Have you ever wondered why your low back pain just keeps sticking around even after you have faithfully seen a physical therapist, chiropractor, or massage therapist? Most of the time, these professionals are addressing the spine and sometimes even the hips. But why do we neglect the very foundation of the spine? Your spine begins at your tailbone, which is one of the three bones of the pelvis. Muscles that attach to and support your pelvis and tailbone include back muscles, abdominal muscles, glutes and other hip muscles, as well as a small set of muscles at the base called your pelvic floor. If your pelvic floor is not getting assessed and treated, you are missing a huge piece of the puzzle that is low back pain.
As pelvic floor physical therapists, we’ve always known there is a close relationship between the pelvic floor and low back pain. For many of our patients, one of the first symptoms they notice is sciatica or other low back pain; often, they don’t realize it might be related to their pelvic floor until their initial evaluation. Recent research has shown this is even more prevalent that we realized.
Of women with low back pain, more than 95% had pelvic floor dysfunction as well!
This included pelvic tenderness (71%), weakness (66%) and even pelvic organ prolapse (41%). Other research has tied low back pain to urinary incontinence, with nearly 80% of women with chronic back pain reporting at least occasional incontinence.
The Chicken or the Egg?
It’s not always clear which comes first. A major role of the pelvic floor is to help stabilize the core and lower back, so when the back is in pain, the pelvic floor muscles may tighten to try and protect the sensitive area. This can overwork the pelvic floor, causing trigger points to form in the muscles and creating additional symptoms (see graph below). In other cases, the pelvic floor dysfunction may have come first and altered the spine's mobility and stability, thus triggering low back pain. Either way, there is a feedback loop where low back pain and pelvic floor dysfunction reinforce each other. Both must be addressed for full resolution of symptoms.
Resolving Chronic Low Back Pain
This is why it’s so important to address both the internal and external causes. A traditional orthopedic physical therapist will address the common causes of low back pain and prescribe some stretching and strengthening exercises for the low back. However, many patients will find that the treatment doesn’t ‘stick’ - they feel better for a few days, but lasting relief is elusive. In these cases, the pelvic floor dysfunction isn’t being addressed, so the low back regresses and gets pulled back into dysfunction.
The same issues arise when only the internal pelvic floor muscles are treated. Even if the trigger points in the pelvic floor are cleared out and a strengthening program put in place to resolve weakness, if the lower back isn’t addressed the pelvic floor dysfunction will simply reoccur. For true healing to occur, both the pelvic floor and low back must be addressed together.
So what does this mean for the treatment of low back pain? Our philosophy is that complex low back and pelvic floor patients need at least an hour of hands-on physical therapy with a pelvic PT who can address both the internal and external aspects of the issue. However, it can be difficult to find this kind of hands-on treatment philosophy in today’s medical world. Some patients do well when working with both a skilled orthopedic and pelvic floor physical therapist concurrently, treating both components of the problem at once. A massage therapist can also be a valuable tool in conjunction with a traditional, internal-only pelvic floor physical therapist. The massage can focus on the glutes, low back, and hamstrings while the pelvic PT resolves internal trigger points.
For sustained relief of lower back pain, often both the pelvic floor and lower back must be looked at together.
Dr. Nicole Cozean is the founder of PelvicSanity physical therapy, Orange County's premier pelvic floor physical therapy clinic. One of only 270 PTs to be board-certified in the pelvic floor, and the first PT to serve on the ICA Board of Directors, Nicole is the author of the acclaimed and best-selling book The Interstitial Cystitis Solution (2016). She is an adjunct professor at her alma mater, Chapman University. The PelvicSanity blog focuses on presenting practical, positive information to help patients beyond the walls of Nicole's clinic.