenko et al., 2006).The possibility that stress and emotion are

aetiologically linked to CPP is not universallyaccepted. For example Henderson (2000) states,in relation to IC: ‘‘Stress is often cited as theunderlying cause of the disorder, and relaxation isthe first treatment option—regardless of the factthat neither stress nor psychological factors hasbeen show to cause IC.’’

Nevertheless, the fact that this paper focuseslargely on the structural features of pelvic painconditions is not meant to ignore the possibilitythat, in some instances, profound psychosocialelements may have been part of the aetiology ofthe condition, or that they may be importantfeatures in maintenance of such problems (Krir,2000).

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L. Chaitow332

High tone? low tone?

Despite some of the studies reported on aboveconfirming the presence of excessive pelvic floormuscle tone, it is important to acknowledge that inmany instances the cause of such symptoms mayrelate to low-tone pelvic floor conditions, and toprolapse. It is of course possible, and indeed likely,that in some instances some of the pelvic floor/lower abdominal/inner thigh muscles (some hous-ing active TrPt) might be hypertonic, while othersare hypotonic.

The treatment studies described earlier, andthroughout this paper, relate in the main to high-tone conditions, and not to prolapse-relatedsymptoms, where quite different strategies wouldbe more appropriate than Thiele massage, as usedin the high-tone settings described above. (Saps-ford, 2004; Hagen 2004).

With some studies demonstrating relatively high(o70%) success rates when Kegel-type toningexercises are employed (Nygaard et al., 1996),and others relatively low (�50%) success rates(Chaiken et al., 1993), it is clear that categoriza-tion of patients with IC and/or UI, into high-tone(where toning exercise may be less appropriate) orlow-tone (where toning may be more appropriate)groups, remains an inexact science. In somestudies, where high-tone issues prevail, and wheresuccess was achieved via Thiele massage as themain therapeutic tool, Kegel exercises were never-theless employed as part of home care. Weiss(2001) for example reports that ‘‘In addition tooffice [i.e. Thiele massage] treatment, the patientis instructed in a home programme consisting ofbiofeedback and Kegel instruction, external pelvicmuscle stretches and strengthening, and stressreduction techniques.’’

Investigation of clinical methods for differentiat-ing whether high-tone or low-tone pelvic floordysfunction (or mixtures of these states) areoperating, and therefore selecting appropriatetreatment strategies in any given case, offer apotentially fruitful area for research.

Pelvic floor problems and back pain

A number of studies have pointed to an associationbetween LBP and pelvic symptoms, such as thosediscussed earlier, particularly UI. For exampleEliasson (2006) reports that UI was noted by 78%of 200 women with LBP. In comparison with areference group, the prevalence of UI and ‘‘sig-nificant UI’’, as well as signs of dysfunctional pelvicfloor musculature, were greatly increased in those

with back pain. Analysis of the evidence shows thatsuffering from LBP, and inability to interrupt theurine flow, increases the risk for UI.

Smith et al (2006) evaluated these, and othersymptoms, in a total of 38,050 women, from threeage-cohorts. They found that unlike obesity andphysical activity, disorders of continence andrespiration were strongly related to frequentback pain. It was considered that this relationshipmight be explained by physiological limitations ofco-ordination of postural, respiratory and conti-nence functions of the trunk muscles (Fig. 5).

The breathing connection

Hodges (2007) has observed that there is a clearconnection between respiratory function, pelvicfloor function, and SIJ stability, particularly inwomen. He notes that if pelvic floor muscles aredysfunctional, spinal support may be compromised,increasing oblquus externus activity that alters

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Figure 5 Diagrammatic representation of the abdomino-pelvic cavity surrounded by muscles, which contribute tospinal stability, intra-abdominal pressure and continence(from Sapsford et al., 2001, with permission).


pelvic floor muscle activity, possibly leading to UI.Smith et al. (2007) has confirmed this relationshipbetween spinal support, pelvic and abdominalmusculature, with implications for dysfunctioninvolving UI.

Earlier Barbic et al. (2003) revealed evidencethat the pelvic floor muscles actively assist lumbo-pelvic stability, as well as urinary and fecalcontinence. A motor control deficit, operating inincontinent individuals, affects levator ani andpubo-coccygeus muscles, and therefore lumbopel-vic stability. In addition, motor control can beshown to be disturbed by the effects of breathingpattern disorders such as hyperventilation (Chai-tow, 2004, 2007).

Earlier still Hodges et al. (2001) had demon-strated that after approximately 60 s of over-breathing (hyperventilation), the postural (tonic)and phasic functions of both the diaphragm andtransversus abdominis are reduced or absent, withmajor implications for spinal stability.

Recently O’Sullivan and Beales (2007) haveshown the benefits of rehabilitation of motorfunction to pelvic floor, diaphragm and sacroiliacfunction, when applied to individuals with SI jointpain. The combined evidence that emerges sug-gests that there is a complex inter-relationshipbetween spinal and sacro-iliac stability, and avariety of pelvic floor/organ problems, includingUI, as well as diaphragmatic (and thereforerespiratory) function. Somewhere in this mixmyofascial trigger point activity emerges as asignificant symptom causing, aggravating or main-taining, feature.

The evolution of trigger points and theirinfluences

Anxiety and other emotions have been shown toencourage recruitment of a small number of motorunits that display almost constant, or repeated,activity when influenced psychogenically. In onestudy, low-amplitude myoelectric activity (mea-sured using surface electromyography) was evi-dent, even when muscles were not beingemployed, in situations of mental stress (Waerstedet al., 1993): ‘‘A small pool of low-threshold motorunits may be under considerable load for prolongedperiods of timeymotor units with Type 1 [postural]fibres are predominant among these. If the subjectrepeatedly recruits the same motor units, theoverload may result in a metabolic crisis.’’

