I respectfully disagree….

Hi Dr. Oz,

Thanks for tackling such a difficult women’s health issue pelvic organ prolapse. Many women suffer in silence. It is extremely valuable for women to see that they are not alone and that there are things they can do to address this issue. I was glad to see that you were recommending conservative, active measures versus simply suggesting surgery.

However, it is vital for women to be provided with correct information regarding how the pelvic floor functions. Yes, it is connected with the diaphragm, and works best when they are linked together in breath. However, the pelvic floor should lower on inhale accepting the abdominal and pelvic contents. It should rise on exhale. This is critical for proper activation of the central stability complex that is the inner core, which supports posture, movement as well as pelvic organs.

In addition, in the women’s health world we are advocating functional, integrative work for the pelvic floor. An isolated contraction of the pelvic floor like a Kegel will not train it for its role in movement, core, fitness or sport.

I demonstrated these pelvic floor “fun facts” in this video: The Fit Floor Part 1: Training Your Pelvic Floor for Fitness. Using the pelvic floor as it functions is the first step towards healing a pelvic organ prolapse.

Thanks for helping women seek solutions for tough issues!

Julie Wiebe, PT

Women’s Sports Medicine Physical Therapist

I am in a different camp….the “let’s-see-the-Kegel-for-what-it-is-(an early rehab tool, if done correctly)-and-then-let’s-take-the-next-step” camp. Kumbaya!

In short, a Kegel strengthens the pelvic floor by performing an isolated, isometric hold of the pelvic floor. Isometrics, referred to as sets, are early rehabilitation activities that get muscles rolling again and help patients figure out how to re-connect with an injured or weak muscle (examples-quad sets are thigh squeezes that help patients restart their quad; glute sets squeeze the bum to get it moving again). But in order to get that quad or those glutes to start to support someone for say running, the activities must move from isolated, squeezing activities to more challenging, functional and running-like activities that link them back together with all the other muscles that participate in running. No rehab or fitness pro would stop at a quad set to rehabilitate a knee or prepare an athlete (recreational or pro) for return to play. Yet that is what a Kegel is for the pelvic floor. Is it any wonder women leak horribly when they try to return to fitness or sport? The pelvic floor hasn’t been trained for that kind of physical demand.

The pelvic floor muscle group is made of the same kind of muscle tissue as the quads and glutes, so it needs to be trained the way other muscles are! To rehabilitate the pelvic floor and get it to perform for an activity like running or zumba or chasing your little one around- the training program must move from an isolated contraction (Kegels) to one that exercises it in functional, and dynamic ways.

So, the right question is: where do we go from here?  The first step towards a new way of training the pelvic floor to be dynamic and ready for fitness is to understand how it functions. Here are some pelvic floor fun facts to get you started:

Kumbaya!

1. Trainer refers to any of your body parts as food. Your bum is not made of lard, your gut is not a muffin top, and your legs are not sausage links. Condescension is not a motivator. A trainer with more tricks in their tool bag to keep you moving might be a better bet.  Time to walk, ladies.

2. Mat class teacher looks worse than you do. If someone who has constant access to gym equipment, bands and kettle balls cannot whip their own body into shape, what exactly can they offer you? Find the exit.

3. Your trainer can’t walk the line between challenge and injury producing routines. Some clues that you and they have crossed that line?

• pain from a workout that is not diminishing after 36-48 hours
• pain in your joints instead of the middle of the muscle you worked
• they refer to you as “Soldier”, “Plebe” or “Recruit”

Run, do not march…out.

4. You still don’t like what you look like naked. The trainers website had great testimonials and pics of transformations, but your bulges aren’t budging….then they haven’t created a program that is right for your needs. Time for a refund.

5. Your mat class, boot camp, or trainers program includes crunches, or worse sit-ups, horror of horrors! Your trainer/teacher is not up on the latest fitness research. Sit-ups left the scene decades ago. Crunches are bad for backs, bad for pelvic floors, wreck your posture and don’t really flatten your abs. Time to say adios!

6. Your Yoga-fusion teacher can’t make it through the whole class without a trip to the ladies room. Her pelvic floor is getting hammered by her exercise routine, so what’s it doing to yours? You and your pelvic floor need to scram.

