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The Orthopedic Physical Therapist's Guide to Pelvic Floor

Screening, Evaluating, Treating, and Referring

Kim McCole Durant PT, DPT, OCS, FAAOMPT

Meghan Musick PT, DPT, OCS, OMPT, PHC

Objectives:

1. Define the current evidence and established link between pelvic floor dysfunction and low back and hip pain

2. Gain an understanding of internal and external anatomy, and the relationship between lumbar spine, diaphragm, hip complex, and pelvic

floor structures.

3. Review appropriate screening outcome measures and history questions to rule in/rule out pelvic floor dysfunction for patient with main

complaint of hip and low back pain

4. Demonstrate muscle assessment including observation and external

palpation appropriate for low complexity pelvic floor dysfunctions.

5. Demonstrate techniques to integrate pelvic floor into a core

coordination retraining program

Schedule:

8:15-8:45 am - Literature Review

8:45-9:05 am - Anatomy and physiology review

9:05-9:35 am – How to screen

9:35-10:05 am - External examination

10:05-10:35 am - External treatment

10:35-10:40 am - When to refer, know your limitations!

10:40-11:05 am - Case studies

11:05-11:15 am - Closing remarks / Q&A

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Bridge Needed:

Over the next 30 years chronic health problems associated with pelvic floor

dysfunction are projected to increase by 50%due to increasing number of women reaching the age of 651.

Women who are forced to modify or cease exercise due to their PF symptoms are at an

increased risk of physical inactivity, associated chronic health conditions and social isolation2-

3.

Remove the bias towards pelvic floor

When we first start thinking

about treating patients with

pelvic floor dysfunction….

Women, geriatrics,

pregnancy, postpartum

Who we should be thinking

about when treating patients

with pelvic floor dysfunction…

EVERYONE!

Literature Review

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PT Journal - 2017 -> observational, cross-sectional study

125,645 sample size

Strong relationship of UI and back problems

UI more than doubles the risk of also experiencing low back problems

In men and women!4.

Are you asking your patients with low back pain about bladder health?

Cross-sectional analysis from Kentucky Women’s Health Registry

2,341 women

Chronic back pain significantly more likely to have SUI

Odds of SUI increased by 44% for women with CBP compared with those not reporting CBP

Important for all trunk muscles, including the pelvic floor muscles to function in coordination with one another5.

Scary Statistics

95.3% of participants with LBP had some form of pelvic floor dysfunction6.

200 women with primary complaints of LBP – 78% reported urinary

incontinence7.

Out of 1636 women with low back pain/pelvic girdle pain, 57% had pelvic

floor complaints6.

43% of females reported symptoms of UI pre THA; 3 months post-op

symptoms improved in 64% but persisted or worsened in 36%8.

311 female triathletes responded to a survey - 1 in 5 women reported pelvic

girdle pain9.

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Postpartum population

UI affects exercise participation in 1 in 2 symptomatic women; with some completely stopping exercise or modifying their participation10.

Of the women who experienced PF symptoms while participating in high-impact sports/exercise,

42% stopped their exercise participation secondary to symptoms10.

3,763 women postpartum followed over 12 years

Prevalence of persistent UI was 37.9%

Among those who reported UI at 3 months, 76.4% reported it at 12 years11.

Urinary incontinence does not resolve on its own!

Established Link

Low back pain and pelvic floor dysfunction

Lots of evidence

Pelvic floor dysfunction can occur in:

Men AND women, athletes, patients post op THA…EVERYONE!

Urinary incontinence does not resolve on its own

Not enough pelvic PTs to treat everyone with pelvic floor involvement

Anatomy Review

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Beyond the Pelvis Pelvic floor muscles work in conjunction

with other spinal stabilizers:

Diaphragm

Psoas

Transverse Abdominus

Internal oblique

External oblique

Rectus abdominus

Multifidus

Thoracolumbar fascia

Canister Example:

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A case example of a female runner

• 45 y/o female distance runner referred to outpatient PT with a diagnosis of ‘proximal L hamstring strain’

• C/C of hamstring, gluteal and ischial tuberosity pain

• Initial onset 4 months ago during a trail run, sensation of “pulling a muscle” while attempting to avoid a fall

• Significant exacerbation of symptoms 6 weeks later after sitting on a hard surface for several hours

• Pt no longer able to run due to pain, unable to sit for > 15 min12.