This sequence parallels the proposed aetiologicalevolution of myofascial TrPt, as suggested by

Simons et al. (1999) with major implications forthe development and exacerbation of myofascialpain conditions. Simons et al. have clearly demon-strated that an ischaemic environment is a naturalbreeding ground for TrPt. This has recently beenconfirmed by remarkable techniques involvingmicroanalytical assays of the milieu of living musclein the region of active TrPt (Shah et al., 2005). Inaddition ischaemia is a natural result of bothexcessively long-held muscular tone, and over-breathing (Jammes et al., 1997; Chaitow et al.,2002).

It has been hypothesized that in situations ofhypotonia and joint laxity, symptoms deriving fromthe presence of active trigger-points, may repre-sent a stabilizing response to the resulting hyper-mobility (Chaitow and DeLany, 2002). Trigger pointevolution in associated muscles appears to be acommon accompanying feature of relatively laxligaments (Kerr and Grahame, 2003). The authorhypothesizes that these energy efficient (if painful)entities (TrPts), may offer a means of achievingrelative stability.

The implications of this are that, if myofascialTrPTs are serving functional roles, such as instabilization of hypermobile joints, or in thecontext of our present discussion, enhancementof pelvic floor stability in stretched or lax tissues,their deactivation may ease pain, but at the cost ofstability. Simons (2002) concurs ‘In this case it iswise to correct the underlying cause of instabilitybefore releasing the MTrP tension.’

It is also important to consider that, at times,apparent symptoms may represent a desirablephysiological response to imbalance or hypotonia(Thompson, 2001).

Lewit and Horacek (2004) report that active TrPtin the erector spinae of the thoracic region arecapable of inducing strong contractions of thelumbar erector spinae, extending the lumbar spineand pelvis (Silverstolpe, 1989). Lewit and Horacekhave also identified a trigger point in the coccygeusmuscle that if deactivated, also deactivates theerector spinae TrPt. Subsequent maintenance ofthe resulting improvement is then best achieved,these authors assert, by the individual learning torelax the muscles of the pelvic floor. Skoglund(1956) showed, using EMG evidence, that thesetriggers and reflexes are linked to what he termed‘mechanical pelvis dysfunction.’

Noting that ‘[the coccygeus muscle] shares acommon attachment to the pelvic diaphragm viathe pubococcygeus muscles’, Liebenson (2000)reports that symptoms associated with these sameTrPts may also affect ‘LBP, coccygeal pain, pseu-dovisceral pain’.

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L. Chaitow334

Undoubtedly such scenarios (hypermobility, re-flex influences) can be clinically confusing, and aredeserving of clinical research that may ultimatelyoffer clear guidelines as to when to deactivate, andwhen to consider not deactivating, symptom-producing, active, TrPt.

Fortunately most TrPt affecting pelvic structures(both internal and external) are well documentedand mapped (Simons et al., 1999; Chaitow andDeLany, 2002) (Figs. 6–8).

Urethral and sacro-iliac stability andinstability

It is abundantly clear that symptom-related TrPtdevelop in pelvic floor and other muscles local tothe lower pelvis, such as those muscles attaching tothe pubic region. The local causes of their evolu-tion might relate to excessive tone in these

muscles, however some may relate to psychogenicsymptoms such as anxiety.

Chronically dysfunctional postural patterns mayfurther add to instability in the pelvic region.

Janda (1983) identified crossed-syndrome pat-terns in which particular muscle groups were eitherinhibited or lengthened, while opposing musclegroups tightened and shortened, in response topatterns of overuse and misuse, often involvingpostural factors.

Key et al. (2007) have observed and catalogued anumber of variations within the patterns ofcompensation/adaptation associated with chronicpostural realignment involved in crossed-syn-dromes. Such modified postural patterns arecommonly associated with pelvic deviation and orrotation, with profound implications for bothrespiratory and pelvic floor function. For exampleKey et al. report that, in relation to what theyterms the posterior pelvic crossed syndrome,characterized by ‘‘a posterior [pelvic] shift withincreased anterior sagittal rotation or tilt’’, to-gether with an anterior shunt/translation of thethorax, among many other stressful modifications,there will inevitably be poor diaphragmatic controland altered pelvic floor muscle function.

Efficient control of the urethra is essential fornormal bladder control. Force closure of theurethra involves a similar mechanism to the force

ARTICLE IN PRESS

Figure 6 Trigger point location and referral patternlateral abdominal muscles (from Chaitow and DeLany,2002 adapted with permission from Travell and Simons,1992).

Figure 7 Trigger point location and referral patternpectinius muscles (adapted with permission from Travelland Simons, 1992).


closure feature that is a requirement for optimalsacro-iliac stability (Lee and Lee, 2004). Animportant part of the achievement of urethralcontrol, and sacroiliac stability, relates to howthese structures and functions respond to loadtransfer during movement of the body, and this isdependent on the efficiency of muscles thatproduce adequate force closure, including levatorani, pubococcygeus, the diaphragm and multifidi.There appears to be a direct functional connectionbetween pelvic floor muscle activity and the majorabdominal muscles such as transversus abdominis(Sapsford et al., 2001).

Lee and Lee (2004) remind us that achievementof continence relies on a combination of endopelvicsupport for the urethra, the active muscularinvolvement of levator ani that offers a constantdegree of tone, and a muscular control system thatis dependent on pudendal nerve innervation oflevator ani, as well as reflex interactions between

the detrusor muscle and pelvic floor muscles. Thesemuscular relationships confirm that pelvic organfunction, respiration and many of the majormuscles involved in spinal support, are all inti-mately related.