Be safe and smart out there ladies! Look for these red flags and keep on walking until you find a class or trainer that can build workout intensity gradually and work with you to set and achieve attainable goals. A great resolution would be injury-free fitness and to NOT need a physical therapist in 2012!

Here’s to a fit and fabulous year!

This post is a bit of a departure from those regularly seen here, but it is connected to the overall message/mission of Interior Fitness. I began seeking solutions for pregnancy recovery for my female patients in 2003. It grew into a passion for bringing about a change in the way rehab and fitness is delivered to women and girls from puberty through menopause. At the heart, is my true desire to help women of all ages.

Every year I give 10% of my business profit to charitable causes. This year I have decided on two charities, one global and one local, that are on their own missions to help women and girls. I wanted to share them with you in hopes that you too will be moved by the causes they serve and consider a donation.

The first is She Dances www.shedances.org . They have created a safe house in Honduras for young girls (11-18) who have been trafficked and sexually exploited. I was floored when an organization rep told me that some girls are trafficked from early childhood.

Their Mission: “We believe that every girl deserves a life of love, opportunity, family, and a hopeful future. We believe that every girl deserves to dance in freedom. Through a peaceful home nestled in the hills of Honduras, weʼre providing holistic restoration for innocent and forgotten young girls who have been trafficked and sexually exploited.”

The second is Harvest Home www.theharvesthome.net . They have created a home here in Los Angeles for homeless, pregnant women and their children. I was shocked to learn that pregnant women are turned away by most shelters, so they are forced to the streets.

Their Mission: “To transform the lives of homeless, pregnant women and their children by identifying and overcoming the root causes of homelessness, and by promoting physical and emotional health, spiritual growth, and financial independence.”

Please consider caring for women and girls in need by supporting these great causes through their websites!

Happy Holidays to you and yours!

Julie Wiebe, PT

The rehab and fitness communities are in the midst of a little family fight over the work of two of our field’s visionaries; Paul Hodges, the grandfather of TA isolation and Stuart McGill, the um…step-dad of bracing. Despite our lack of conclusions or resolution internally, our private fight has leaked to the public in a NY Times Well piece. The tide seems to be turning against the TA (transversus abdominis) isolation programs sparked by Hodges work while McGill’s methodology of bracing the whole trunk is picking up momentum.

The Times article seems to support McGill’s position of whole trunk bracing over TA isolation, based in part on the cited  British Journal of Sports Medicine (BJSM) study (a discussion piece based on the results of the original study published in the Journal of Orthopedic and Sport Physical Therapy (JOSPT)). But it’s worth taking a step back and a second look before kicking the elements of the inner core to the curb and running down another single-minded path. All my patients did TA’s  too, but learning from our past mistakes and from all the available research will help us avoid another decade of running ahead of the evidence and allow us to implement mindful program-building.

The debate between the two camps -TA isolation versus bracing- is setting up a polarizing choice for practitioners. TA isolation relies heavily on one muscle and does not link to the inter-relationship that exists between all the muscles of the postural system. However, bracing ignores the sequencing of inner core component activation prior to outer core components that has been demonstrated in the literature.

The BJSM/JOPST study brought new understanding of how the TA activates. TA-based programs were historically developed around the idea (and the early work of Hodges) that the TA activated simultaneously on both sides of the abdomen before an arm movement began. Thus the “pull navel-to-spine” cue became a rehab and fitness mantra. However, the BJSM/JOPST study showed that the TA did not activate in the same way on different sides of the body. They found that the TA on the opposite side of the body from the movement (ex: left arm movement, Right TA) fired before the TA on the same side as the arm movement. (Nerd Alert: This is what physical therapists fight about – its no Jerry Springer, but it is important to how we build exercise programs). The authors of the BJSM/JOSPT study concluded that programs that elicit simultaneous activation of the TA on both sides of the body (“navel to spine”) may not mimic how the TA actually functions.