Building the Bridge

Initial treating diagnosis and POC:

Primary working hypothesis of hamstring syndrome

Re-examination: after 4 visits, pain levels improved from 7/10 to 3/10 with sitting, c/o a deep ache which the therapist was unable to palpate externally; referred for a PF examination

PF Exam (internal):

Symptom reproduction with palpation of obturator internus and levator ani muscles

Weak contraction of PF muscles (2/5 using Oxford grading scheme)

Poor PF muscle relaxation following contraction

Revised intervention:

Treatment added to address pelvic floor overactivity/hypertonicity including STM/mobilization, muscle energy techniques and EMG biofeedback

Outcome

7 more sessions over 2 months

Pt able to sit > 2 hours with pain no greater than a 1/10; 8 hours with use of wedge cushion

Pain-free SL hop, walking or running up to 15 miles

6 month f/u via phone: pt pain-free and running marathons without complaint12.

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Screening and History

Function of Pelvic Floor

The 5 ‘S’s

Sphincter control

Support

Stability

Sexual function

Sump pump

Common PF dysfunctions:

Urinary Incontinence

Stress

Urge

Mixed

Pelvic Organ Prolapse

Cystocele

Rectocele

Fecal incontinence

Pelvic Pain

Dyspareunia

Vaginismus

Vestibulodynia

Endometriosis

Pudendal Neuralgia

Constipation

DRA

Pelvic Floor Muscle Overactivity

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Incontinence:

Unwanted loss of urine at any time

Very common, but NOT normal

Lots of causes

Three types

Stress

With increased abdominal

pressure

Urge

Urge to void leading to leakage due to not making it there in time

Mixed

Urge and stress

Pelvic Organ Prolapse:

Lack of support of the connective tissues around the pelvic organs

causing one or more organs to be in a lower position

Sx:

Feeling of heaviness

Pelvic pain

Incomplete emptying of bowel and bladder

Back pain13.

Formal Screening Tools:

Cozean screening tool

https://backinmotionpt.com/files/pdf/CozeanPelvicDysfunctionScreeningProtocol.pdf

AAOMPT SIG screening tool

https://aaompt.org/Main/About_Us/SIGs/Pelvic_Health/Main/Education/Pelvic_Health_SIG.aspx

3 Incontinence Questions

https://www.racgp.org.au/getattachment/1bd242ff-e656-4fa3-8b36-b51f7cc57706/Appendix-13A.pdf.aspx

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Functional Outcome Measures

Pelvic Floor Disability Index (PFDI-20)

20 questions

Urinary Distress, Prolapse, Anal Distress

MCID – 13.5 points14.

Pelvic Floor Impact Questionnaire (PFIQ-7)

7 questions asking affect on bladder, bowel, and pelvis

MCID – 12%15.

Central Sensitization Inventory

associated with PFM tenderness/overactivity16.

Patient Specific Functional Scale

MCID – 2 points

Further history questions:

Urinary: Do you or have you experienced any urinary leakage (even just drops) with laughing, coughing, sneezing or physical activity? Will you sometimes feel a strong sense of urgency and have to rush to the bathroom? Do you experience any urinary leakage while rushing to the bathroom?

Bowel: Do you have a h/o constipation? How often do you have a BM? Do you ever have to strain to initiate or complete a BM?

Sexual Function: Do you experience any pain or discomfort with tampon insertion, gynecological exams or intercourse? Do you have difficulty achieving or maintaining an erection?

Supportive Function: known risk factors associated with levator ani tears

OB/GYN: How many pregnancies? How did you deliver? Hold old were you when you delivered? How long did you push for? Any complications with delivery Tearing? Instrument use? Episiotomy?

OB Hx Screen - PFM defect / avulsion

PFM defects during vaginal delivery are estimated at 10-36%

Pre delivery risk factors:

women’s age at her first delivery → likelihood of major PFM defect, is < 15% for mothers aged 20 yrs, compared to 50% or more among 40 yrs or older

Known delivery risk factors:

Prolonged 2nd stage labor

Use of forceps or vacuum

Episiotomy

Sphincter tears

Large fetal head17.

