Over the next few weeks/months I will be sharing, some highlights, questions, insights and comments generated by the group and my responses. You, too, can join the conversation by weighing in here on my blog, and following the links to the blogs of others, Linked In, Facebook, etc. Don’t be shy!

One question really started it all.

Antony Lo (@physiodetective) posed this question on twitter:

What specific conditions do you think need specialist Women’s Health care?

My twitter response: I think the answer [to] that can’t be a formula and I think if we can change how we address MSK [musculoskeletal] & pelvic floor and treat them together from the get go then women wouldn’t end up [with] the really awful stuff that internal [physios] have to sort thru. When I give courses I equate it to a drafty window that eventually turns into a huge reno project [because] the true issue wasn’t addressed early. Let’s normalize the pelvic floor, integrate it early in MSK and see if we can avoid the major reno projects internal therapists are seeing. Your thoughts?

Antony followed up with a  great blog on the subject! He discussed the pelvic floor as the primary or  secondary (“the victim”) source or manifestation of dysfunction.

My blog response (partial):

I liked how you distinguished between the primary pelvic floor vs secondary pelvic floor manifestation of a global dysfunction. I am very clear with folks [that I treat] when I think their symptoms are a primary pelvic floor issue what their options for treatment are, and that we should see fast results if I have the right skill set for them. If the results aren’t happening then we need to collaborate with an internal therapist.

While I like the distinction you made, I also see the secondary pelvic floor issues as well, primary. This is due to the critical role of the pelvic floor in rebalancing how our movement system functions as a whole, not just as it relates to a typical women’s health type diagnosis. I also consider even some of the primary pelvic floor issues (true pathophysiology) as more global issues. Even a PF tear or damage say due to a delivery should ultimately have a global or systems solution b/c the pregnancy contributed to creating dysfunction in the relationship of the PF to the rest of the musculoskeletal system and in the woman’s alignment in the first place.

I don’t have a cool graphic like Diane Lee’s rubric ( I too, am a huge fan of hers!), but I have a few additional things I look at and address with my patients before referring them on or even giving manual care. Specifically I integrate the pelvic floor back in with the rest of the neuromuscular system, and the IAP pressure system. I train it as a foundational component of an inside-out force production in movement patterns and functional activities with optimized alignment. This addresses both the secondary and primary issues with a whole body solution. I start there for ALL diagnoses whether they are primary or secondary pelvic floor issues – jaws, knees, incontinence, prolapse, even shoulders (see a blog on that here http://bit.ly/bWQWdG).  And as you said if the results aren’t happening fast I am missing something or it is time for a different set of skills and eyes.

As your previous blog stated…we all need to move more toward the center…women’s health and musculoskeletal. Integration, integration, integration!!

The conversation then moved to Linked In where physiotherapists, chiropractors, and osteopaths from Australia, Canada and the US weighed in. So grab a cup of coffee, check it out and join the #pelvicmafia!

Stay tuned for more great highlights coming soon!

“I can’t get high heels off fast enough when I have to wear them…but what about my most favorite, comfy pair of Nike ’shocks’…that have a bit of a heel in the ’shock’ part meant for running. Is that gonna mess with my tendon? I kinda like that it helps me stay on the balls of my feet, where flip flops/flats keep my weight on my heels (which probably messes with my posture?) Just curious about other shoes other than extreme heels…”  Sydney

Thanks for the question, Sydney.

I think one of the take aways from the study is that these ladies wore heels…A LOT. They embedded that muscular pattern with heavy heel use, so that even when the heels came off the muscular pattern remained. The “normals/controls” absolutely have occasionally worn heels in their history, they’re chicks. So wearing them occasionally won’t create that same kind of muscular adaption. Same goes for your shoes (Nike Shocks). You should mix up your shoewear, so that no one way of using your muscles develops (like the frequent heel wearers).

Here’s the other reality check-saying you can’t ever where heels is unrealistic! We all have the occasional red carpet to walk, bridesmaid outfit to don, etc. So the key in whatever shoe you choose- Nike Shocks or bare feet- is to be able to maintain your alignment- keep that bum untucked and ribs living over the pelvis. The slight heel in your Nike shoes has the capacity to gentle lean you out of your heels so you can keep an untucked bum, and better engagement of your pelvic floor and the rest of the core (see the video below).