However, not mentioned in the NY Times article, is that the original JOSPT study found that the TA on both sides of the body still activated before all the other muscles studied. This continued to support the original concept of early TA activation understood through Hodges work. Without this critical piece of information a lay person or a pro might be misled. Also not recognized by the NY Times article is that the concept of bracing elicits a similar simultaneous activation of not one muscle but all of the muscles on both sides of the whole trunk. So here is the big finish: multiple studies, not just the one in the BJSM/JOSPT, have shown us that the trunk muscles respond differently depending on the demands of the task. The trunk muscles are an intricate system of checks and balances that create stability within the constant changes brought by movement. The trunk muscles do not have a uniform response to different tasks. Picking up a grocery bag and throwing a ball require a different sequence of muscle activation. However, both bracing and TA isolation train the trunk for a uniform response.

The NY Times article seemed to promote that the TA isn’t important. A better interpretation of the BJSM/JOSPT study is that the TA is smarter than we originally thought! It too has an adaptable response to the demands of the task AND yet it still fires first in the sequence of trunk muscle activation required to accomplish a movement task.

How we apply this understanding for more mindful fitness and rehab programs is our critical task as practitioners.

The clinical question is: TA or Bracing? How about neither! My beef with both ideas is the same – they advocate a static, simultaneous sustained hold at the center: a uniform response. Essentially activating a trunk isometric while performing peripheral arm and leg movements. An isometric is simply put: un-functional, the opposite of the growing trend toward functional patterning programs. What does a whole trunk isometric (bracing) or a TA isometric teach our clients about movement? About balance? About performance? Before we all jump from TA isolation to the bracing bandwagon, the most important question to answer is: Does a static hold train the trunk in the way that it actually produces central postural control within movement patterns?

Non-specific bracing seems to throw the baby out with the bath water. Is it wise to ignore the progress we have made clinically with the understanding of the existence of the inner core team (the TA has teammates: the Diaphragm, Pelvic Floor and Multifidus)? I am an old enough PT to remember the exercises we used to give out before core exercises existed…and they look a lot like the ones promoted in the NY Times article. Bird-dog (On all-4’s alternating a lift of opposite arm and leg) is not a new exercise. The understanding of neutral spine through McGill’s work is a major improvement on the old theme. But the resultant bracing program is familiar nonetheless . We all happily ditched similar programs when “core” hit the scenes, feverishly following the core path, because something was missing from those old low back stability programs. They didn’t totally hit the mark for our patients, either. Yet it seems we have come full circle again, rejecting one for the other.

So my question is this: Why the polarizing choice? The two systems co-exist in our movements, why shouldn’t they co-exist in our clinical and exercise programs. McGill reminded us that it takes a village to create movement. But let’s not forget that every village has a leader, that anchors the tribe and sets it’s course. Hodges introduced us to the leadership of the inner core, although in our excitement it seems we may have screwed up the secret tribal handshake with navel-to-spine. Programs that restore that leadership and involve the whole village will get the best result.

Those who forget the past are condemned to repeat it. Creating clinical models that are reflective of all the emerging evidence are critical to our evolving best practice.

Author’s note: I broke up with the TA as the leader of the inner core a while ago. I now teach programs that access the inner core through the dynamic relationship between the Diaphragm and Pelvic Floor. My caution to readers of the NY Times article is that although the TA may not the system entry point we thought it was, the function of the anticipatory inner core system is still critical to central/proximal stability. Linking a dynamic inner core (tribe leader) to the outer core (village) prepares the body to have the stability and flexibility to address the functional or fitness task at hand. Learn more here.

Check out Hodges (not interviewed for the NY Times Well piece) response to the debate here.

Their exercise form sucks. There I said it.

The trainer pushes them on to sprinting with bad form, doing crunches with bad form, lunges, push-ups, planks, hills….all with the same bad form. They all have their bums tucked under, creating a flattened junkless trunk. Rehab pro’s would call this a posterior pelvic tilt. It’s the position most women find themselves in as their pregnancy progresses. The pelvis often rocks under to balance and make room for the added baby and abdomen out front. They get stuck in that bum tucked under position post-partum because their muscles change length and weaken keeping the pelvis tipped. The posture is reinforced over the years by daily sitting in a slump, standing and walking with bums tucked…and horror of horror exercising that way.

