Low Back Pain and Pelvic Floor Disorders

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Original Editors

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Search Strategy

Search Databases: CINAHL, PubMed, Cochrane, PT Journal, Medline, Google Scholar

Keywords: Low Back Pain, Pelvic Floor Disorders, Incontinence

Search Dates: 4/6/2011 - 4/29/2011

Definition/Description

Low back pain (LBP) is a condition of localized pain to the lumbar spine with or without symptoms to the distal extremity whose etiology is commonly unknown.⁵  Pelvic floor disorders (PFD) include urinary incontinence, pelvic organ prolapse, fecal incontinence, and other sensory and emptying abnormalities of the lower urinary and GI tracts.²   Current evidence shows that individuals with low back pain have a significant decrease in pelvic floor function compared to individuals without low back pain.¹ 

Epidemiology /Etiology

Low back pain (LBP) is one of the most common musculoskeletal conditions; approximately 70-80% of the population will experience at least one episode of LBP during his/her lifetime. Trauma, disease and even poor postural habits are some of the myriad causes of LBP, however, only about 15% of cases can be attributed to a specific cause. Studies show a poor correlation between the pathology and associated pain and disability.1

Over 25% of all women and more than a third over the age of 65 experience PFD. The true prevalence of PFD is underestimated for several reasons: heterogeneity in study populations, lack of standardized definitions, and under-reported symptoms due to the sensitive nature. Even though PFD is a physiological problem, the psychosocial impact can be much more detrimental to the patient’s quality of life. Chronic health problems associated with PFD are estimated to increase by 50% over the next 30 years due to the increasing numbers of women reaching age 65.3 PFD does not typically have one specific cause. The major risk factors are: pregnancy/childbirth, age, hormonal changes, obesity, lower UTI, and pelvic surgery. The development of PFD most likely involves components anatomical, physiological, genetic, reproductive and lifestyle.3,5

Anatomy

Lumbopelvic Stability System

Optimal control of the lumbar spine and the pelvis is achieved by the following factors: bone and ligament structures (form closure), appropriate mm compression forces (force closure) and control by the nervous system. The bone and ligament structures include the inert structures of the lumbar spine, symphysis pubis and SI joints. The arrangement of the bones and ligaments of the pelvis permit weight from the upper body through the lumbosacral spine, across the pelvis to the femoral heads. Control of the lumbar spine and pelvis is dependent on the local muscles which consist of the diaphragm, transversus abdominis, the PFM, and the multifidus. The synergistic activity of these muscles influences postural control by regulating intra-abdominal pressure, and by increasing the tension in the thoracolumbar fascia. For correct movement, the nervous system must be able to evaluate the requirements of lumbopelvic control, determine the current status of the lumbopelvic region and develop strategies to meet those functional demands. 14

The pelvic floor forms the inferior border of the abdomino-pelvic cavity. 3 The pelvic floor muscles are the only transverse load bearing muscle group in the body and support the abdomino-pelvic organs. The PFMs function as a unit, instead of contraction of each muscle on its own. They play an important role in maintaining and increasing IAP while performing functional tasks such as lifting, sneezing, coughing, and laughing. The contribution of PFM to IAP and trunk stability has been explained by feedforward activation of these mms in response to trunk perturbations, along with the other stabilizers of the trunk such as the deep abdominal mms and the multifidus. 1

Differential Diagnosis

PFD is difficult to diagnose because it presents many challenges because of poor association between pathophysiology, poor patient reported signs and symptoms, and anatomical evidence.³ 

• Cauda Equina Syndrome
• Sexual Dysfunction
  
• Urinary Tract Infection

Examination

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Medical Management (current best evidence)

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Key Research

Eliasson et al. (2008). Urinary Incontinence in Women with Low Back Pain

The purpose of this study was to explore the occurrence of UI in women with LBP and to compare this group with a reference group with similar demographics.  The study used previously collected original data for the reference group.  Two hundred women with LBP completed a validated questionnaire; subject inclusion criteria included LBP, female, not pregnant, age between 17 - 45 years old.  Study results found 78% of women with LBP reported UI.  Compared to the reference group, the prevalence of UI and signs of PFD were significantly increased in the LBP group (p <.001). 

Arab et al. (2010). Assessment of Pelvic Floor Muscle Function in Women with and without Low Back Pain Using Transabdominal Ultrasound

The purpose of this study was to investigate the PFM function in women with and without LBP using transabdominal ultrasound.  A cross sectional design was used to compare 40 nonpregnant women between the ages of 20 and 50 years (20 with LBP; 20 without LBP); subject inclusion criteria for the LBP group included LBP >6 week, on/off back pain and had experienced at least 3 episodes each lasting at least a week.  Each participant underwent transabdominal ultrasound normalized to their calculated BMI; PFM function differs according to each individuals BMI.  Baseline was established as the base of the bladder before contraction, and the change in distance of the base of bladder from pre and post contraction was used to determine significance of findings. Study results found a significant difference of (p = .04) in the transabominal ultrasound measurements of PFM function btw subjects with LBP and those without LBP.  Participants with LBP  displayed a pattern of decreased pelvic floor function when measured with transabdominal ultrasound.

Resources

https://www1.columbia.edu/sec/itc/hs/medical/anatomy_resources/anatomy/pelvis/index.html

Clinical Bottom Line

Transabdominal ultrasound has proven that the PFM and trunk musculature co-contract to provide stability to the lumbar spine and pelvis.  Lack of neuromuscular control in the PFM can be associated with trunk instability which results in LBP.^{1,4, 13,14,15,16,17}  It is important for the physical therapist to consider pelvic floor dysfunction when evaluating and treating patients with LBP.  Although recent research has made many gains in relating LBP and PFD, much more progress is needed to definitively establish the relationship between the two conditions and identify successful intervention techniques.  

Recent Related Research (from Pubmed)

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References

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