[ case report ]

Elizabeth E. Painter, DPT, OCS1 • Melissa D. Ogle, DPT, CSCS2 • Deydre S. Teyhen, PT, PhD, OCS3

Lumbopelvic Dysfunction and Stress

Urinary Incontinence: A Case Report
Applying Rehabilitative Ultrasound Imaging
Downloaded from www.jospt.org at Ball State University on November 21, 2014. For personal use only. No other uses without permission.

P
revalence rates of stress urinary incontinence (SUI) vary Thirty percent of women (563 surveys
between 10% to 55% in women between the ages of 15 to 64 completed) reported that they leaked
urine during activity to the extent that it
years.2 Although SUI is a condition traditionally thought to
was a social or hygienic problem.
occur in older, multiparous women, a number of descriptive Several mechanisms have been sug-
studies have reported SUI in young, nulliparous women,2-4,12,23 typically gested as contributing to SUI, including
as an involuntary loss of urine that occurs when pressure is exerted insufficiency of the pelvic floor muscles
on the bladder by sneezing, coughing, laughing, or any other physical (PFMs).1 PFMs dysfunction has also been
noted in patients with lumbopelvic dys-
Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

activity that increases intra-abdominal
pressure.7 Bo et al4 have reported that
20% of otherwise fit, healthy, nullipa-
rous women have urine loss that caused
social or hygienic problems. Prevalence
in female athletes varies between 0% to
80%,2 with a higher incidence reported
in athletes participating in high-impact
Journal of Orthopaedic & Sports Physical Therapy®
sports (eg, trampolinist, gymnast, track
and field events).2 Further, 28% of nul-
liparous elite athletes reported urine loss
while participating in athletic events.29
Davis et al9 conducted a descriptive study
at 3 United States Army training facili-
ties to assess the prevalence of urinary
incontinence among female soldiers.
function.30,34 The PFMs, along with the
transversus abdominis (TrA), multifi-
dus, and diaphragm, appear to play an
important role in the motor control that
provides dynamic stability to the spine
and pelvis.18,19,32,34 Delayed or altered ac-
tivation of these deep trunk muscles has
been demonstrated in those with lumbo-
pelvic dysfunction11,21,27,28,30 and SUI.1,6 A

t Study Design: Case report.
t Background: It has been suggested that
altered neuromuscular control of the transversus
abdominis and pelvic floor muscles may contrib-
ute to sacroiliac joint (SIJ) region pain and stress
urinary incontinence. There are limited examples
describing the evaluation and management of
individuals with both SIJ region pain and stress
urinary incontinence in the literature. This case re-
port describes a patient with both conditions and
details the integration of rehabilitative ultrasound
imaging (RUSI) during physical therapy evaluation.
t Case Description: A 35-year-old female
soldier presented with a 6-week history of left
buttock pain and 4-year history of stress urinary
incontinence during activities that involved run-
ning, jumping, and fast walking. RUSI was used
to supplement the physical assessment process,
revealing altered motor control strategies of the
transversus abdominis and pelvic floor muscles,
and as a form of biofeedback during the rehabilita-
tion process.
t Outcomes: After completing a rehabilitation
program that incorporated principles of lumbar
stabilization and pelvic floor muscle re-education,
this patient was able to complete all physical ac-
tivities in basic combat training without SIJ region
pain or urinary leakage.
t Discussion: This case demonstrates the
importance of considering pelvic floor muscle
dysfunction and training in a patient with primary
complaints of SIJ region pain. It also highlights
the potential role of RUSI as both an evaluation
and biofeedback tool for the deep abdominal and
pelvic floor muscles. J Orthop Sports Phys Ther
2007;37(8):499-504. doi:10.2519/jospt.2007.2538
t Key Words: biofeedback, pelvic floor mus-
cles, transversus abdominis, sonography, spine
cadaveric study by Pool-Goudzwaard et
al31 demonstrated that simulated ten-
sion of the female PFMs significantly
stiffened the sacroiliac joints (SIJ) by
8.5% and produced a backward rotation
of the sacrum. The authors suggest that
increased activity of the PFMs may help
compensate for inadequate pelvic stabili-
ty and improve the ability to transfer load
through the lumbopelvic region.31
Physical therapy, consisting of training
of the PFMs, has been proven effective
in treating SUI. A Cochrane systematic
review by Hay-Smith and Dumoulin14
evaluated randomized controlled trials
of conservative therapy for urinary in-
continence (stress, urge, or mixed). They
concluded that training of the PFMs