You might ask…”but isn’t it good to sort of tuck your bum to you know…make it disappear?” Or “My mother (or insert other primary influence here: trainer, PT, Jane Fonda, pamphlet at the doctors office, etc) told me to tuck under for better form and/or posture. What gives?”. This exercise norm of days past is now a no-no. Just as full sit-ups gave way to crunches, and now crunches are moving aside for planks, research is evolving.

Join the evolution! Here are five reasons not to tuck your bum during exercise (or ever):

1. A tucked under bum reduces the action of the pelvic floor. Studies have shown us that  the pelvic floor is least active when bums are tucked when compared to postural alignment that is untucked (Neutral pelvic tilt).  The result: a less active pelvic floor while exercising will lead to leaks with exertion and can contribute to hip and back aches during exercise.

2. If you run with bum tucked under, it keeps the “engine” for your run, forward in your quads. The result: a running style that is quad dominant. This results in an up/down bouncy cadence creating high impact as each foot hits the ground. The added impact of running up and down and the lack of balanced muscle action around the joints can lead to knee and foot pain.

3. A tucked under bum running posture and quad dominance, also means you cannot stride out behind you and use the gluts to power walking/running. The result: No glut support for hips and backs during running. When gluteus maximus engages,there is an upward lift of the pelvic floor. So no gluts also means no pelvic floor. No g(l)uts, no glory.

4. Bum tucked under is the most open position of the SI joint; where the pelvis connects to the spine. The result: A sustained bum tucked under position leaves this joint susceptible to irritation, particularly with impact activities including walking, running, jump rope, or simply stepping off a curb wrong. Combine a more vulnerable position of the SI with reduced pelvic floor activity (#1) and you have a recipe for low back disaster waiting to happen.

5. When you tuck your bum, you also flatten your low back. The result: a loss of the shock absorption capacity of the curves in the spine. When the low back curve disappears the discs and joints are susceptible to the wear and tear of repeat impact.

So how do you know if this is you? Here is your junkless trunk checklist:

• Can you fill your jeans up in the rear like you used to?
• When you squat down do you get that underwear revealing gap between your waistband and low back (it’s not just the cut of the jeans ladies)
• Do you have low back, hip, knee or SI pain that gets worse with exercise?
• Do you leak while you exercise?

Sound familiar??

Tucked – No Junk	Untucked – Full on Junk

Time to untuck that bum!  A visual image often used to enhance posture is of a string that pulls us up through the top of the head to help us get into the right alignment. Instead imagine the string is tied to the top of your bum. Pull it gently to the sky, recreating a soft curve in your low back. This promotes what is called a neutral pelvic position which is the optimum alignment for pelvic floor and gluteal function. Sitting, standing, and exercising with a neutral tilt will reduce your vulnerability to injury and promote a better result from your fitness program. And best of all-your “trunk” will look great in those jeans again!

The following is a summary of a more formal case study (submitted for future publication) of the response of a 12-year-old boy, Michael (name changed for privacy), had to the Dynamic Core for Kids approach. Co-created with Shelley Mannell, this pediatric application of the core program developed for adults, integrates the pelvic floor and diaphragm into core rehabilitation and fitness programs.  These photos actually capture his progress better than our words! His response was exciting and we are seeing a similar response in kids and adults with a variety of diagnoses.

Case Study of a 12 year old male with Cerebral Palsy:

Initial Presentation:

Michael had a stroke at birth that primarily impacted his right arm and leg, causing them to be weak and tight (spastic). His trunk was very weak and he experienced compensatory left-sided arm and leg deficits as well. The resulting postural weakness (see photos below) made it difficult for him to sit still for longer than 10 minutes. In addition, he had trouble keeping his eyes at the horizon resulting in an elevated gaze. This made social eye contact, and visual demands of reading the chalkboard at school challenging. Michael had difficulty maintaining balance when moving from sitting to standing and had falls due to poor balance in walking. His primary resource for creating stability at his center for seated and standing postures and to help with movements was to hold his breath.

