Motherhood, Leaky Bladders, and Back Pain – Part 2


In last week’s blog post, “Motherhood, Leaky Bladders, and Back Pain – Part 1” I introduced the musculoskeletal structures of the pelvic diaphragm and their purpose. This week’s follow-up post will cover:

  • Correlation Between Chronic Back Pain and Stress Urinary Incontinence
  • Pelvic Diaphragm Facilitation and Multifidus Facilitation
  • Exercises to identify the Muscles of the Pelvic Diaphragm!!!
  • Exercises to Strengthen Muscles of the Pelvic Diaphragm

Correlation Between Chronic Back Pain and Stress Urinary Incontinence

Research has established the role that the pelvic diaphragm muscles play in continence.  Given that the pelvic diaphragm muscles facilitate sacroiliac joint stability, which in turn support lumbar vertebral column stability, one could hypothesize that there is a positive correlation between chronic back pain and stress urinary incontinence.  That is, the likelihood of having stress urinary incontinence is increased if one suffers from chronic back pain.

Bush et al., (2013), conducted a survey of 2,341 women who suffered from chronic back pain and found that 44% of these women also suffered from stress urinary incontinence (p.4).  Furthermore, Bush et al., (2013), references multiple studies with similar findings:

Finkelstein et al reported a strong association between “back problems” and UI in both men and women (find details from experts in New Jersey Neck & Back Institute, P.C.).  A cross-sectional study of women only by Smith et al found a relationship between continence disorders and back pain “in the past 12 months.”  In addition, Kim et al found women with greater UI severity also have a higher perceived severity of LBP and LBP perceived disability.  Lastly, Elliason et al surveyed women who were receiving physical therapy for LBP and reported 78% of these women also reported UI  (Bush, Pagorek, Kuperstein, Guo, Ballert, and Crofford, 2013, p.2).


Pelvic Diaphragm Facilitation and Multifidus Facilitation

Multifidus originates at the sacrum, the posterior superior iliac spine, the mammillary processes of the lumbar vertebrae, the transverse processes of the thoracic vertebrae, and the articular process of C04-C07.  It inserts to the spinous process two to four vertebrae superior from it’s origin.  According to Martini, Nath, Bartholomew (2012), it’s action is to extend the vertebral column and rotate towards the opposite side (p.341).

A study involving thirteen men and women who had chronic low back pain was conducted by Huang et al.  The goal of this study was to investigate the effects of an intervention that involved: 1) proprioceptive neuromuscular facilitation, 2) neuromuscular joint facilitation, and 3) neuromuscular joint facilitation combined with pelvic diaphragm muscle exercises.  According to Huang et al. (2013), neuromuscular joint facilitation combined with pelvic diaphragm exercises produced the greatest multifidus change (p.813).  Huang et al. (2013), speculates that while neuromuscular joint facilitation promoted isometric contractions of the multifidus, the pelvic floor exercises promoted increased intraabdominal pressure, thereby increasing lumbopelvic stability and enhancing the effectiveness of multifidus (p.813).

Case Study

Jellad, Bouzaouache, Salah, Migaou, & Sana (2009), conducted a case study in which they designed a rehabilitation program for a patient suffering from osteoarthritis of the sacroiliac joint.  The rehabilitation program involved strengthening the transversus abdominis, internal obliques, coccygeus, pubococcygeus, and iliococcygeus, as well as stretching psoas (p.511).  The program was found to have a positive effect on reducing the patient’s pain and functional impairments.

Exercises to identify the Muscles of the Pelvic Diaphragm!!!

Calais-Germain (2003) recommends the following two exercises for identifying muscles of the pelvic diaphragm:

  1.  Balloon Exercise
    1. While sitting, pretend you are blowing into a balloon.  Look to identify one of the three possible pelvic region responses:
      1. blowing caused the urge to urinate
      2. blowing caused the pelvic floor to be pushed down
      3. blowing caused the pelvic floor to draw up (p.104)

Calais-Germain (2003), notes that the urge to urinate is symptomatic or weak pelvic diaphragm, while the drawing up sensation is symptomatic of well-toned pelvic diaphragm (p.105).

