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Core and the Pelvic Floor

There are only two reactions to “core exercises” – either you LOVE them or you HATE them. The muscles that are commonly referred to as the “core” are the front abdominal muscles – the rectus abdominis (6-pack), transverse abdominis, and obliques. They’re what everyone wants, but are incredibly hard to achieve without a strict and clean diet…or an incredibly high metabolism. What’s not commonly thought of as the “core” though, are the OTHER muscles and structures that make it up. The core is made up of your respiratory diaphragm at the apex of the abdomen, the abdominal muscles in the front, the lumbar paraspinal muscles in the back, and the pelvic floor muscles at the base. These groups together help keep your body strong and stable, as well as performing other duties we won’t touch on here. And these muscle groups can be exercised in a myriad of ways – both the traditional “core” exercises (such as crunches) and not so commonly thought of exercises (such as squats). What I seek to do with this blog is hit on 4 commonly performed exercises that strengthen the core and how they impact the pelvic floor. These exercises are: low front planks, sit-ups (butterfly), bird dog, and squats.

Low Front Plank

The plank is great for activating the spinal muscles as well as the abdominal muscles. However, is an exercise that brings to mind a “NEVER do that” connotation. Many believe that due to the impact this exercise can have on the pelvic floor, it’s an exercise that should NEVER be done. But I don’t believe that are true “nevers” in life. Planks can really help wake up the abdomen – whether used as a warm-up or a strengthener. To say you can “never again” do a plank is ridiculous. But at the same time, jumping into a 5 minute plank 2 weeks postpartum is also ridiculous. It’s something that needs to be consistently performed and increased at a safe progression.

The reason the pelvic floor can be affected is because of possible pressure created on it while in the plank position. If your abdomen and low back isn’t taking the brunt of the demand, then your pelvic floor may take on more of that work. So, rather than jumping straight into an “as long as possible” plank, maybe do short intervals first – making sure the pelvis is tucked and there isn’t sag in the low back. Then progress from there!

Sit-Ups

This is what first comes to mind when trying to predict what others will think of when considering “core” exercises. What I think of first when I consider a sit-up in a workout is “why do I want to add a sit-up in?” If it’s because I want them to get better at sit-ups or because they have a sit-up test coming in the future, then I’ll likely throw it in there. If it’s because I want them to feel like they’re really moving, but also be able to slow down the amount of movement, then I’ll likely throw them in there. If the reason is because I want to do core work, I might choose another exercise that will bank in on more muscle groups at the same time.

The sit up will target specifically the abdominal muscles – and possible the hip flexors depending on how you’re set up in this movement. It doesn’t really activate the low back or the pelvic floor as much – meaning it won’t assist in co-contracting different muscle groups. Because of the increase in intra-abdominal pressure, it also means that if you’re not strong enough for this exercise it will put more pressure on the pelvic floor. If the pelvic floor (like with the plank) isn’t ready for that demand, then it’ll cause issues (either in incontinence or eventual pain).

There’s some concern with diastasis recti with sit-ups. With a diastasis recti, there’s a split in the rectus abdominis muscle – what is traditionally considered the “6-pack muscles.” This occurs in 100% of women in the 3rd Trimester, due to the amount of space required for the growing fetus. However, in most women it either resolves completely or is asymptomatic. Diastasis remains in 32-46% of women, causing pelvic floor dysfunction or low back pain. However, what we’re looking at when deciding on if sit-ups are appropriate is the absence or presence of that pelvic floor dysfunction or low back pain. In the absence of low back pain/pelvic floor dysfunction, with a baseline strength, and with having a benefit to performing sit-ups, then get it!

Bird Dogs

Bird dogs is one of my favorite exercises for “core” – it encompasses so many parts. It challenges balance, it challenges the abdominal muscles, it challenges the low back muscles. It’s versatile, you can add so many things to it – from combining bands to weights to increasing hold times. You can add pelvic floor contractions with it, and add pelvic floor relaxation to it. Like I said, it’s incredibly versatile!

The biggest benefit there is to adding a bird dog in, whether as a warm-up to ensure the low back and abdominal muscles are firing well before getting into movement, or as part of a core-circuit, is that it enhances co-contraction behaviors in the muscles. This muscular co-contraction means everything is going to work and move together better. With the core being made up of specifically 3 different muscle groups – this is vastly important when considering a “core” workout.

Squats

Squats are likely the least-thought of core-exercise. However, studies show that squats – especially heavy squats – increase the activation of low back muscles (especially the lower portion of the back). And that activation of the trunk musculature on heavy squats, creating a ballooning effect, can increase the stability within the squat. However, now that we’re getting into heavy squats and the intra-abdominal pressure pattern for heavy squats – it’s a great time to talk about what happens to the pelvic floor with this activity.

When the breath is held in the lungs, the diaphragm is kept in a descending position. Because of its relationship to the pelvic floor, that means the pelvic floor is held in a stretched position throughout the movement. Like any other muscle group, if it’s held in a stretched position it has a harder time contracting and assisting to hold up. Meaning that incontinence within this movement is likely – or pressure creating prolapse – due to the forces on the pelvic floor. Does this mean it will definitely happen to you? NO! But like everything else in this blog post, you have to train for that. You can’t move from squatting 105# to squatting 300# and not expect things to fail out on you or at the very least to have some sort of issue. It also means that you need to train specific motions within the squat to keep your pelvic floor from failing (which in itself would be a separate blog post).