Intervention:

We utilized a holistic approach to restore his core function. The adult physical therapy literature has demonstrated that the components of the inner core (Diaphragm, Transversus Abdominis, Pelvic Floor, and Multifidus) all become more active automatically in a neutral alignment of the pelvis and the ribcage. Thus, we initially focused on creating a core-optimizing alignment through the use of pillows, wedges and towels. In these core-optimizing positions, we helped Michael access his inner-core components through the use of blow toys to stimulate his diaphragm. The diaphragm has been shown to elicit a response for the other elements of the inner core. Michael was encouraged to use the mantra “Blow before you go” to elicit core support for his posture before each repetition of his therapeutic activities, each transitional movement, and as he participated in play. Following this training approach, his core strengthened and began to hold his alignment without the need of additional propping from seating aides. The improved alignment improved the activation of his core during daily activity, school work, and play. (Michael does use a wedge at school to improve his tolerance for full day activity).

Results:

As seen in the series of seated photos, Michael made a significant improvement in maintaining a more neutral postural alignment both with and without seating support.  Michael now sits independently for school work without time limitations.  Improved posture also resulted in a significant change in his eye gaze positioning, which has the potential to positively impact both social interaction and school work success. His seated alignment facilitates his ability to rise from sitting to standing without using his arms. Similar development is evident in the standing photos. His parents noted that Michael displayed improved standing balance.

Treatment was provided over a series of weekly 1 hour sessions for 2 months to address sitting posture.

September 2009                   November 2009                November 2009

Treatment was subsequently provided for another series of weekly 1 hour sessions for 2 months to address standing posture.

September 2009        Treatment Jan- March 2010

>

Conclusion:

This case illustrates the possibilities for improved postural control and movement capacity in a child with CP using the Dynamic Core for Kids approach.

For more detailed description of the study please see Shelley Mannell’s blog at www.heartspacept.com. For more information on the clinical approach please see http://interiorfitness.com/services/for-pros/ . Photographs used with permission.

Bibliography

Claus AP, Hides JA, Moseley GL, Hodges PW. 2009. “Different ways to balance the spine: subtle changes in sagittal spinal curves affect regional muscle activity.” Spine 34(6): E208-14.

Hodges PW, Butler JE, McKenzie DK, and Gandevia SC. 1997. “Contraction of the human diaphragm during rapid postural adjustments.” The Journal Of Physiology 505 (Pt 2): 539-548.

Hodges PW and Gandevia SC. 2000. “Changes in intra-abdominal pressure during postural and respiratory activation of the human diaphragm.” The Journal of Applied Physiology 89: 967-976.

Hodges PW, Sapsford R, and Pengel LH. 2007. “Postural and respiratory functions of the pelvic floor muscles.” Neurourology And Urodynamics 26, no. 3: 362-37

Liu WY, Zaino CA, McCoy SW. 2007.  Anticipatory postural adjustments in children with cerebral palsy and children with typical development.  Pediatric  Physical Therapy 19(3): 188-95.

Sapsford RR, Richardson CA, Maher CF, and Hodges PW. 2008. “Pelvic floor muscle activity in different sitting postures in continent and incontinent women.” Archives of Physical Medicine & Rehabilitation 89, no. 9: 1741-1747.

Van der Heide JC, Begeer C, Otten B et all. 2004.  Postural control during reaching in preterm children with cerebral palsy.  Developmental Medicine and Child Neurology 46: 253 – 266.

My Father-in-law’s favorite joke is to lift his arm only to shoulder level and say “Hey doc! I can only lift my arm this high.” Then as he raises his arm to straight overhead, he says “But I used to be able to lift it this high.”

After ruling out the need for a psyche consult, a doctor would likely send a patient with a shoulder issue to see a physical therapist. Shoulder problems come in many forms. Regardless of the cause, in order to fully rehabilitate a shoulder, the pelvic floor needs to be a part of the rehab plan.

Pardon me? Psyche consults all around!

You can’t address a shoulder problem without addressing joint alignment, and shoulder joint alignment relies on postural alignment. Postural alignment needs a strong Core, and you can’t have a strong Core without a strong pelvic floor. Cancel that consult!