  1. Face Cloth Exercise
    1. Fold a small face cloth into quarters.  Place the folded cloth between the two ischia, and between the coccyx and the pubis.
    2. Notice  pelvic sensations during normal breathing and while practicing the balloon exercise in this position.

Exercises to Strengthen Muscles of the Pelvic Diaphragm

Calais-Germain (2003) recommends the following exercises for strengthening muscles of the pelvic diaphragm:

  1. In a sitting, or supine-crook position, visualize your two ischia and your pubic symphysis.  From here mentally visualize two inches above the ischias and pubic symphysis.  Now, draw theses two areas of visualization upward and inward.
  2. Contract your anal sphincter.  Notice how it constricts and draws up.  Now, try to contract your anal sphincter without constricting it, but just drawing it up.
  3. After performing the above exercises, relax completely and feel the weight of pelvic organs dilate.

The research suggesting that pelvic diaphragm muscles enhance lumbopelvic stability is convincing.  Pel, Spoor, Pool-Goudzwaard, Hoek Van Duke, and Snijders (2008) showed a decrease in sacroiliac joint shear force by 20% with a 400% increase of transversus abdominis and pelvic diaphragm muscles (p.415).   Additionally, Bush et al. showed that nearly one-half of women who suffer from chronic low-back pain also suffer from urinary incontinence (p.4).  Huang et al (2013), suggests that the compressive forces that the pelvic diaphragm muscles can exert between the coxal bones and the scarum enhance lumbar vertebral and trunk stability (p.813).  Lastly, Jellad, Bouzaouache, Salah, Migaou, & Sana (2009) successfully applied a rehabilitation protocol for a women suffering from sacroiliac joint pain that involved pelvic diaphragm exercises (p.511).

That’s it ladies (and gents) not only will strengthening your pelvic floor muscle recover urinary incontinence it will also enhance lower back strength. Get to it, find those pelvic floor muscles and when you can, incorporate pelvic floor contractions into whatever exercises you are working on, whether that be supine ab exercises, standing arm exercises, leg exercises like squats, or whatever. Now, onward, upward, and inward!


Bush, H. M., Pagorek, S., Guo, J., Ballert, K. N., & Crofford, L. J.  (2013).  The Association of Chronic Back Pain and Stress Urinary Incontinence: A Cross-Sectional Study.  Journal of women’s health physical therapy, 37(1), p.11-18.  doi: 10.1097/JWH.0b013e31828c1ab3

Calais-Germain, B.  (2003).  The Female Pelvis: Anatomy & Exercises.  Seattle, Wa.: Eastland Press Inc.

Floyd, R.T.  (2012).   Manual of Structural Kinesiology.  New York, NY: McGraw Hill.

Huang , Q., Li, D., Yokotsuka, N., Zhang, Y., Ubukata, H., Huo, M., & Maruyama, H.  (March 1 2013).  The Intervention Effects of Different Treatment for Chronic Low Back Pain as Assessed by the Cross-sectional Area of the Multifidus Muscle.  Journal of Physical Therapy Science, 25(7), p.811-813.  doi: 10.1589/jpts.25.811

Jellad, A.,  Bouzaouache, H., Ben Salah, Z., & Sana, S. (July 2009).  Osteoarthritis of the sacroiliac joint complicating resection of the pubic symphysis. Interest of a rehabilitation programme.  Annals of Physical and Rehabilitation Medicine, 52(6), p.510-517.  doi: 10.1016/

Martini, F. H., Nath J. L., & Bartholomew, E. F.  (2012).  Introduction to Anatomy and Physiology.  San Francisco, CA: Pearson Education Inc.

Nestor, K.  (n.d.).  Sacroiliac Joint.  Physiopedia.  Retrieved from:

Pel, J. J. M., Spoor, C. W., Pool-Goudzwaard, A. L., Hoek Van Dijike, G. A., & Snijders, C. J.  (18 January 2008).  Biomechanical Analysis of Reducing Sacroiliac Joint Shear Load by Optimization of Pelvic Muscle and Ligament Forces.  Annals of Biomedical Engineering, 36(3), p. 415-424.  doi: 10.1007/s10439-007-9385-8

Visible Body Software.  (2014).  [All images].

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