A number of factors that appear to be capable ofinterfering with force closure of the urethra bythese muscles include:

� Trauma (major or repetitive minor) that leads toloss of anatomical integrity or neurophysiologi-cal function of the pelvic floor (Lee and Lee,2004).

� Inefficient load transfer involving excessiveincreases in intra-abdominal pressure, resultingin bladder and other pelvic organs being repeti-tively compressed inferiorly. Sapsford et al.(2001) suggests that this may result in repetitivemicrotrauma to the fascial support of theurethra, or altered recruitment of the pelvicfloor muscles.

� Female SUI has been associated with bladder-neck hypermobility (Balmforth et al., 2006).

� An inherited element involving reduced collagenin the individual’s connective tissue has beensuggested as one aspect of hypotonic pelvic floorstructures, with decreased collagen content inthe tissues of women affected by prolapse.Biopsy specimens of women with striae alsoshow a diminution of collagen far more fre-quently than is observed in non-prolapse women(Salter et al., 2006).

� Straining during bowel movements has beenfound to be common in women with uterovaginalprolapses and SUI, often involving alteredlumbopelvic posture (Spence-Jones et al., 1995).

� Uterovaginal prolapse is often associated withreduced lumbar lordosis and back pain (Nguyenet al., 2000).

� Vaginal delivery may impair normal pelvic floormuscle strength (Allen et al., 1990).

� Ashton-Miller et al. (2001) report that failure ofthe endopelvic fascial support for the urethra,preventing optimal closure, may sometimes bethe result of damage to the nerve supply to thelevator-ani muscle, caused during labor.

In examples where tone is inadequate, or wheretissues have been over-stretched, it is not unrea-sonable to hypothesize (as discussed above)that trigger point evolution might be seen as aphysiological response that is attempting to restoretone in damaged, dysfunctional or denervatedtissues.

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Figure 8 Designated areas in the anterior abdominal andpelvic region to which pain may be referred by myofascialtrigger points (reproduced with permission from Chaitowand DeLany, 2005, after Travell and Simons, 1992).

L. Chaitow336

Summary

� Pelvic pain may be associated with a variety ofconditions involving genitourinary function in-cluding IC, stress incontinence, vulvodynia,prostatitis, prostatodynia, penile pain and dys-pareunia (Ottem et al., 2007).

� Pelvic problems involving low back and pelvicpain, as well as pelvic floor dysfunction, mayinvolve failed load transfer through the muscu-loskeletal components of the pelvic girdle, and/or failed load transfer through the organs of thepelvic girdle. Load transfer, force closure andmotor control of urethra is very similar to that ofthe SI joint. (Lee and Lee, 2004).

� Treatment strategies should reflect assessmentfindings. There may be joint or bladder neckhypo- or hypermobility, High or low muscle tone,or combinations of these features (Lee, 2007;O’Sullivan, 2005)—with or without the presenceof active TrPt that contribute to the pain beingexperienced.

� Pelvic-floor muscle training (PFMT) may beuseful in rehabilitation of control of bladderfunction, particularly where evidence exists ofhypermobility of the bladder neck. PFMT hasbeen shown to increase the resting tone of thepelvic floor, improve bladder elevation duringvoluntary pelvic-floor contraction, and reducebladder displacement during straining (Balm-forth et al., 2006).

� A cautionary note is raised by Key et al. (2007)who suggest that there is currently an over-emphasis on core control/stability, which mayresult in ‘core rigidity’: ‘‘Over-applied corestability training can become ‘core rigiditytraining’—inducing central fixing behaviouraround the body’s centre of gravity and asso-ciated dysfunctional breathing patterns’’. Andby implication, pelvic floor dysfunction.

Assessment and treatment

Before commencing manual/structural interven-tions, there should be consideration of Red flagsymptoms that might suggest the need for referralto eliminate serious pathology (Fall et al., 2004).

Additionally, signs and symptoms should beconsidered that suggest that psychological issuesshould be evaluated, and possibly treated, by asuitably trained health care provider (Savidge andSlade, 1997).

In order to develop a manual treatment planwhere biomechanical features appear to be con-

tributing to the patient’s symptoms, a comprehen-sive overview of patterns-of-use and function isnecessary, in which there would be evaluation of:

� Posture-particularly crossed syndrome patterns.� Gait and other functional movement patterns.� Spinal and pelvic (e.g. SI, pubic) status: mobility,

restriction and-if appropriate-form and forceclosure tests (Lee, 2004).

� Possible shortness of key pelvic and relatedmuscles: multifidi, iliopsoas, thigh adductors,piriformis, QL, hamstrings, quadriceps, abdom-inals (internal oblique) as well as internal pelvicmuscles.

� Possible weakness of key pelvic and relatedmuscles: as above and gluteals, abdominals(transversus).

� Possible presence of diastasis recti (Fitzgeraldand Kotarinos, 2003).

� Hypermobility tendencies.� Firing sequences of major muscle groups (e.g.

Janda’s (1983) hip extension and hip abductiontests).

� Presence of active TrPt (i.e. TrPt that whenstimulated reproduce symptoms recognizable tothe patient as relating to current symptoms) inkey pelvic muscles, as well as in the abdominalwall, inner thigh, pelvic floor. Recognizing thatpelvic floor status may be important to both thepathogenesis and maintenance of pelvic neuro-visceral pain syndromes, a study was conductedof female pelvic floor pressure pain thresholds,involving ten healthy female volunteers, using anovel vaginal pressure algometer (Tua et al.,2006). The mean pressure pain threshold of thefemale levator ani and obturator complex was1.59 kg/cm2 (SD ¼ 0.55), while thresholds ofnon-muscle vaginal sites (anterior and posteriorraphe) were 1.68 kg/cm2 (SD ¼ 0.68).