1
Chief, Physical Therapy Clinic, General Leonard Wood Army Community Hospital, Fort Leonard Wood, MO. 2 Physical Therapist, Physical Therapy Clinic, General Leonard Wood
Army Community Hospital, Fort Leonard Wood, MO. 3 Assistant Professor and Director, Center for Physical Therapy Research, US Army-Baylor University Doctoral Program in
Physical Therapy, San Antonio, TX. The opinions or assertions contained here in are the private views of the Authors and are not to be construed as official or as reflecting the
views of the Departments of the Army or Defense. Address correspondence to Elizabeth Painter, Physical Therapy Clinic, General Leonard Wood Army Community Hospital, 126
Missouri Ave, Fort Leonard Wood, MO 65473. E-mail: Elizabeth.painter@na.amedd.army.mil

journal of orthopaedic & sports physical therapy | volume 37 | number 8 | august 2007 | 499

resulted in fewer incontinent episodes
per day, and women who participated in
training of the PFMs were more likely to
report improvement or cure than those
who received no treatment, sham, or pla-
cebo. Although traditional techniques,
such as digital palpation and perineom-
etry, are used to evaluate the function of
Downloaded from www.jospt.org at Ball State University on November 21, 2014. For personal use only. No other uses without permission.
the PFMs and provide biofeedback, the
use of rehabilitative ultrasound imaging
(RUSI) has also been described for both
assessment and biofeedback training for
contractions of the PFMs, based on its
ability to assess the elevating function of
the PFMs.10,40
The purpose of this case report is to
highlight the importance of considering
the PFMs as part of the evaluation and
treatment in women with lumbopelvic
dysfunction. In addition, it demonstrates
Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
the possible role of RUSI in evaluating
the PFMs and providing biofeedback to
ensure an elevating contraction of these
muscles during the cognitive phase of
motor learning.
CASE DESCRIPTION
History
Journal of Orthopaedic & Sports Physical Therapy®
T
he patient was a 35-year-old
female undergoing United States
Army basic combat training (BCT)
at Fort Leonard Wood, MO. She present-
ed with a 6-week history of lumbopelvic
dysfunction, with pain over her left SIJ
region and left lower extremity weak-
ness associated with sit-ups and pro-
longed periods of walking and standing.
The patient rated her resting SIJ region
pain as 5 to 6 on a 10-point numeric pain
rating scale (0 indicating no pain and 10
the worst pain imaginable), and 7 with
attempts to run. She was not able to run
greater than 400 m due to pain. She de-
nied referral of her symptoms into her
lower extremities and noted that walk-
ing at her own pace lessened her pain.
She related that her symptoms started
when she performed the flutter kick ex-
ercise during physical training at BCT.
Previous interventions since her injury
included SIJ region manipulation5,13 on
500 | august 2007 | volume 37 | number 8 | journal of orthopaedic & sports physical therapy
[ case report ]
3 occasions and lower extremity mus-
culature stretching. Both interventions
provided short-term pain relief but did
not improve her functional ability to
participate in BCT. Her current medica-
tions included acetaminophen 325 mg as
needed for pain relief and a triphasic oral
contraceptive.
Special questioning revealed a history
of urinary leakage associated with run-
ning, jumping, coughing, and laughing.
She reported restricting fluids and wear-
ing a sanitary pad daily because of her
urinary leakage. She first started having
urine leakage with running 4 years ago,
9 years after her last vaginal delivery,
and attributed it to drinking too much
water. At the time of the examination,
her urinary incontinence symptoms had
worsened with the physical activity asso-
ciated with BCT. She reported a history
of 4 pregnancies, with 3 normal vaginal
deliveries (9, 10, 11 years prior) and 1
emergency cesarean section for placenta
previa (7 years prior). She denied hav-
ing pelvic pain, low back pain (LBP), or
urinary incontinence during or after her
pregnancies.
The patient’s prior medical history in-
cluded a left proximal diaphyseal femur
fracture, treated with open reduction in-
ternal fixation (ORIF) using a medullary