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Consider Patient A…

32 y/o female USPS clerk presenting to outpatient PT with a CC of LBP

Achy, throbbing, burning pain over LB and sacrum; NRPS 5/10 (best) to 10/10 (worst) “feels like my back is going to give way”

Initial Onset 2 years ago during pregnancy with no other known MOI

Recent CT non-significant

Previous therapies: Underwent PT at another facility within 1 year PP with no improvement in symptoms

More to the story…

OB hx: 1 abortion, 2 live births delivered via C-section

Bladder function: stress UI worsening after most recent pregnancy

Bowel Function/GI: h/o constipation, abdominal bloating, frequent straining needed to initiate and complete a BM

Supportive Function: denies symptoms of abdominal or vaginal heaviness, splinting

Sexual Function: (+) dyspareunia for initial and deep penetration, worsening after most recent pregnancy

How might this new info influence your original plan/hypothesis?

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Screening recap:

5 functions of the pelvic floor

3 screening tools

Cozean, AAOMPT Decision Tree, 3IQ

FOM

PFDI-20, PFIQ, PSFS, CSI

OB PFD risk factors

Moving beyond the generic bowel and bladder history question

Let’s practice asking the hard

questions!

Zoom breakouts

Objective: External Examination

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Objective: Observation

Posture

Ankle DF associated with anterior rotated pelvis and greater PFM activation compared to neutral and ankle PF18

Women with pelvic floor dysfunction had:

Increased thoracic kyphosis

Decreased lumbar lordosis

Knee varus

Foot pronation19

Continent vs incontinent women

Continent women maintained a greater lumbar lordosis in sitting20

Objective: Observation

Standing posture

Where is their ribcage in relation to their pelvis?

Where is the weight on their feet?

How are they breathing?

Functional testing:

https://blogs.bmj.com/bjsm/2019/05/20/ready-steadygo-ensuring-

postnatal-women-are-run-ready/

Load transfer

Squat

Hinge

SLS

Step down

Lifting

Carrying

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Objective: Abdominal Wall

Soft tissue appearance

Scar mobility

Diastasis check

Abdominal wall strength and

load transfer

Blow up balloon

ASLR

Diastasis Rectus Abdominus (DRA)

• How to measure in clinic:

• Assessing for depth, tension, and tissue quality

• Fair interrater reliability and good intrarater reliability

Two fingers perpendicular to linea alba

Patient performs head-lift

Assess above, at level, and below umbilicus

(+) if > 2 finger widths or 2.5 cm21.

DRA

Postpartum

6 weeks -> 60%

6 months -> 45.4%

12 months -> 32.6%21.

No agreement on definition and cut-off values for DRA or normal DRA

Evidence is shifting to focus on tissue ability to generate tension

Head lift, Curl-ups, curl-ups with rotation close the IRD

Pre-activation of TrA and PF led better tensioning of the tissue22.

Evidence is mixed

Link between IRD and lumbopelvic pain is uncertain23.

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Objective: Special Tests

Forced FABER

LBP studies

Pelvic Girdle Pain cluster

Active Straight Leg Raise Test (ASLR)

ASLR with lateral compression

Posterior Pelvic Pain Provocation Test

Forced FABER test24.

Pelvic Floor Considerations:

Educate on intent and expectations.

Obtain informed consent.

Use clear, respectful, and professional terminology.

If the patient has used other terms to describe their anatomy, use your patient’s language

Respect patient privacy and comfort.

External Pelvic Floor Assessment

Patient self assessment Coccyx Motion Palpation (CMP)

Position hand over sacrum and middle finger over the coccyx

Ask the patient to perform a PFM contraction

Assess if there was movement in the coccyx indicating proper contraction25.

Therapist assessment

Contract

Relax

Bear down

Symmetry? Difficulty? Delayed? Unable?

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External Pelvic Floor Assessment

Palpate medial to ischial tuberosities (stickers)

Assess for compensation strategy (breath holding,

glutes, adductors)

Assess for any pelvic pain

Assess for movement

during cough

Examination:

Observation

Posture

Breathing pattern

Functional movement patterns

Special tests

Active Straight Leg Raise

Forced FABER

Abdominal screen

DRA

External pelvic floor palpation

Thoracic rotation mobility

AROM/PROM hip abduction,

internal rotation, and external rotation

Core coordination assessment

PRACTICE on Monday ☺

Treatment Incorporating the pelvic floor

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What the literature has shown us:

PF and diaphragm work with the abdominals acting as part of the

anticipatory postural control system26-27.

Consistent increase in PF activation prior to inc abdominal pressure -->PF activation

matched abdominal force28.