� Breathing function (particularly evaluating for aparadoxical patterns).

� Diaphragm and rib status.

Conclusion

Pelvic floor muscles may be hyper or hypotonic inrelation to chronic pelvic pain and dysfunction.Such conditions are frequently related to lumbo-pelvic or sacroiliac dysfunction (restriction orinstability), although the aetiological relationshipis not always clear.

Manual treatment methods (broadly covered bythe term Thiele massage for internal TrPt andexcessive tone) might include digital deactivation

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of TrPt, and/or use of dry needling (Baldry, 2005),and/or rehabilitation methods involving biofeed-back, relaxation and/or toning of the dysfunctionalpelvic floor muscles.

The manner in which force closure of the SI jointis achieved is closely mirrored by the way urethralcontrol of urination is achieved, and dysfunction ofone may be related to the other, as well as beinginfluenced by respiratory function and dysfunction.

Myofascial TrPt situated in high-tone muscles ofthe pelvic floor, the lower abdomen and theabductors, adductors, internal and external rota-tors of the hips, are a common feature of chronicpelvic pain.

Therapeutic approaches that endeavour to deac-tivate TrPt contributing to symptoms, as well asnormalizing joint and soft tissue imbalances,together with concomitant postural and breathingpattern disorders, have all been shown to becapable of modifying, modulating or eliminatingassociated symptoms, including chronic pelvicpain.

Several areas of evaluation of patterns ofpelvic floor dysfunction would benefit fromresearch, particularly in relation to identification,in a clinical setting, of methods for establishingwhether symptoms relate to high or low-toneconditions, as well as whether or not triggerpoint deactivation is an appropriate treatmentstrategy.

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Ashton-Miller, J.A., Howard, D., DeLancey, J.O.L., 2001. Thefunctional anatomy of the female pelvic floor and stresscontinence control system. Scandinavian Journal of Urologyand Nephrology Supplement, 207.

Baldry, P., 2005. Acupuncture, Trigger points and musculoskele-tal pain. Elsevier/Churchill Livingstone, Edinburgh, 353pp.

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classification system guiding diagnosis and therapeutic carein spinal pain and related musculo-skeletal syndromes: aparadigm shift. Journal of Bodywork & Movement Therapies,in press.

Krir, J., 2000. The importance of psychosocial aspects in clinicalassessment. British Journal of Chiropractic 4 (2–3), 50–53.

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Liebenson, C., 2000. The pelvic floor muscles and the Silver-stolpe phenomena. Journal of Bodywork and MovementTherapies 4 (3), 195.

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McKay, et al., 2001. Treating vulvar vestibulitis with electro-myographic biofeedback of pelvic floor musculature. Journalof Reproductive Medicine 46, 337–342.

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Bodywork and

Journal of

Movement Therapies

SELF-MANAGEMENT: PATIENTS SECTION

Functional problems associated withthe knee—Part 2: Do tight hamstrings onlyneed stretching?$

Craig Liebenson, DC�

L.A. Sports and Spine, 10474 Santa Monica Blvd., #202 Los Angeles, CA 90025, USA

Accepted 7 November 2006

Most active people and trainers place a great dealof emphasis on stretching tight hamstrings. Sadly,the tightness usually only decreases for a short timeonly to come back over and over again. If a muscleis very tight it is better to find out the cause of thetightness, rather than to continue to treat thesymptom (e.g. poor flexibility, pulled muscles).

One of the main factors associated with kneeproblems is weak hamstrings. Most people utilizethe front of their thighs (the quadriceps) too muchwhich puts added stress on their knees. A key wayto help reduce knee pain and improve stability is tostrengthen the hamstring muscles in the back of thethigh and knee. This will also help the muscles tostay relaxed since they will not be constantlygetting overloaded causing a vicious cycle ofoverload breactive tightness bmore overload.

It is simple to strengthen the hamstrings using abridge exercise on a gymnastic ball.

Bridge up and down

� Place your heels on the apex of the ball.� Press your heels into the ball to bridge your

body up.

� Lower down.� Perform 8–12 repetitions (see Figs. 1a and b).� To progress the exercise either attempt the

Curl exercise or perform with a single leg(see Fig. 2).

� Perform with your arms at your sides for betterbalance.

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Figure 1

1360-8592/$ - see front matter & 2006 Published by Elsevier Ltd.doi:10.1016/j.jbmt.2006.11.003

$This paper may be photocopied for educational use.�Tel.: +1 310 470 2909; fax: +1 310 470 3286.E-mail address: [email protected].

SELF

-MANAGEM

ENT:PATIENTS

SEC

TION

Curls


body up.

� Without lowering down curl the ball backtowards your buttock.

� Then push the ball out until your legs arestraight, but stay in an elevated position.

� Perform 8–12 repetitions (see Figs. 3a and b).� To progress the exercise either attempt the

Short-arc curl exercise or perform with a singleleg (see Figs. 4a–c).

Short-arc curls

� Bend your knees to a right angle and place yourheels on the apex of the ball.

ARTICLE IN PRESS

Figure 4

Figure 3

Figure 2

Figure 5

C. Liebenson62

SELF

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ENT:PATIENTS

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Curls


body up.

� Without lowering down curl the ball backtowards your buttock.

� Then push the ball out until your legs arestraight, but stay in an elevated position.

� Perform 8–12 repetitions (see Figs. 3a and b).� To progress the exercise either attempt the

Short-arc curl exercise or perform with a singleleg (see Figs. 4a–c).

Short-arc curls

� Bend your knees to a right angle and place yourheels on the apex of the ball.