nail, 17 years ago following a motorcycle
accident. Four years ago she was diag-
nosed with left greater trochanteric bur-
sitis that was initially treated with local
corticosteroid injections, which provided
only temporary relief. She subsequently
underwent partial surgical removal of her
femoral internal fixation hardware. She
reported that she regained full function
of her left lower extremity but was not
accustomed to being as physically active
as she was required to be at BCT. The
patient’s goal for physical therapy was
to successfully complete BCT and learn
exercises to strengthen her left lower
extremity.
Tests and Measures
Observation The patient demonstrated
normal posture and gait. Her right lower
extremity was 0.5 cm longer than the left
when measured supine. She reported that
the discrepancy was longstanding since
her left femur ORIF surgery.
Range of Motion The patient demon-
strated a reduction of 25% of the avail-
able range of motion (ROM) in both
lumbar extension and right sidebend-
ing due to pain in the left SIJ region. All
other lumbar ROM and bilateral hip and
knee ROM were full and pain free. No
aberrant motion was noted with lumbar
ROM.14
Neurological Exam Muscle strength test-
ing revealed that left hip flexion, exten-
sion, and abduction were strong (5/5) but
reproduced her pain at the left SIJ region.
All other lower extremity manual muscle
testing was strong (5/5) and pain free. Bi-
lateral muscle stretch reflexes and sensa-
tions were symmetrical and normal.
Special Tests The patient reported local-
ized pain with posterior-anterior force
applied to the L4 and L5 spinous pro-
cesses and to the left sacral base. Hyper-
mobility was subjectively perceived when
a posterior-anterior force was applied to
the right and left sacral base as well as
to the spinous processes of L3, L4, and
L5. The FABER test for the left hip re-
produced the patient’s SIJ region pain.
The prone instability test17 was positive
when assessed at L5. A straight-leg-raise
test to assess for neurologically related
lower extremity symptoms was normal
bilaterally. A passive straight-leg-raise
test demonstrated hip flexion greater
than 91° bilaterally.
The active straight-leg-raise (ASLR)
test has been proposed to evaluate the
form and force closure31 of the pelvic ring
and is thought to be a reliable means to
assess the load transfer through the lum-
bopelvic region.23-25 When the patient
lifted her left lower extremity approxi-
mately 5 cm from the table in the supine
position, she noted “heaviness” compared
to when she lifted the right lower extrem-
ity. When manual compression was ap-
plied through the ilia during the ASLR,
her complaints of heaviness diminished,
indicating a positive test.25 Compression
 Thickness Values (mm) of the Transversus
TREATMENT
TABLE 1 Abdominis (TrA) Muscle at Rest and During Initial Therapy Session

R
the Abdominal Drawing-in Maneuver (ADIM) USI was used to provide biofeed-
back as the patient was instructed
Left Right SEM*
to preferentially contract the TrA
At rest 8.0 6.5 0.32
muscle (using the ADIM),15,36 as well as
During ADIM 10.8 7.0 0.45
produce an elevating contraction of the
*The standard error of the measurement (SEM) represents the error value associated with a single
Downloaded from www.jospt.org at Ball State University on November 21, 2014. For personal use only. No other uses without permission.

measurement of the muscle.31

pelvic floor.37 Verbal and tactile cues
were employed to reduce excessive activ-
ity of the internal and external oblique
Clinical Signs and Symptoms of Patients With muscles. The ultrasound biofeedback
TABLE 2 Lumbopelvic Dysfunction That Predict Success session lasted 5 minutes. Upon comple-
With a Lumbar Stabilization Training Program14 tion, visual assessment of the ultrasound
image revealed that the patient was able
Predictors of Success* Findings in This Patient to properly perform the ADIM and pel-
Positive prone instability test Present vic-floor-elevating contraction.
Aberrant motion present during flexion or return from flexion Absent In addition to the motor control train-
Average straight-leg raise of .91° Present ing, the patient was fitted with an SIJ belt
Age ,40 y Present (Saunders Group, Chaska, MN) and in-
Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