But even a slight heel will pitch some folks forward enough that they over-correct with a posterior rib cage shift or tucked bum to keep their balance. So the key, in any type of footwear from flip flops to stilettos is to be aware of how you are holding your posture in them. You have to be in charge!! If you can’t hold your alignment, make a change in your footwear. But if you can hold that alignment for your big debut on the red carpet, than I say- You go girl!!

Take care- Julie

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!

2011 is off to a great start with a recent trip back to our old stomping grounds of Toronto to teach Dynamic Pelvic Floor for Core Programs to a great group of PTs, ATs and Kinesiologists. It was a great opportunity to share the concepts of an integrated, neuromuscular model for core recruitment driven by the relationship between the diaphragm and pelvic floor, not just the abs.

A physical therapist that attended the course just sent me an encouraging note about the results her patients are experiencing when she implemented the concepts into her patient programs:

“Having done orthopaedics all my life and love (treating) spinal problems, taught manual therapy courses for 15 years as well as doing a lot of acupuncture and osteopathy/canial- sacral courses, I have never seen such fast results as what we learned from you…Two young men 19 and 22 with severe back pain for 6 months to 1&1/2 years with solid disc pathology and pains of 8/10. Both of them went down to 5/10 pain after 1 treatment. They were both down to 2/10 after the second treatment.”  Cathie, PT

Next stop is Edmonton, Alberta on May 27-29, 2011 to teach a new course called Dynamic Core Across the Lifespan. This three-day course will apply the neuromuscular model to patient populations from pediatrics to geriatrics. Topics Shelley Mannell, my pediatric teaching partner, and I will be exploring include pediatric core development and dysfunction, the role of neuromuscular core dysfunction in non-contact ACL injuries in adolescent girls, musculoskeletal complaints in pregnancy and beyond and in elderly balance dysfunction. Detailed course information can be found  here: http://interiorfitness.com/events/?event_id=24 , including a link to the host. The course host Jeff Cubos,BPHE MSc, DC, FCCSS(C), CSCS is offering an early bird discount for registrations before April 17. So please pass the information on to any practitioners that you think might be interested!

All the best!

Julie Wiebe, PT

Are You Ready for Your Close-up?

Preproduction has finally begun on my new DVD. The focus will be on restoring women suffering from the aches, pains and leaks associated with all the stages motherhood to a fitness program that deliver results. We are looking for women in the Los Angeles area who are willing to share their stories and participate in the DVD. If you’d like to participate, please contact Producers Kasey McCartie at Kasey@interiorfitness.com .

The Blog:

Our program is not just for moms, everyone has a core! A 12-year-old boy with Cerebral Palsy had dynamic results. Read more. http://bit.ly/eK9626

What does your pelvic floor have to do with that shoulder problem? More than you might think. Read more. http://bit.ly/fuv1Rf

Upcoming Courses:

Professionals! Don’t be afraid of the pelvic floor. Come learn external cueing of the pelvic floor and how to integrate it into Core programs. Courses coming to a town near you!

For PT’s:
Dynamic Pelvic Floor for Core Programs: Moving Rehab Beyond TA and Kegels
March 25-26 Greater Toronto Area, Ontario: (exact location TBA)
May 29, 30 Vancouver, BC (exact location TBA, dates approximate)
Nov 6-7 Regina, Saskatchewan (Wascana Rehabilitation Centre)

For Kins/ATs/Fitness Pros:
Dynamic Pelvic Floor for Core Programs: Moving Exercise Beyond TA and Kegels
March 27-28 Greater Toronto Area, Ontario (exact location TBA)
May TBA Vancouver, BC Area: (exact location TBA)

For Pediatric Professionals (PT, OT, SLP)
Dynamic Core for Kids
May May 26, 27, 28  Vancouver, BC (exact location TBA, dates approximate)
Nov 3-5 Regina, Saskatchewan (Wascana Rehabilitation Centre, dates approximate)

For more information on the PT course please see my website: http://interiorfitness.com/events/?event_id=18

For more information on the Kin/AT course please see my website: http://interiorfitness.com/events/?event_id=19

For more information on the Pediatric course, please see my website: http://interiorfitness.com/services/for-pros/#PR

Talk Back!

Please join the conversation! Send your comments and questions to me at julie@interiorfintess.com.

All the best!

Julie Wiebe, PT