ARTICLE IN PRESS

Figure 4

Figure 3

Figure 2

Figure 5

C. Liebenson62

SELF

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ENT:PATIENTS

SEC

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� Press your heels into the ball to bridge your bodyup while curling the ball all the way in towardsyour buttock.

� Then lower your buttocks to the floor whilepushing the ball out until your knees are bent ata right angle.

� Perform 8–12 repetitions (see Figs. 5 and b).� To progress the exercise perform with a single

leg (see Figs. 6a and b).

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Figure 6

Functional problems associated with the knee 63

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� Press your heels into the ball to bridge your bodyup while curling the ball all the way in towardsyour buttock.

� Then lower your buttocks to the floor whilepushing the ball out until your knees are bent ata right angle.

� Perform 8–12 repetitions (see Figs. 5 and b).� To progress the exercise perform with a single

leg (see Figs. 6a and b).

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Figure 6

Functional problems associated with the knee 63

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Bodywork and

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Movement Therapies

REHABILITATION AND CORE STABILITY

Pilates and the ‘‘powerhouse’’FII

Joseph E. Muscolino*, Simona Cipriani

7, Long Ridge Road, Redding, CT 06896, USA

Abstract Part one of this article described the key principles of the Pilates Method ofbody conditioning and then went on to investigate in detail the principle of centering.Further, the concept of the powerhouse was presented and described and the majoreffects of Pilates exercises upon the powerhouse were analysed. The sum total ofthese effects is to create what may be termed the Pilates Powerhouse Posture. Parttwo relates the concept of having a strong powerhouse to the concept of core-stabilization and describes some of the benefits of core-stabilization. While manyPilates exercise may not seem to be directed toward affecting the powerhouse, thepowerhouse is always foremost in the mind of the Pilates instructor when the client isperforming each and every Pilates activity. A number of Pilates exercises are shownand the focus upon the powerhouse is described for each one. These exercises aredivided into two categories: (1) those exercises whose sole purpose is to attain andcreate the Pilates Powerhouse Posture by directly addressing and working the musclesof the powerhouse, and (2) those exercises that may seem to be focusing on anotherpart of the body where motion is being directed to occur, but meanwhile theunderlying focus and intent is directed just as much, if not more so, toward thestabilizing contractions of the muscles of the powerhouse.& 2003 Elsevier Ltd. All rights reserved.

KEYWORDS

Pilates;

Powerhouse;

Core-stabilization;

Contrology;

Exercise

The powerhouse and core-stabilization

The powerhouse is the core of the body. Therefore,having a strong powerhouse creates a stabilizedcore from which muscles can contract. Mostmuscles of the body can be said to have a proximalattachment and a distal attachment; often theseproximal attachments are onto the spine. Theessence of the muscular system is that when amuscle contracts, it creates a pulling force upon

both of its attachments that is directed toward itscenter. Even though either attachment may move,in most instances, movement of the distal attach-ment is desired. For the distal attachment to moveefficiently and with maximal strength, the proximalattachment must be fixed or stabilized. This is theessence of core-stabilization: strengthen the coreof the body so that the proximal attachment is wellstabilized; as a result, the distal attachment canmove strongly and efficiently. When the core of thebody is weak and not well stabilized, not only willthe strength of the movement of the distal bodypart be diluted, but damage will tend to occurproximally as well (Chaitow and DeLany, 2002). Thisis due to the fact that when the core is less stable,the pulling force of the contracting muscle willgenerate greater movement at the proximal

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*Corresponding author. Tel.: þ 1-203-938-3323; fax: þ 1-203-938-9284.E-mail addresses: [email protected] (J.E. Muscolino),

[email protected] (S. Cipriani).URLs: http://www.learnmuscles.com,

http://www.artofcontrol.com.

1360-8592/$ - see front matter & 2003 Elsevier Ltd. All rights reserved.doi:10.1016/S1360-8592(03)00058-5


attachment. In the case of the spine, theserepeated movements over time create a wear andtear that can lead to increased stress upon thejoints and concomitant degeneration of the spinaljoints.

A strong and healthy powerhouse improves thebody’s health in another manner. The greater thecurves of the spine become, the less efficient thespine becomes at bearing the weight of the bodythrough it. Further, as the curves of the spineincrease, the apexes of the curves become weakerpoints in the chain of vertebrae; greater stress isborne upon them and degeneration occurs morerapidly. The effect of lengthening the spinedecreases the degree of spinal curves and countersthis tendency toward early degeneration.

The Pilates method of attaining thePilates Powerhouse Posture

Pilates exercises have one factor in common; theyall strengthen the powerhouse because all Pilatesexercises constantly work the powerhouse (Siler,2000). Indeed, every Pilates exercise that is done,even the exercises that seem to have nothing to dowith the powerhouse of the body, are done with afocus and intent on working the powerhouse.Brooke Siler calls this ‘‘Integrated Isolation’’ andexplains this concept as follows: ‘‘It is commonlythought that the areas of the body that are inmotion during an exercise are the areas in whichthe mind should be focused; this is known as‘isolating’ a particular group of muscles. Theproblem with this ideology is that it ignores theother areas of the body that are not in motionyitis most effective to think of focusing on stabilizing,or anchoring, the area of the body that is not inmotion’’ (Siler, 2000, p. 21). This area that is not inmotion that the Pilates method focuses upon is thepowerhouse. This concept is very important if oneis to understand and appreciate what is happeningduring a Pilates workout. For example, it is toosimple to view a Pilates exercise that is being donein which the arms are the only body parts movingand believe that the only reason for doing thisexercise is to strengthen the arms (see Fig. 1).