*When 3 of these 4 predictors are present, the positive likelihood ratio for success is 4.0.15
of the ilia is thought to assist the form
closure of the pelvis.22,25
Abdominal Muscle Ultrasound An ultra-
sound imaging system (Sonosite 180; So-
nosite, Inc, Bothell, WA) with a 5-MHz,
60-mm curvilinear transducer was used
to evaluate the lateral abdominal wall and
Journal of Orthopaedic & Sports Physical Therapy®
twice the standard error of measurement
(SEM), as reported by Springer et al. 35
PFMs Ultrasound Using a 5-MHz,
60-mm curvilinear transducer, a trans-
abdominal approach, as described by
O’Sullivan et al,30 was utilized to obtain
both a transverse and perisagittal view
structed in proper wear. After putting on
the SIJ belt, the patient noted immediate
improvement during the ASLR and while
walking. She was encouraged to wear the
SIJ belt with activity as needed to help
minimize her symptoms.
Subsequent Therapy Sessions
This patient met 3 of 4 criteria (Table 2),

TrA. The ultrasound imaging technique
used to assess the TrA muscle at rest and
during the abdominal drawing-in ma-
neuver (ADIM) was based on previously
described protocols.35,36 Decreased thick-
ness of the left TrA muscle at rest and
during the ADIM was noted as compared
to the right (Table 1). The difference in
thickness between sides was greater than
of the bladder and PFMs. Qualitatively,
minimal lift of the bladder base was
noted during contraction of the PFMs,
as visualized on ultrasound imaging
(measurements to quantify the lift were
not conducted). Images demonstrating a
bladder with the PFMs at rest and during
an elevating contraction are provided in
the Figure.
as reported by Hicks et al,16 for success
with a lumbar stabilization program. She
was treated 2 times per week for 3 weeks
in the clinic with stationary bike warm-
up, weight-bearing left hip-strengthening
exercises using a resistance band while
maintaining an ADIM and pelvic-floor-
elevating contraction, and basic lumbar
stabilization exercises to include bridg-

FIGURE. Transabdominal (transverse view) ultrasound imaging of a bladder with perceived rest of the pelvic floor muscles (A). With a contraction of the PFMs (B) before and
(C) after motor control training. Note that the rectus abdominus (RA) muscle had similar thickness values at rest and while performing PFMs contraction, suggesting minimal
activity of this muscle during the PFMs contraction.

journal of orthopaedic & sports physical therapy | volume 37 | number 8 | august 2007 | 501

