Reviewed by Tyler Tice, PT, DPT, OCS, ATC
Introduction
Pelvic floor dysfunction (PFD) and chronic low back pain (CLBP) often coexist due to overlapping biomechanical, neuromuscular, and pain mechanisms.1 These conditions affect movement patterns, core stability, and quality of life, presenting a unique challenge for physical therapy. While traditional pelvic floor muscle (PFM) exercises, such as Kegels, remain a cornerstone for treating PFD, emerging research suggests that functional and specialized exercises may offer superior engagement and adherence.2,3 This review integrates findings from recent studies exploring the connection between PFD and CLBP while proposing alternative exercise methods to enhance pelvic floor rehabilitation outcomes.
Pelvic Floor Dysfunction and Low Back Pain: Shared Pathways
A study by Algudairi et al. highlighted the prevalence of PFD among women with CLBP, with 43% reporting at least one pelvic floor symptom and 52% exhibiting neuropathic pain (NP). NP was strongly associated with greater pelvic floor distress, as measured by the Pelvic Floor Distress Inventory.1 The findings suggest that PFD exacerbates CLBP through mechanisms such as central sensitization and impaired core stability. This highlights the importance of addressing both pelvic and lumbar dysfunctions in a comprehensive rehabilitation plan.
Functional Exercises for Pelvic Floor Muscle Activation
Traditional PFM exercises, such as Kegels, rely on isolated contractions to strengthen the pelvic floor. However, Díaz-Mohedo et al. demonstrated that functional movements like trunk stability push-ups (PU) achieve PFM activation levels comparable to or exceeding those of Kegel exercises.2 Using electromyography (EMG), the study revealed that PUs produced high PFM activation (112% of maximal voluntary contraction), highlighting the benefits of functional exercises in training the pelvic floor indirectly. Such exercises, which simultaneously target core and pelvic floor stability, offer a practical alternative for individuals struggling with adherence to isolated PFM exercises.2 Similarly, Crawford et al. compared traditional Kegel exercises to specialized movements designed to naturally engage the pelvic floor. Using wireless surface EMG sensors, the study analyzed ten dynamic movements, including lunges, squats, and bridges. Results showed that all ten movements significantly increased PFM activation compared to isolated Kegels. For example, bridges produced a 56% greater activation; while hovering exercises achieved a 49% increase.3 These findings suggest that incorporating PFM contractions into functional and dynamic tasks can enhance motor unit recruitment and improve training efficiency.
Pelvic Floor Training and Chronic Low Back Pain Management
Functional exercises that engage PFMs indirectly, such as lunges, squats, and push-ups, not only strengthen the pelvic floor but also address core stability deficits commonly observed in CLBP patients. Additionally, incorporating specialized movements that synchronize PFM contractions with dynamic tasks—such as bridges and cat-cow stretches—provides a more comprehensive approach to improving lumbopelvic stability. Neuropathic pain, often associated with PFD, can further complicate CLBP treatment. Algudairi et al. emphasized the importance of addressing NP through multimodal interventions, including pain education, graded motor imagery, and myofascial release. Combining these strategies with dynamic PFM training offers a pathway to manage both pelvic and lumbar dysfunctions effectively.
Conclusion and Implications for Physical Therapy
The integration of functional and dynamic PFM exercises represents a shift in the management of PFD and its associated low back pain. Studies by Díaz-Mohedo et al. and Crawford et al. demonstrate that functional movements like bridges, squats, and push-ups can significantly enhance PFM activation, outperforming traditional Kegels in many cases. These exercises also promote broader neuromuscular adaptations, addressing core stability deficits and improving adherence by embedding pelvic floor training into everyday movement patterns.
Physical therapists can leverage these findings to develop individualized rehabilitation programs that address both PFD and CLBP. Functional PFM training can be incorporated into standard protocols, complemented by interventions targeting neuropathic pain and compensatory movement patterns. This comprehensive approach not only optimizes pelvic and lumbar health but also enhances overall functional outcomes, reducing the risk of recurrence and improving quality of life for patients.
References
- Algudairi G, Aleisa E, Al-Badr A. Prevalence of neuropathic pain and pelvic floor disorders among females seeking physical therapy for chronic low back pain. Urol Ann. 2019;11(1):20-26. doi:10.4103/UA.UA_123_18
- Díaz-Mohedo E, Odriozola Aguirre I, Molina García E, Infantes-Rosales MA, Hita-Contreras F. Functional Exercise Versus Specific Pelvic Floor Exercise: Observational Pilot Study in Female University Students. Healthcare (Basel). 2023;11(4):561. doi:10.3390/healthcare11040561
- Crawford B. Pelvic floor muscle motor unit recruitment: Kegels vs specialized movement. American Journal of Obstetrics & Gynecology. 2016. Accessed January 25, 2025. https://www.ajog.org/article/S0002-9378(16)00035-1/fulltext