This misjudgement of the underlying purpose ofthis exercise is easy to make because the averagelay person, as well as a number of professionals inthe health and fitness field, have become incul-cated by the fitness world’s focus on ‘‘isolating’’certain muscles and/or muscle groups that aremoving during an exercise. The result is that focushas been lost on the other muscles that are working

as stabilizers, the Pilates Powerhouse Muscles. It isthese key muscles at the core of the body thatultimately prove to be the key to health andstability.

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(a)

(b)

Figure 1 The Hundred: (a) demonstrates the startingposition of The Hundred; (b) illustrates the upwardmovement of the arms that is done during The Hundred.The Hundred is an indirect Pilates Mat exercise for thepowerhouse. In The Hundred, the client moves her armsup and down sequentially (between the position seen in(b) and the position seen in (a). These movements offlexion and extension of the arms at the shoulder jointsare done while maintaining a static posture of neckflexion at the spinal joints and thigh flexion at the hipjoints. These arm movements are repeated 100 times,hence the name. This is a Pilates mat exercise that isusually done at the beginning of a workout. While theintent seems to be to concentrically and eccentricallywork the sagittal plane muscles of the arm at theshoulder joint (along with isometrically working theanterior neck and hip joint muscles, as well as being acardiovascular warm-up); strict attention is always beingpaid to isometrically maintain the Pilates powerhouseposture. Toward this end, the focus is on isometricallyengaging the abdominals, pressing the navel to the spineand lengthening up in a cephalad direction. This exercisemay also be done using apparatus, and there arealternate versions of the hundred that are easier toperform.

Pilates and the ‘‘powerhouse’’FII 123

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(a)

(b)

(c)

(d)

Figure

2TheRollUp:(a)demonstratesthestartingpositionofTheRollUp;(b)showsthenext

stepin

whichthearmsarebrough

tto

ave

rtical

position;(c)an

d(d)

illustrate

therollupitself.Theseco

ndphaseoftheexe

rcisewould

beto

return

tothestartingposition.TheRollUpisadirect

PilatesMat

exe

rciseforthepowerhouse.

InthefirstphaseofTheRollUp,theclientco

nce

ntrically

contrac

tsherab

dominal

musclesto

bringherupperbodyove

rherlowerextremities;

thisac

tionisflexionof

thetrunkat

thespinal

joints

(anteriortilt

ofthepelvisat

thehip

joints

isalso

occurring).In

theseco

ndphaseoftheexe

rcise,theclienteccentrically

contrac

tsher

abdominal

musclesto

carefullyco

ntrolherdescentbac

kto

themat;thisac

tionis

extensionofthetrunkat

thespinal

joints.This

exe

rciseissimilar

innature

tothe

trad

itional

sit-up/c

url-up.Howeve

r,beyo

ndthesimple

objectiveofbringingtheupperbodytowardthelowerextremities,

theclientfocu

sesonmaintainingthePilates

powerhouse

posture

ofke

epingthenav

elto

thespine.Ontheway

bac

kdown,theclientis

carefulto

lowerherbodybac

kto

themat

‘‘oneve

rtebra

atatime’’.

Additionally,ke

epingthearmsparallelan

dthehead

straightis

nece

ssaryas

partoftheprecise

controlofthis

exe

rcise.

124 J.E. Muscolino, S. Cipriani

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(a)

(b)

(c)

Figure

3Flat

BackontheSh

ort

BoxSe

ries:

(a)demonstratesthestartingpositionofTheFlat

Bac

kexe

rcise;(b)an

d(c)demonstrate

thetrunkbeingbrough

tin

aposteriordirectionwithastraight(flat)bac

k.Theseco

ndphaseoftheexe

rcisewould

beto

return

tothestartingposition.TheFlat

BackontheSh

ort

Boxisadirect

PilatesApparatusexe

rciseforthepowerhouse.Itisdoneontheap

paratusca

lledtheReform

er.Theac

tual

move

mentisat

thehip

joints.Duringthefirstphaseonthe

way

down,theclientposteriorlytiltsherpelvisat

thehip

joint(w

orkingherhip

flexo

rseccentrically);

duringtheseco

ndphaseontheway

upshean

teriorlytiltsher

pelvisat

thehip

joint(w

orkingherhip

flexo

rsco

nce

ntrically).

Just

asin

old-fashionedstraight-legsit-ups,

thean

teriorab

dominalsmust

isometrically

contrac

tto

hold

hertrunkstraight(since

grav

itywould

otherw

iseco

llap

sehertrunkinto

extension).

Thisisan

otherdirect

powerhouse

exe

rcise.Howeve

r,ab

ove

andbeyo

ndtheeffort

exp

endedbythean

teriorab

dominalsto

keepthetrunkstraight,

thefocu

sis

onmaintainingthepowerhouse

posture

ofnav

elto

thespinean

dup.Indeed,acritical

aspect

ofthis

exe

rciseis

toco

nstan

tlybereac

hingupto

thece

iling,

lengtheningthespineas

themove

mentoccurs.


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(a)

(b)

(c)

Figure

4Sw

anDive:(a)demonstratesthestartingan

dendingpositionofTheSw

anDive;(b)showsthefirststepin

whichthebac

kisarch

edposteriorlywiththekn

ees

bent;

(c)thenillustratestheseco

ndstepin

whichthebodyisco

mpletely

straightenedout.

TheSw

anDiveisadirect

PilatesApparatusexe

rciseforthepowerhouse.Itis

doneonan

apparatusca

lledtheLa

dderBarrel.Themainmove

mentoccurringhere

isextensionan

dthenflexionofthetrunkat

thespinal

joints.Therefore,theclient

must

work

spinal

extensormusclesco

nce

ntrically

toarch

herbac

k(step1),an

dthenwork

thespinal

extensormuscleseccentrically

toco

ntrolherdescentto

thestraight

position(step2)

andthento

controlherreturn

tothestartingposition.Doingthis

directly

worksthepowerhouse

bystrengtheningtheposteriorab

dominal

muscles.