In 2007, a research team lead by Paul Hodges (1) compared how the pelvic floor and shoulder muscles interacted when a study participant lifted their arm in different directions. One of the things they observed was that the pelvic floor engaged before the arm lifting deltoid muscle every time, no matter which direction the arm went. In a nutshell, the pelvic floor, along with the other inner Core components (Diaphragm, Transverse Abdominis, and Multifidus), secure our physical center to create a sturdy anchor for the muscles that support and create shoulder motion before we start moving our arm, every time we move our arm, no matter which way we move our arm.

A paraphrased “Dem bones, dem bones, dem dry bones” ditty highlights this relationship with an anatomy lesson that works from the outside-in. The shoulder bone’s connected to the shoulder blade  The shoulder blade’s connected to the ribcage. The ribcage’s connected to the spine, and the spine’s connected to the pelvis. Muscles help make all of those connections. However, Hodges research demonstrated that the timing of the muscular connections should follow the pattern of the pelvic floor first, securing the pelvis before all other muscle work begins. So we have to reverse the “dry bones” anatomy lesson and move from the inside-out. Secure the pelvis first with our pelvic floor then rehabilitate and train the muscular and structural chain back out to the shoulder. Who’s crazy now??

The pelvic floor’s claim to fame is its role in keeping us from leaking, and it gets a lot of press for providing better sex. However, It is also a powerful ally in the health of our musculoskeletal system. I have highlighted the particular relationship it has with shoulder motion here-if the pelvic floor isn’t working well then the shoulder won’t work well either. The pelvic floor also works in the same way with other body parts- hips, knees, necks, etc. to optimize the function.

So what is a woman who has had a few kids and has a few leaks when she coughs or laughs  to do about her achey shoulder? Start by understanding how the two issues, leaking and achy shoulders, are connected. Also, know that when you go to the doctor to talk to him/her about what are historically perceived as two separate issues- you too may be considered a nut job!  Hand them a copy of this blog with the research reference below. Then ask for an Rx for a physical therapist in your area who can help you from the inside-out!

1. Hodges PW, Sapsford R, and Pengel LH. 2007. “Postural and respiratory functions of the pelvic floor muscles.” Neurourology And Urodynamics 26, no. 3: 362-371

Our current definition of the Core is well…ill-defined. I know I have beaten this drum before, but in magazine articles, blogs, internet resources, even research articles, different muscles are included in the “Core” depending on who you read. I even hesitate to use the word because it means something different to each rehab practitioner, and fitness professional (or client) I talk with. Each of us thinks we are doing “Core” work with our patients and clients, but how can we be sure if our starting definitions are so vastly different.

Do we simply agree to disagree? Does this serve the people in our care? Or could we all take a step back and reconsider our understanding of the Core. I will take the first kick at the can on a new perspective of the Core and how to train it.

No matter which muscles we include in our definition, I think we can all agree on the BASIC purpose of the Core, which is to create a strong postural center and maintain central postural control within movements. Our physical center must be a stable, controlled anchor so that muscles that perform movements have something sturdy to pull against. This reduces stresses on spinal and pelvic joints, rather than have them yanked about by exterior forces. A strong center promotes better day to day posture and less achy back and neck muscles. Also, the prepared postural center sets the body up for better performance/efficiency of the shoulders and hips, and of course, the added bonus of a flat belly!

However, HOW the Core achieves this ultimate purpose is where the water gets muddy.

It is easy to understand the inclusion of large postural muscles in a definition of Core. If the ultimate purpose is a stable, controlled postural center, then muscles that assist with posture make sense. So we can throw in Lats, Obliques, Rectus Abdominis, Erector Spinae, Glutes, etc. (often referred to as the outer Core). Looking at the purpose of the Core, these muscles DO promote ongoing postural control during physical action, but they do not activate first to create a central stable anchor prior to movement to insure control and improved performance. They can become those naughty external yanks on an un-prepared, unstable spine and pelvis.

In fact, we have multiple studies that have shown that in a simple arm movement the four muscles often referred to as the inner Core unit – Diaphragm, Transversus Abdominis, Pelvic Floor, and Multifidus -  activate before the shoulder muscles that create the movement. These four are the only muscles in the trunk that have the unique capacity to create preparatory or anticipatory contractions in a consistent way to control the center before movement begins. In the same studies, the other postural muscles or outer Core reacted in a different pattern depending on which direction the arm was moved, and they switched on after the inner Core components.  Meaning the outer Core also relied on the inner Core to set up a sturdy anchor, so they could do their job of  reactive postural adjustments within the arm movement. The action of both sets of Core muscles are intertwined for the achievement of efficient, effective movements.