ing, lateral lean, prone alternate upper
and lower extremity movements over an
exercise ball, mini lunges, and crunches
on the exercise ball. Ice was applied to
the left SIJ region for symptom relief as
needed. In addition, the patient partici-
pated in a generalized upper- and lower-
body-conditioning aquatic program twice
Downloaded from www.jospt.org at Ball State University on November 21, 2014. For personal use only. No other uses without permission.
per week that was designed for soldiers
recovering from a variety of different
musculoskeletal injuries.
Home Exercise Program
She was instructed in a home exercise
program of pelvic floor elevation exer-
cises, to be performed 3 to 5 times per
day, with 10 to 12 repetitions per session.
The pelvic floor elevation exercises were
performed in multiple positions (sitting,
standing, and supine), with a 5- to 10-
Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
second hold per contraction. Emphasis
was also placed on the importance of
the timing of the PFMs contraction to
maintain urinary continence in response
to increased abdominal pressure associ-
ated with daily activities.26 In addition,
she was instructed in the importance of
proper hydration and avoidance of blad-
der irritants. The use of the ADIM during
Journal of Orthopaedic & Sports Physical Therapy®
daily activities was encouraged.
OUTCOME
O
n a follow-up exam 6 weeks
after the initial evaluation, the pa-
tient demonstrated normal, pain-
free lumbar spine ROM and normal,
pain-free strength (5/5) for left hip ab-
duction, flexion, and extension. The ASLR
test was now negative and the patient did
not note any heaviness while lifting either
lower extremity. She was able to perform
the ADIM and pelvic floor exercises with-
out verbal cueing or other forms of aug-
mented feedback, as assessed by RUSI. In
reviewing her exercise program, she was
able to demonstrate good lumbopelvic
control, with all the prescribed lumbar
stabilization exercises. She reported that
she wore her SIJ belt with running and
jumping activities only for the duration of
treatment. She denied any urine leakage
502 | august 2007 | volume 37 | number 8 | journal of orthopaedic & sports physical therapy
[ case report ]
with previously aggravating activities and
reported daily compliance with the pelvic
floor elevation exercises. Objective testing
(eg, a pad test) to confirm the patient’s re-
ported cure of SUI was not conducted.
Two months after the initiation of her
physical therapy treatment, the patient
was able to successfully complete BCT
and advanced individual training. Com-
pletion of BCT involved her completing
many rigorous physical activities: a 15-
km road march with a 15-kg ruck sack,
the Army physical fitness test (2-mile
run, push-ups, and sit-ups) to gender-
age standards, basic marksmanship, and
participation in obstacle courses. Her SIJ
region pain had completely resolved. She
reported that her SUI symptoms were re-
solved and that she had not experienced
leakage with any of the physical activities
required during training.
On telephone follow-up 6 months
later, the patient noted that she was able
to participate in full activity to include
running, jumping, and sit-ups, without
SIJ region, lumbar, or hip pain, or urine
leakage. She was no longer performing
her lumbar stabilization program but
was participating in yoga 2 to 3 times per
week. She reported that her pelvic floor
elevation exercises had become a daily
habit and that she used her SIJ belt on
very rare occasions. Overall, she reported
satisfaction with her outcome and noted
that she was able to perform her full mili-
tary duties and recreational sports with-
out pain or fear of urine leakage.
DISCUSSION
T
his case report illustrates the
importance of considering SUI in
women who present with lumbopel-
vic dysfunction. The frequent coexistence
of SUI and LBP has been reported in the
literature. For
���������������������������
instance, Pool-Goudzwa-
ard et al22,31 identified that 38% of wo-
men with SUI also have LBP, and 82% of
these women report having LBP as their
first symptom. ��������������������
Further, Smith et al34 have
identified that urinary incontinence is
more strongly related to frequent LBP in
women than obesity or physical activity.
This clearly demonstrates the importance
of screening for SUI in patients present-
ing with low back or SIJ region pain.
A treatment program consisting of
