Episode 1602 - Breathing, voicing, and the pelvic floor

Dr. April Dominick // #ICEPelvic // www.ptonice.com

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick discusses the anatomy & physiology of phonation, the mechanics of breathing, and the relationship between the pelvic floor & the demands of speaking/singing. In addition, April covers unique considerations for professional singers & speakers and implications for physical therapy treatment.

Take a listen to learn how to better serve this population of patients & athletes.

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EPISODE TRANSCRIPTION

INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today.APRIL DOMINICK What's up PT on Ice fam? This is Dr. April Dominick from the Ice Pelvic Faculty Division here today to talk about the pelvic floor and its role in breathing and voicing today. I have a feeling it'll take your breath away. But first, some updates from our pelvic division. First, we have our last live course offering of 2023. It is happening December 2nd and 3rd. with Christina Prevett, and that is gonna be in Halifax, Nova Scotia. And let's not forget about not one, but two of our online eight-week course offerings. Level one is going to kick off next year on January 9th, and the brand new level two advanced concepts are going to get rolling on April 30th. So head over to ptonice.com and secure your seat in one or all three of those offerings. So we wanted to hop on today to outline what we know about the pelvic floor and its essential tasks and things that you've probably already done today like breathing and talking.

THE PELVIC FLOOR & PHONATION I'll discuss the essential anatomy and then the structures that are involved and then we'll unpack the complex physiology of breathing and voicing with a special focus on what the literature supports right now in terms of what the pelvic floor's role is in phonation. Spoiler alert, there's not a ton. And when I say phonation or voicing, all those terms mean talking. So we need to understand what normal function is in order to identify dysfunction during pelvic floor assessment, especially when it comes to an individual complaining of any bladder issues or bowel dysfunction, leakage, pelvic heaviness, or pain during tasks like breathing and talking, or yelling and singing, This can happen to anyone. Think about the last time you were in a really loud bar or at a concert and you're yelling at someone or trying to talk to people and your voice gets a little fatigued. Maybe there's some fatigue in the pelvic floor as well. This can also happen with other occupations that primarily use their voices. So I'm thinking about teachers, maybe chefs in a busy kitchen or coaches, professional singers even. Another point to bring up is breathing and more recently phonation have been used in the clinic by physical therapists to treat pelvic floor dysfunction. Yet we lack robust evidence to support these clinical practices. So when it comes to breathing and voicing, I want you right now to think of some body parts or structures that are involved. I'll give you three seconds or you can pause.

THE ANATOMY OF PHONATION Most of us probably thought of the obvious structures like the nose, the mouth, the lungs, and maybe even the diaphragm. And those are great starts. And we're going to run through the other important players for breathing and voicing. Breathing and voicing work in a closed system, which involves the interplay of three regions. with different diaphragms. So the cervicothoracic diaphragm, the respiratory diaphragm, that's the diaphragm that you think of when we talk about the diaphragm, the dome shape, and then the pelvic diaphragm. So when it comes to the cervicothoracic diaphragm, the major surrounding structures of interest are the oral and nasal cavity, the larynx, which is also known as the voice box, and that houses the vocal folds, the trachea, and then there's supporting musculature. There's paralangeal musculature like the SEM and scalenes, as well as the intercostal muscles. From a nerve standpoint, we cannot talk about the pelvic floor or voicing or breathing even without talking about the vagus nerve, as well as the phrenic nerve that runs along this area. The vagus nerve innervates the vocal folds and the phrenic nerve innervates the diaphragm. So that's the cervicothoracic region and diaphragm. Then we've got the respiratory diaphragm. That's going to separate the thoracic cavity from the abdominal cavity. And the diaphragm at rest, it's that dome-shaped muscle And it's got many origins, the xiphoid process, some of the lower ribs, the lumbar spine. Indirectly, it also attaches to the psoas and QL or quadratus lumborum. And then in that same region, we have the abdominals and they aid in power production for respiration or phonation. We're talking the internal and the external obliques, the rectus, and then the transverse. Then we have the pelvic diaphragm, our third area. The pelvic floor muscles are actually the floor of this entire closed-core canister system. Its three layers involving the levator ani, the coccygeus, piriformis, optorenus, and ternus are all muscles that span from the pubic bone back to the coccyx, and then from the ischial tuberosity to the other ischial tuberosity. Functionally, the pelvic floor is involved in so many things, abdominal and pelvic support, modulation of intra-abdominal pressure, postural and respiratory support, bowel, bladder, sexual function and arousal, and reproductive function. When those pelvic floor muscles contract, they close off the urethral, vaginal and anal openings. When they relax, they open those openings so that if we need to, we can urinate or poop or do any of those things. So that's the anatomy piece.

THE PHYSIOLOGY OF PHONATION Now I want to go into the relevant physiology when it comes to pressure generation and management. So breathing is the transmission of air into and out of the lungs. Sounds simple. Right? No, not so much. We're going to go through how each region that we just discussed supports respiration in two forms, inhalation and exhalation. For the cervicothoracic diaphragm, the vocal folds are there and they march their own drums. So during inhalation and exhalation, those vocal folds stay open, and that's to allow airflow in and out. In terms of the intercostals, during inhalation, the external intercostals are going to elevate the ribs and go upwards and outwards, which expands the thoracic cavity, and then they'll relax on exhalation. The SEM and scalenes are going to assist in the inhalation portion as well as provide some postural support for the head and neck. So that was a cervicothoracic diaphragm.

THE MECHANICS OF BREATHING Now we're going to go into the respiratory diaphragm physiology and mechanics of breathing. So during inhalation, that dome-shaped muscle contracts and changes from dome-shaped and then flattens as it descends towards the abdominal cavity. This is going to create a vacuum that pulls air in. And then during exhalation, that flat diaphragm passively relaxes and returns back to its dome shape. Then we have the abdominal muscles. They are a little more straightforward. On inhale, they're going to relax and expand outward. On exhalation, they're going to contract and draw inward. Then we have the pelvic diaphragm. So during inhalation, the pelvic floor muscles relax and elongate. Then on exhalation, in the presence of now increased intra-abdominal pressure, the pelvic floor should contract and lift, which closes those openings, preventing any unwanted leakage or prolapse symptoms. And we have a few confirmations of this happening in the literature. In 2011, there was a group Telus et al, and they confirmed that these pelvic floor movements are happening with respiration during real-time dynamic MRI. We love some of that research. We also have other studies