So, can this lead us to an inclusive definition for the Core that is win-win for all the Core camps? How’s about the classifying things as the Anticipatory Core and Reactive Core*.  Both groups of muscles need to be trained in order to create a strong postural center and postural control within ongoing movement patterns. However, because they have different roles in achieving that purpose we must train them differently, but in relationship to one another in order to maximize patient and client outcomes.

Core camps unite! Do your Core training programs ensure the Anticipatory and Reactive Core work together within each exercise? Is a plank a true Core exercise if the patient/client holds their breath to create an anticipatory stabilization, so they can pull it off? Is exercise on the stability ball Core work if clients are seated in a hunch reducing reactive postural muscle function?

I have now officially kicked the can, your turn! Please weigh in below.

*I must give credit for these terms to Carolina Stock, OT. She put a name to the concepts of inner and outer Core interplay in a conversation we had at the Core Restoration in Kids class I taught a few weeks ago. I loved it so much, it inspired a blog!

My Father-in-law’s favorite joke is to lift his arm only to shoulder level and say “Hey doc! I can only lift my arm this high.” Then as he raises his arm to straight overhead, he says “But I used to be able to lift it this high.”

After ruling out the need for a psyche consult, a doctor would likely send a patient with a shoulder issue to see a physical therapist. Shoulder problems come in many forms. Regardless of the cause, in order to fully rehabilitate a shoulder, the pelvic floor needs to be a part of the rehab plan.

Pardon me? Psyche consults all around!

You can’t address a shoulder problem without addressing joint alignment, and shoulder joint alignment relies on postural alignment. Postural alignment needs a strong Core, and you can’t have a strong Core without a strong pelvic floor. Cancel that consult!

In 2007, a research team lead by Paul Hodges (1) compared how the pelvic floor and shoulder muscles interacted when a study participant lifted their arm in different directions. One of the things they observed was that the pelvic floor engaged before the arm lifting deltoid muscle every time, no matter which direction the arm went. In a nutshell, the pelvic floor, along with the other inner Core components (Diaphragm, Transverse Abdominis, and Multifidus), secure our physical center to create a sturdy anchor for the muscles that support and create shoulder motion before we start moving our arm, every time we move our arm, no matter which way we move our arm.

A paraphrased “Dem bones, dem bones, dem dry bones” ditty highlights this relationship with an anatomy lesson that works from the outside-in. The shoulder bone’s connected to the shoulder blade  The shoulder blade’s connected to the ribcage. The ribcage’s connected to the spine, and the spine’s connected to the pelvis. Muscles help make all of those connections. However, Hodges research demonstrated that the timing of the muscular connections should follow the pattern of the pelvic floor first, securing the pelvis before all other muscle work begins. So we have to reverse the “dry bones” anatomy lesson and move from the inside-out. Secure the pelvis first with our pelvic floor then rehabilitate and train the muscular and structural chain back out to the shoulder. Who’s crazy now??

The pelvic floor’s claim to fame is its role in keeping us from leaking, and it gets a lot of press for providing better sex. However, It is also a powerful ally in the health of our musculoskeletal system. I have highlighted the particular relationship it has with shoulder motion here-if the pelvic floor isn’t working well then the shoulder won’t work well either. The pelvic floor also works in the same way with other body parts- hips, knees, necks, etc. to optimize the function.

So what is a woman who has had a few kids and has a few leaks when she coughs or laughs  to do about her achey shoulder? Start by understanding how the two issues, leaking and achy shoulders, are connected. Also, know that when you go to the doctor to talk to him/her about what are historically perceived as two separate issues- you too may be considered a nut job!  Hand them a copy of this blog with the research reference below. Then ask for an Rx for a physical therapist in your area who can help you from the inside-out!

1. Hodges PW, Sapsford R, and Pengel LH. 2007. “Postural and respiratory functions of the pelvic floor muscles.” Neurourology And Urodynamics 26, no. 3: 362-371