lumbar stabilization exercises, pelvic
floor elevation exercises, and the use of
a SIJ belt appears to have contributed to
this patient’s return to a very high level
of physical function and diminished SIJ
region pain and incontinence symptoms.
This is consistent with the literature that
suggests that compression of the ilia in
those with SIJ region or pregnancy-relat-
ed pelvic pain decreases symptoms asso-
ciated with the ASLR test,25,30 augments
dynamic stability of the pelvic region,24
and improves pelvic floor elevation dur-
ing the ASLR.30
The treatment program was designed
to address motor control deficits in the
TrA and PFMs, based on both clinical
findings and reports of delayed or al-
tered contractions of these deep trunk
muscles in those with lumbopelvic dys-
function11,21,27,28,30 and incontinence.1,6,20
The addition of pelvic-floor-elevating ex-
ercises may have assisted with the lumbar
stabilization exercise regimen, based on
the findings by Critchley,8 who found that
a cocontraction of the PFMs with a TrA
muscle contraction increased the thick-
ness of the TrA muscle more than an iso-
lated TrA contraction in normal subjects.
Given that this patient demonstrated sig-
nificant symptomatic and functional im-
provement in 8 weeks suggests that her
SIJ region pain and SUI may have been
more related to altered motor control
strategies than significant strength loss.
Additionally, this case report high-
lights the possible role of RUSI as a tool
for both assessment and treatment. We
utilized a transabdominal ultrasound
technique using both a transverse and a
perisagittal view to assess the elevating
function of the PFMs. It has been sug-
gested that this technique is relatively
easy to learn, quick to perform, and
noninvasive.37 Further, this assessment
technique does not restrict lower ex-
tremity movement and can therefore be
 performed in multiple postures and func-
tional activities.30 In addition to allowing
visualization of this patient’s diminished
ability to elevate the base of the bladder
during contraction of the PFMs on initial
examination, this imaging technique was
used for biofeedback training. Similar to
the findings of Dietz et al,10 our patient
Downloaded from www.jospt.org at Ball State University on November 21, 2014. For personal use only. No other uses without permission.
was able to learn to properly perform an
elevating contraction of the PFMs in 5
minutes of augmented feedback. Whit-
taker40 has noted that orthopaedic physi-
cal therapists have good techniques to
evaluate and treat the deep abdominal
and lumbar multifidus muscles but have
often neglected the PFMs because of lim-
ited assessment methods. RUSI may be
a noninvasive tool to assist with a more
encompassing examination of those that
present with lumbopelvic dysfunction
Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
combined with SUI.
Limitations
Although this case report suggests the
use of transabdominal RUSI for the eval-
uation and training of the PFMs, it is not
the intention of the authors to suggest
that this technique is a substitute for the
comprehensive management employed
Journal of Orthopaedic & Sports Physical Therapy®
by an urogynecological physical thera-
pist. Rather, it highlights how RUSI can
contribute to a more comprehensive as-
sessment of the spine and pelvis.37 More
research is needed to correlate the abil-
ity of the PFMs to impact the bladder as
seen on RUSI with objective measures
of improvement in urinary incontinence
symptoms.
Although this patient’s SUI and heavi-
ness associated with the ASLR test ap-
peared to be associated with TrA and
PFMs contractile insufficiency, it is im-
portant to acknowledge that difficulty
obtaining pelvic floor elevation can be a
result of hypertonicity of the PFMs, which
renders the PFMs weak and incapable of
reacting to increased intra-abdominal
pressure. Further, increases in intra-
abdominal pressure due to splinting of
the diaphragm and oblique abdominals
can result in hypertonicity of the PFMs,
causing further impaired function.33,38,39
journal of orthopaedic & sports physical therapy | volume 37 | number 8 | august 2007 |
However, given that this patient’s ASLR
test improved with the provision of ex-
ternal compression by the therapist,
hypertonicity of the PFMs was unlikely.
Had this patient’s SUI not improved with
the treatment employed, referral to an
urogynecological physical therapist for