PF activation precedes leg

movements29.

The pelvic floor, diaphragm and abdominal wall coordinate together during breathing and coughing in healthy women30.

Synchronous phase locked parallel movement of diaphragm and PF during quiet and forceful

breathing and coughing30.

IAP increases with inhale; TA and

PF responded to diaphragm26-27.

Core Coordination - start with the breath

Supine hands on lower ribs

“open and close umbrella”

“breathe into your hands”

Supine hand on chest, hand on belly

”try to get both hands to move together”

Progressing into sitting -> standing

Use towel as feedback

Core coordination – whole canister

Layering in the rest of the team

Cue in PF and TA with exhale

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Core coordination – whole canister

Standing forward lean

Progressing into lunge/step

with breathing pattern

Exhale during step

Core coordination – whole canister

Core integration exercises:

Band pull

Resisted push/pull

Squats / sit<>stands

Wall burners

Deadlift progression

Static lunge with lat pull

Core coordination – whole canister

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Pelvic Floor Lengthening Strategies

Most people tend to have difficulty lengthening their PF

Pain

Urgency and frequency

Constipation

The need to ‘strain’ when voiding

Anxiety

Over-active PFM’s can still present as ‘weak’

Women with incontinence demonstrated increased PF EMG compared to continent women both prior to and during postural perturbations31.

95% of women with LBP demonstrated PFM tenderness and/or impaired coordination on internal exam6.

Downtraining

Happy baby

Thoracic rotations

Butterfly stretch

Childs pose

Standing horizontal forward fold

Deep squat

Downtraining

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Virtual Lab Breakout!

Core coordination :

Qped belly drops with diaphragm, TrA, and PF

Resisted push/pull

Band pulls

Down training:

Happy baby

Standing horizontal forward fold

Child’s pose

When to refer for internal pelvic floor assessment…

Referral:

Suspected pelvic organ prolapse

At least one symptom of PFD combined with failure to progress with

traditional PT

Pain with intercourse

Unresolved coccyx pain

Extensive pelvic pain history

If you perform external PFM assessment and are not sure of your findings

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How to refer – resources

• APTA: https://aptaapps.apta.org//APTAPTDirectory/FindAPTDirectory.aspx

• Herman and Wallace: https://pelvicrehab.com/

• Global Pelvic Health Alliance: https://pelvicguru.com/directory/

• International Pelvic Pain Society:

https://www.pelvicpain.org/IPPS/Patients/Find_A_Provider/IPPS/Content/Professional/Find_A_Provider.aspx?hkey=ac3c51ec-0939-499f-a6a0-c72d0aa2f427

Case studies

Consider Patient B…

You are treating a 38 yo female patient with chronic R proximal, posterior hip pain.

3 month history

MRI (-) for hamstring pathology

Denies B/B problems on intake

4 children

Yoga instructor

Pain with resisted hip extension

Limited active hip IR

Limited, painful, and fearful of active trunk flexion

MMT: R hip ER (4-/5), IR (4/5), extension (3+/5)

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More to the story…

6 pregnancies

4 children

One miscarriage

One abortion

Went on bed rest for the 1st pregnancy after the 5th month due to increased BP

Postpartum depression after each pregnancy

Urinary leakage present after increased activity (jogging or jumping) which

she rarely does

Pain is worse during menstrual cycle

Treatment

Internal assessment:

Pain reproduced with palpation of R obturator internus and levator ani

Weak with endurance holds of pelvic floor

Treatment:

Soft tissue lengthening of R obturator internus internally with active hip abduction and adduction

Strengthening of pelvic floor

Graded exposure to fearful positions (bridging and forward folds)

Consider Patient C:

58 yo female referred following L2-S1 spinal decompression

Subjective History:

LBP beginning 25 years ago

R posterior thigh and lateral calf soreness and tingling

Main complaints:

Impaired sleep

Difficulty sitting > 1 hour

Difficulty standing > 1 hour

Difficulty walking > half a mile

Lumbar AROM:

Limited with extension and with R side bending

Sensory Intact to light touch

Reflexes Normal

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More to the story:

Pelvic floor dysfunction for 12 years including rectocele repair, pelvic floor lift, and hysterectomy that resulted in major complications

Splinting with BM

Urgency with urination

Urgency with BM

Perimenopause

Treatment:

Mixed of internal and external interventions

Internal -> PF lengthening then strengthening

External -> core coordination with hip/glute strengthening

In closing:

Start screening for these patients

Screening tools

Asking the hard questions in your history

Or use your intake forms

Moving away from the generic B/B question

Assessing pelvic floor externally

When in doubt – refer to an internal PF therapist

Incorporating the whole canister with core coordination

Breathing pattern

Question and Answer?!