Further,move

ments

oftheupperan

dlowerextremitiesarealso

occurringwhichincreasethedifficu

ltyofthisexe

rcise.Theentire

exe

rcisemust

bedonein

asm

ooth,

precise

andco

ntrolledman

ner;

thepowerhouse

posture

must

bemaintainedwiththefocu

sonlengtheningthespineuptowardthece

iling.


When assessing the wide breadth of Pilatesexercises, two broad categories may be viewed:category one includes those exercises whose solepurpose is to attain and create the Pilates Power-house Posture by directly addressing and working

the muscles of the powerhouse; category twoincludes those exercises that may seem to be

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(a)

(b)

Figure 5 Teaser 1: (a) demonstrates the first part of TheTeaser in which the thighs are raised; (b) illustrates thesecond part in which the trunk is flexed upward withthe upper extremities brought to a position parallel tothe lower extremities. The second phase of the exercisewould be to return to the starting position. The Teaser 1is a direct Pilates Mat exercise for the powerhouse. Theclient begins flat on her back and then flexes her thighs atthe hip joints to a 45-degree angle. She then rolls up to a‘‘V’’ position, with her hands reaching toward her toes,all the time keeping the navel to the spine andlengthening upwards. She then returns to the mat,controlling her descent. To accomplish this exercise,concentric and then eccentric contraction of her anteriorabdominal musculature is clearly required. The addeddifficulty is to create these movements with the lowerextremities held at 45 degrees of flexion and the upperextremities held straight and perfectly parallel to thelower extremities. Of course, the powerhouse posture ofnavel to the spine and lengthening upwards along withaccomplishment of this exercise in a smooth, precise andcontrolled fashion is as critically important, in fact morecritically important, than the actual accomplishment ofraising and lowering the trunk with parallel extremities.

(a)

(b)

Figure 6 Footwork: (a) demonstrates the startingposition of The Footwork Exercise; (b) illustrates theextended position attained by pushing against the barwith one’s feet. The second phase of the exercise wouldbe to return to the starting position. The Footworkexercise is an indirect Pilates Apparatus exercise for thepowerhouse. It is done on an apparatus called theReformer. In the initial phase of the exercise, the clientpushes her feet against a bar. The force that she createspushes her body away from the bar. This movementoccurs against the resistance of springs that are attachedto the board that her body is lying on. In the second phaseof the exercise, she then returns to the initial startingposition in a controlled manner (resisting the force of thesprings to pull her back to the starting position). Thisexercise requires concentric contraction of knee and hipjoint extensors for the initial phase and then eccentriccontraction of the same muscles for the second ‘return’phase of the exercise. Again, the apparent purpose ofthis exercise seems to be to strengthen extensors of thehip and knee joint. However, constant attention is beingpaid to the proper maintenance of the powerhouseposture during these lower extremity movements, byfocusing on lengthening the spine by bringing the naveltoward the spine and up toward the head. There are aseries of these footwork exercises that change theposition of the foot upon the bar so that the toes, archesor heels are in contact with the bar.


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(a) (b)

(c) (d)

Figure 7 Chest Expansion: (a) demonstrates the starting position of The Chest Expansion exercise; (b) illustrates thefirst step of pulling the bar down with the arms. (c) and (d) illustrate the final step of turning the head and neck first toone side and then to the other. The second phase of the exercise would be to return to the starting position. The ChestExpansion exercise is an indirect Pilates Apparatus exercise for the powerhouse. It is done on an apparatus called theCadillac. In the first step of this exercise, the client pulls a bar down toward the body with both arms. Given theresistance of the springs to which the bar is attached, this movement requires concentric contraction of the extensorsof the arms at the shoulder joints. In the second step, the client rotates the head and neck in both directions whileholding down the bar; this step both works the rotators of the head and neck concentrically and stretches the samemuscles. The second phase of the exercise requires bringing the bar back to the initial starting position in a slow,controlled manner; this exercises the shoulder joint extensors eccentrically. As in other exercises of this category, themain purpose of this exercise is not the surface movements of the shoulder and neck joints. The main focus is tomaintain the Pilates Powerhouse Posture, while forces are being transmitted to the trunk by the bar attached tosprings. As the bar is moved in the first and last phases of this exercise, these transmitted forces change requiring fineadjustments for the powerhouse muscles. Thus, this core stability exercise is more dynamic than the previouslydemonstrated exercises.


focusing on another part of the body where motionis being directed to occur, but meanwhile theunderlying focus and intent is directed just asmuch, if not more so, toward the stabilizingcontractions of the muscles of the powerhouse,and therefore, maintenance of the Pilates Power-house Posture. Generally, category one incorpo-rates those exercises that create concentric andeccentric (and isometric) contractions of power-house muscles while category two incorporatesthose exercises that create isometric contractionsof powerhouse muscles, while concentric andeccentric (and occasionally isometric) contractionsare occurring in other regions of the body. Categoryone exercises may be termed Direct PowerhouseExercises and examples of these are seen in Figs. 2–5. Category two exercises may be termed IndirectPowerhouse Exercises and examples of these are

seen in Figs. 1, 6 and 7. Figure 8 is an example of anexercise that is both an indirect and direct exercisefor the powerhouse.

Regardless of which type of exercise is beingdone, the focus of the Pilates instructor is alwaysupon the proper posture of the client’s power-house. Even slight deviations from it, while doingan exercise that is seemingly distant from thepowerhouse, will elicit admonitions for fine adjust-ments in core posture from the Pilates instructor. Itis largely for this reason that Joseph Pilates feltthat precision was so very important. The precisionis aimed at maintaining the proper Pilates power-house posture at all times.