additional assessment would have been
indicated.
CONCLUSION
T
his case report describes the
successful integration of TrA and
PFMs training, facilitated by RUSI,
to treat a patient with SIJ region pain and
SUI. Ultimately, this patient was able to
return to a very high level of functional
activity in a relatively short period, sug-
gesting the importance of addressing
motor control deficits of these muscles in
patients with these conditions.
ACKNOWLEDGEMENT
We would like to thank Robert Boyles, PT,
DSc, OCS, FAAOMPT for his thoughtful
review of this manuscript. t
references
1. B arbic M, Kralj B, Cor A. Compliance of the
bladder neck supporting structures: importance
of activity pattern of levator ani muscle and
content of elastic fibers of endopelvic fascia.
Neurourol Urodyn. 2003;22:269-276.
2. Bo K. Urinary incontinence, pelvic floor dys-
function, exercise and sport. Sports Med.
2004;34:451-464.
3. Bo K, Borgen JS. Prevalence of stress and urge
urinary incontinence in elite athletes and con-
trols. Med Sci Sports Exerc. 2001;33:1797-1802.
4. Bo K, Stien R, Kulseng-Hanssen S, Kristofferson
M. Clinical and urodynamic assessment of nul-
liparous young women with and without stress
incontinence symptoms: a case-control study.
Obstet Gynecol. 1994;84:1028-1032.
5. Childs JD, Fritz JM, Flynn TW, et al. A clinical
prediction rule to identify patients with low
back pain most likely to benefit from spinal ma-
nipulation: a validation study. Ann Intern Med.
2004;141:920-928.
6. Constantinou CE, Govan DE. Spatial distribution
and timing of transmitted and reflexly generated
urethral pressures in healthy women. J Urol.
1982;127:964-969.
7. C riner JA. Urinary incontinence in vulner-
able populations: female soldiers. Urol Nurs.
2001;21:120-124.
8. Critchley D. Instructing pelvic floor contraction
facilitates transversus abdominis thickness
increase during low-abdominal hollowing. Phys-
iother Res Int. 2002;7:65-75.
9. Davis G, Sherman R, Wong MF, McClure G, Perez
R, Hibbert M. Urinary incontinence among fe-
male soldiers. Mil Med. 1999;164:182-187.
10. Dietz V, Quintern J, Boos G, Berger W. Obstruc-
tion of the swing phase during gait: phase-de-
pendent bilateral leg muscle coordination. Brain
Res. 1986;384:166-169.
11. Ferreira PH, Ferreira ML, Hodges PW. Changes in
recruitment of the abdominal muscles in people
with low back pain: ultrasound measurement of
muscle activity. Spine. 2004;29:2560-2566.
12. Fischer JR, Berg PH. Urinary incontinence in
United States Air Force female aircrew. Obstet
Gynecol. 1999;94:532-536.
13. Flynn T, Fritz J, Whitman J, et al. A clinical
prediction rule for classifying patients with
low back pain who demonstrate short-term
improvement with spinal manipulation. Spine.
2002;27:2835-2843.
14. Hay-Smith EJ, Dumoulin C. Pelvic floor muscle
training versus no treatment, or inactive control
treatments, for urinary incontinence in women.
Cochrane Database Syst Rev. 2006:CD005654.
15. Henry SM, Westervelt KC. The use of real-time
ultrasound feedback in teaching abdominal hol-
lowing exercises to healthy subjects. J Orthop
Sports Phys Ther. 2005;35:338-345.
16. Hicks GE, Fritz JM, Delitto A, McGill SM.
Preliminary development of a clinical predic-
tion rule for determining which patients with
low back pain will respond to a stabilization
exercise program. Arch Phys Med Rehabil.
2005;86:1753-1762.
17. Hicks GE, Fritz JM, Delitto A, Mishock J. Inter-
rater reliability of clinical examination measures
for identification of lumbar segmental instability.
Arch Phys Med Rehabil. 2003;84:1858-1864.
18. Hides J, Gilmore C, Stanton W, Bohlscheid E.
Multifidus size and symmetry among chronic
LBP and healthy asymptomatic subjects. Man
Ther. 2006 Oct 26; [Epub ahead of print].
19. Hodges PW, Richardson CA. Altered trunk
muscle recruitment in people with low back pain
with upper limb movement at different speeds.
Arch Phys Med Rehabil. 1999;80:1005-1012.
20. Hodges PW, Richardson CA. Contraction of the
abdominal muscles associated with movement
of the lower limb. Phys Ther. 1997;77:132-142;
discussion 142-134.
21. Hodges PW, Richardson CA. Inefficient mus-
cular stabilization of the lumbar spine as-
sociated with low back pain. A motor control
evaluation of transversus abdominis. Spine.
1996;21:2640-2650.
22. Kjolhede P, Ryden G. Clinical and urodynamic
characteristics of women with recurrent urinary
incontinence after Burch colposuspension. Acta
503