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Meghan Musick

meghanmusick@gmail.com

Kim M DurantKimberlymccole@gmail.com

References:

1. Bonis M, Lormand J, Walsh C. Immediate Effects of Exercise and Behavioral Interventions for Pelvic Floor Dysfunction and Lumbopelvic Pain. J Women’s Health Phys Ther. 2020;44(2):54-62.

2. Moore, I. S., James, M. L., Brockwell, E., Perkins, J., Jones, A. L., & Donnelly, G. M. (2021). Multidisciplinary, biopsychosocial factors contributing to return to running and running related stress urinary incontinence in postpartum women. British Journal of Sports Medicine.

3. Dakic, J. G., Hay-Smith, J., Cook, J., Lin, K. Y., Calo, M., & Frawley, H. (2021). Effect of Pelvic Floor Symptoms on Women’s Participation in Exercise: A Mixed-Methods Systematic Review With Meta-Analysis. Journal of Orthopaedic& Sports Physical Therapy, (0), 1-54.

4. Cassidy T, Fortin A, Kaczmer S, Shumaker J, Szeto J, Madill SJ. Relationship Between Back Pain and Urinary Incontinence in the Canadian Population. Phys Ther. 2017;97(4):449-454.

5. Bush HM, Pagorek S, Kuperstein J, Guo J, Ballert KN, Crofford LJ. The Association of Chronic Back Pain and Stress Urinary Incontinence: A Cross-sectional Study. J Women’s Health Phys Ther. 2013;37(1):11-18.

6. Dufour S, Vandyken B, Forget MJ, Vandyken C. Association between lumbopelvic pain and pelvic floor dysfunction in women: A cross sectional study. Musculoskel Sci Pract. 2018;34:47-53.

7. Eliasson, K., Elfving, B., Nordgren, B., & Mattsson, E. (2008). Urinary incontinence in women with low back pain. Manual therapy, 13(3), 206-212.

References:

8. Tamaki, T., Oinuma, K., Shiratsuchi, H., Akita, K., & Iida, S. (2014). Hip dysfunction‐related urinary incontinence: A prospective analysis of 189 female patients undergoing total hip arthroplasty. International Journal of Urology, 21(7), 729-731.

9. Yi J, Tenfelde S, Tell D, Brincat C, Fitzgerald C. Triathlete Risk of Pelvic Floor Disorders, Pelvic Girdle Pain, and the Female Athlete Triad. Female Pelvic Med Reconstr Surg. 2016;22(5):373-376.

10. Dakic, J. G., Hay-Smith, J., Cook, J., Lin, K. Y., Calo, M., & Frawley, H. (2021). Effect of Pelvic Floor Symptoms on Women’s Participation in Exercise: A Mixed-Methods Systematic Review With Meta-Analysis. Journal of Orthopaedic& Sports Physical Therapy, (0), 1-54.

11. MacArthur, C., Wilson, D., Herbison, P., Lancashire, R. J., Hagen, S., Toozs‐Hobson, P., ... & Prolong Study Group. (2016). Urinary incontinence persisting after childbirth: extent, delivery history, and effects in a 12–year longitudinal cohort study. BJOG: An International Journal of Obstetrics & Gynaecology, 123(6), 1022-1029.

12. Podschun, L., Hanney, W. J., Kolber, M. J., Garcia, A., & Rothschild, C. E. (2013). Differential diagnosis of deep gluteal pain in a female runner with pelvic involvement: a case report. International journal of sports physical therapy, 8(4), 462.

13. Saunders, K. (2017). Recent advances in understanding pelvic-floor tissue of women with and without pelvic organ prolapse: considerations for physical therapists. Physical therapy, 97(4), 455-463.

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References:

14. Wiegersma M, Panman CM, Berger MY, De Vet HCW, Kollen BJ, Dekker JH. Minimal Important Change in the Pelvic Floor Distress Inventory-20 among Women Opting for Conservative Prolapse Treatment. Am J Obstet Gynecol. 2017;216:397.e1-7.