The sharp and precise focus of the Pilates methodis to require the client to use a concentrated mindto precisely control this all-important posture ofthe powerhouse, all the time breathing to maintain

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(a) (b) (c)

Figure 8 Press-Up Bottom: (a) demonstrates the starting position of The Press-Up Bottom Exercise; (b) illustrates thefirst step of raising the body up toward the ceiling. (c) Illustrates the final step of arching the body back into extension.The second phase of the exercise would be to return to the starting position by pushing the pedal back down. The Press-Up Bottom exercise is both an indirect and direct Pilates Apparatus exercise for the powerhouse. It is done on anapparatus called the Electric Chair. In the first phase of the exercise, the client begins on a pedal that is attached tosprings. The first step requires the client to concentrically contract the extensors of the elbow joint, pushing the bodyup into the air; this movement is aided by the tension of the springs. While this step of the Press-Up Bottom exercisemay appear to be simply a vertical version of a push-up exercise aimed at strengthening elbow joint extensors, thePilates instructor is constantly looking for the client to hold the Pilates Powerhouse Posture by pulling the navel to thespine and lengthening the spine upwards. Pilates instructors often instruct their clients to think of the lifting force forthe body as coming from the powerhouse, in effect marshaling the force from the powerhouse to ‘levitate’ their body.This first step could be considered to be an indirect exercise for the powerhouse. The second step requires the client toconcentrically contract the extensors of the spine, creating extension of the trunk at the spinal joints as well as anteriortilt of the pelvis at the lumbosacral joint. As such, this step is a direct powerhouse exercise, specifically a concentricstrengthening exercise of the spinal extensors. The return phase of this exercise requires the client to preciselymaintain the powerhouse posture while returning to the starting position, pushing down against the springs of thepedal.


proper blood flow to bathe the tissues withnutrients and drain away the waste products ofmetabolism. Add onto this the proper flow of oneexercise to the next during a Pilates session and wehave all six key components of Pilates woventogether into one cohesive systematic method.Through a mixture of exercises focused directlyupon the core of the body along with continualisometric stabilization of the core powerhouseduring every exercise, the Pilates method of bodyconditioning obtains the results that it seeks, alengthened, strengthened and flexible spine, bothin a static postural sense and a dynamic functionalsense.

References

Chaitow, L., DeLany, J., 2002. Clinical Applications of Neuro-muscular Techniques. The Lower Body, Vol. 2. ChurchillLivingstone, London, 2002.

Siler, B., 2000. The Pilates Body. Broadway Books, New York, NY.

Dr. Joseph E. Muscolino has been a Chir-opractor and an Anatomy, Physiology andKinesiology instructor for 17 years. He is theauthor of The Muscular System Manual,published by Mosby of Elsevier Science.Simona Cipriani has been an instructor of theAuthentic Pilates method for 9 years and isowner of the Art of Control, a Pilates studio inNew York. She is also a professional dancerand licensed Massage Therapist.

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Bodywork and

Journal of

Movement Therapies

CLINICAL METHODS

Treatment approaches for three shoulder ‘tethers’

Thomas Myers, LMT

318 Clarks Cove Road, Walpole, ME 04573, USA

Received 2 September 2006; received in revised form 28 September 2006; accepted 28 September 2006

KEYWORDSShoulder;Myofascial;Technique;Subclavius;Pectoralis minor;Teres minor

Summary Shoulder dysfunctions are frequently accompanied by a pattern ofretraction in key myofascial components. Soft-tissue release techniques for threepivotal myofascial ‘tethers’ in the shoulder complex—subclavius, pectoralis minor,and teres minor—are described in terms of assessment, palpation, and treatment.& 2006 Elsevier Ltd. All rights reserved.

Introduction

Shoulders can be problematic in upright humanposture for two reasons:

(1) the shoulders are designed for mobility overstability (compared to any quadruped’s fore-limbs), making problems of hypermobility,friction, and displacement far more common,and

(2) the shoulder is yoked over the rib cage in aprecarious manner. The only point of directarticular contact with the axial skeleton is thesternal manubrium (Kapandji, 1982) and other-wise the human shoulder is suspended in awelter of muscles, tendons, bursae, and liga-ments (Levin, 2005)—such that displacementsof the elements of the trunk—pelvis, lumbars,ribs, neck or head—can be a literal ‘drag’ onthe shoulder girdle. The result of even slight

displacements is that the forces from the armsdo not get distributed properly to the trunk,which in turn leads to internal strain patterns asthe shoulder girdle accommodates these forcesin less than optimal ways.

For these reasons, the preconditions for shoulderinjuries, or failure, often build up over years ofeven slight misuse.

Identified ‘conditions’, such as frozen shoulder,deltoid bursitis, or biceps tenosynovitis are alwaysunique to each individual, involving a complex setof relationships—hence the emphatic preamblethat a systemic approach is absolutely essentialfor long-term relief of shoulder dysfunctions. Thatsaid, there is clinical value in familiarity withtechniques focused on three essential ‘tethers’commonly associated with complex strain patterns.Although the techniques described below may

not necessarily address the cause of dysfunction,clinical experience suggests that they are fre-quently part of the resolution, since the shoulder

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E-mail address: [email protected].

commonly tends to shorten around these myofas-cial tethers, no matter what the underlying failure.It is worth noting that when any muscle is

referred to by name this should be understood tobe shorthand for the muscle and all the fasciaeasso

Documents

Editor: Leon Chaitowhandsonseminars.com/JBMT.pdfLeon Chaitow, Editor. ISSN 1360-8592 Journal of Bodywork and Movement Therapies (2007) 11, 327–339 Bodywork and Journal of Movement