Obstet Gynecol Scand. 1997;76:461-467.
23. L arsen WI, Yavorek TA. Pelvic organ prolapse
and urinary incontinence in nulliparous
women at the United States Military Acad-
emy. Int Urogynecol J Pelvic Floor Dysfunct.
2006;17:208-210.
24. Mens JM, Damen L, Snijders CJ, Stam HJ. The
mechanical effect of a pelvic belt in patients
with pregnancy-related pelvic pain. Clin Bio-
mech (Bristol, Avon). 2006;21:122-127.
Downloaded from www.jospt.org at Ball State University on November 21, 2014. For personal use only. No other uses without permission.
25. Mens JM, Vleeming A, Snijders CJ, Stam HJ,
Ginai AZ. The active straight leg raising test
and mobility of the pelvic joints. Eur Spine J.
1999;8:468-473.
26. Miller JM, Ashton-Miller JA, DeLancey JO. A
pelvic muscle precontraction can reduce cough-
related urine loss in selected women with mild
SUI. J Am Geriatr Soc. 1998;46:870-874.
27. Moseley GL, Hodges PW, Gandevia SC. Deep
and superficial fibers of the lumbar multifidus
muscle are differentially active during voluntary
arm movements. Spine. 2002;27:E29-36.
28. Moseley GL, Nicholas MK, Hodges PW. Pain
differs from non-painful attention-demanding
Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
or stressful tasks in its effect on postural con-
trol patterns of trunk muscles. Exp Brain Res.
2004;156:64-71.
29. Nygaard IE, Glowacki C, Saltzman CL. Relation-
ship between foot flexibility and urinary incon-
Journal of Orthopaedic & Sports Physical Therapy®
504 | august 2007 | volume 37 | number 8 | journal of orthopaedic & sports physical therapy
[ case report ]
tinence in nulliparous varsity athletes. Obstet
Gynecol. 1996;87:1049-1051.
30. O’Sullivan PB, Beales DJ, Beetham JA, et al.
Altered motor control strategies in subjects with
sacroiliac joint pain during the active straight-
leg-raise test. Spine. 2002;27:E1-8.
31. Pool-Goudzwaard A, van Dijke GH, van Gurp
M, Mulder P, Snijders C, Stoeckart R. Contri-
bution of pelvic floor muscles to stiffness of
the pelvic ring. Clin Biomech (Bristol, Avon).
2004;19:564-571.
32. Richardson CJ, Hodges PW, Hides J. Therapeutic
Exercise for Spinal Stabilization in Low Back
Pain: Scientific Basis and Clinical Approach.
New York, NY: Churchill Livingstone; 1999.
33. Smith MD, Coppieters MW, Hodges PW. Postural
activity of the pelvic floor muscles is delayed
during rapid arm movements in women with
stress urinary incontinence. Int Urogynecol J
Pelvic Floor Dysfunct. 2007;18:901-911.
34. Smith MD, Russell A, Hodges PW. Disorders of
breathing and continence have a stronger asso-
ciation with back pain than obesity and physical
activity. Aust J Physiother. 2006;52:11-16.
35. Springer BA, Mielcarek BJ, Nesfield TK, Teyhen
DS. Relationships among lateral abdominal
muscles, gender, body mass index, and hand
dominance. J Orthop Sports Phys Ther.
2006;36:289-297.
36. T eyhen DS, Miltenberger CE, Deiters HM,
et al. The use of ultrasound imaging of the
abdominal drawing-in maneuver in subjects
with low back pain. J Orthop Sports Phys Ther.
2005;35:346-355.
37. Thompson JA, O’Sullivan PB, Briffa K, Neumann
P, Court S. Assessment of pelvic floor movement
using transabdominal and transperineal ultra-
sound. Int Urogynecol J Pelvic Floor Dysfunct.
2005;16:285-292.
38. Thompson JA, O’Sullivan PB, Briffa NK, Neu-
mann P. Altered muscle activation patterns in
symptomatic women during pelvic floor muscle
contraction and Valsalva manouevre. Neurourol
Urodyn. 2006;25:268-276.
39. Thompson JA, O’Sullivan PB, Briffa NK, Neu-
mann P. Differences in muscle activation pat-
terns during pelvic floor muscle contraction
and Valsalva maneuver. Neurourol Urodyn.
2006;25:148-155.
40. Whittaker JL. Abdominal ultrasound imag-
ing of pelvic floor muscle function in indi-
viduals with low back pain. J Man Manip Ther.
2004;12:44-49.
@ more information
www.jospt.org