15. Barber MD, Walters MD, Bump RC. Short Forms of Two Condition-Specific Quality-of-Life Questionnaires for Women with Pelvic Floor Disorders (PFDI-20 and PFIQ-7). Am J of Obstet and Gynecol. 2005;193:103-113.

16. Keizer A, Vandyken B, Vandyken C, Yardley D, Macedo L, Kuspinar A, Fagahani N, Forget MJ, Dufour S. Predictors of Pelvic Floor Muscle Dysfunction Among Women with Lumbopelvic Pain. Phys Ther. 2019;99(12):1703-1711.

17. Saunders, K. (2017). Recent advances in understanding pelvic-floor tissue of women with and without pelvic organ prolapse: considerations for physical therapists. Physical therapy, 97(4), 455-463.

18. Lee, K. (2018). Activation of pelvic floor muscle during ankle posture change on the basis of a three-dimensional motion analysis system. Medical science monitor: international medical journal of experimental and clinical research, 24, 7223.

19. Zhoolideh, P., Ghaderi, F., Salahzadeh, Z., Adigozali, H., Azghani, M. R., Jafarabadi, M. A., & Seleme, M. R. (2021). The Relationship Between Static Standing Posture and Common Pelvic Floor Disorders. Muscles, Ligaments & Tendons Journal (MLTJ), 11(1).

20. Sapsford, R. R., Richardson, C. A., Maher, C. F., & Hodges, P. W. (2008). Pelvic floor muscle activity in different sitting postures in continent and incontinent women. Archives of physical medicine and rehabilitation, 89(9), 1741-1747.

References:

21. Sperstad, J. B., Tennfjord, M. K., Hilde, G., Ellström-Engh, M., & Bø, K. (2016). Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. British journal of sports medicine, 50(17), 1092-1096.

22. Gluppe, S. L., Hilde, G., Tennfjord, M. K., Engh, M. E., & Bø, K. (2018). Effect of a postpartum training program on the prevalence of diastasis recti abdominis in postpartum primiparous women: a randomized controlled trial. Physical therapy, 98(4), 260-268.

23. Crommert, M. E., Flink, I., & Gustavsson, C. (2021). Predictors of disability attributed to symptoms of increased interrecti distance in women after childbirth: an observational study. Physical Therapy.

24. Dufour S, Vandyken B, Forget MJ, Vandyken C. Association between lumbopelvic pain and pelvic floor dysfunction in women: A cross sectional study. Musculoskel Sci Pract. 2018;34:47-53.

25. Zhoolideh, P., Ghaderi, F., Salahzadeh, Z., Adigozali, H., Azghani, M. R., Jafarabadi, M. A., & Seleme, M. R. (2021). The Relationship Between Static Standing Posture and Common Pelvic Floor Disorders. Muscles, Ligaments & Tendons Journal (MLTJ), 11(1).

26. Hodges, P. W., Sapsford, R., & Pengel, L. H. M. (2007). Postural and respiratory functions of the pelvic floor muscles. Neurourology and urodynamics, 26(3), 362-371.

27. Hodges, P. W., Butler, J. E., McKenzie, D. K., & Gandevia, S. C. (1997). Contraction of the human diaphragm during rapid postural adjustments. The Journal of physiology, 505(2), 539-548.

References:

28. Sapsford, R. R., Hodges, P. W., Richardson, C. A., Cooper, D. H., Markwell, S. J., & Jull, G. A. (2001). Co‐activation of the abdominal and pelvic floor muscles during voluntary exercises. Neurourology and Urodynamics: Official Journal of the International Continence Society, 20(1), 31-42.

29. Sjödahl, J., Kvist, J., Gutke, A., & Öberg, B. (2009). The postural response of the pelvic floor muscles during limb movements: a methodological electromyography study in parous women without lumbopelvic pain. Clinical biomechanics, 24(2), 183-189.

30. Talasz, H., Kremser, C., Kofler, M., Kalchschmid, E., Lechleitner, M., & Rudisch, A. (2011). Phase-locked parallel movement of diaphragm and pelvic floor during breathing and coughing—a dynamic MRI investigation in healthy females. International urogynecology journal, 22(1), 61-68.

31. Smith, M. D., Coppieters, M. W., & Hodges, P. W. (2007). Postural response of the pelvic floor and abdominal muscles in women with and without incontinence. Neurourology and urodynamics, 26(3), 377-385.

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