SO! We’ve gone through the 4 core-muscle strengthening exercises that I chose. What do you do with this information now? Use it! Plan your programming with your core in mind – plan your patient’s exercises with the core in mind. What the core actually does, what muscles actually make it up, how it works in conjunction with other muscles, and the multiple ways that the core can be challenged. A body goes through a myriad of movements throughout the day – and most of the time they aren’t the exact same movement. Meaning you, your patient, your athlete – their life is variable, and as such – their exercises need to include variability!

References:

Gluppe, S., Hilde, G., Tennfjord, M., Engh, M., Bo, K. Diastasis Recti Abdominis in Postpartum Primiparous Women: A Randomized Controlled Trial. Phys Ther, 2018; 98 (4): 260-268

Ko, M., Song, C. Comparison of the effects of different core exercises on muscle activity and thickness in healthy young adults. Phys Ther Rehabil Sci; 2018, 7(2), 72- 77

Tillaar, T., Saeterbakken, A. Comparison of Core Muscle Activation Between a Prone Bridge and 6-RM Back Squats. Journal of Human Kinetics, 2018; 62, 43-53

Olsson, A., Kiwanuka, O., Wilhelmsson, S., Sandblom, G., Stackelberg, O. Cohort study of the effect of surgical repair of symptomatic diastasis recti abdominis on abdominal trunk function and quality of life. BJS Open, 2019; 3: 750-758

Garcia-Waquero, M., Moreside, J., Brotons-Gil, E., Peco-Gonzalez, M., Vera-Garcia, F. Trunk muscle activation during stabilization exercises with single and double leg support. Journal of Electromyography and Kinesiology, 2012, doi: 10.1016/j.jelekin.2012.02.017

Hamlyn, N., Behm, D., Young, W. Trunk muscle activation during dynamic weight-training exercises and isometric instability activities. Journal of Strength and Conditioning Research, 2007; 21(4): 1108-1112

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Shoulder Impingement Part 3: Addressing Shoulder Stability

In the first two parts of this shoulder impingement series, we reviewed shoulder impingement pathology and how to address mobility restrictions commonly seen with this condition. As you may recall from the first post, shoulder strength and stability are also potential contributors to shoulder impingement. It is not uncommon to see someone suffering from shoulder impingement who has full range of motion and great mobility but lack the strength to support the motion, especially when under load (like overhead pressing). This inability to adequately support the shoulder can contribute to mechanical changes within the joint and surrounding tissue which can then lead to injury. In this article we will go over some exercises and drills for common stability issues that may contribute to shoulder impingement.

Posterior Shoulder Strength:
It’s common to see an imbalance between the front (anterior) and back (posterior) shoulder muscles. Strengthening the back deep rotator cuff and scapula muscles can reduce this imbalance and improve general shoulder mechanics. Below are some of our favorites. Other common gym exercises to work on posterior shoulder strength include reverse flies, face pulls, pull-a-parts, and high rows.

Load Bearing Stability/Balance:
Being able to train the shoulder under load is important to return to sports and overhead weighted activities. Oftentimes, strict overhead pressing is painful for those with shoulder impingement. Fortunately, there are different ways to load the shoulder and provide a similar strengthening stimulus. Loading the shoulder and pressing also engage the serratus anterior muscle, an important scapula muscle. The video below shows some examples of loading the shoulder and activating your serratus anterior using your body weight, kettlebell, or barbell.

Chaos:
One important function of the rotator cuff muscles is to help stabilize the ball in the socket. A great way to train these muscles and challenge the shoulder is by increasing instability (“chaos”) through the use of bands and hanging weights. These exercises also often let those with pain under heavier loads to complete an exercise with less weight but still be greatly challenged. Below are some of the ones we like to use in the clinic. Be careful though as they are generally more challenging than they look!

Kettlebell Carries:
What’s more functional than carrying weight around? Not much. And certain kettlebell carries are great for strengthening the posterior shoulder, upper back, and rotator cuff muscles. Below are a couple variations you can try with kettlebells. You can get a similar effect by using dumbbells, barbell, or sandbags.

Not everyone will have similar benefit to each exercise as each person has different strength and stability limitations. For example, one person may have a large imbalance between the anterior and posterior shoulder muscles and may benefit more from focusing on those posterior muscles. Someone else could have great overall strength but have issues with keeping a good overhead press position. This person may benefit more from overhead carries and chaos exercises. Unfortunately, it’s challenging to tease out specifically what you need. If you find yourself unable to do so, I recommend seeing a physical therapist who can further evaluate and identify areas of weakness.

If you feel you have some shoulder weakness and dealing with shoulder pain, I hope this post has been useful. Please reach out if you have any questions!

Pat
pat.casey@vertexpt.com

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Shoulder Impingement Part 2: Addressing Mobility Impairments

In the first part of this shoulder impingement series, we reviewed the anatomy and mechanics behind it and possible contributors to this movement dysfunction, to include mobility restrictions. “Mobility” here is defined as the body’s ability to move through a joint’s intended range of motion. For example, knee mobility includes the ability to completely lock out the knee. An inability to do so would be considered a mobility restriction or impairment. Such restrictions can be due to limited muscular flexibility, joint capsule extensibility, altered joint structure/mechanics, postural limitations, or a combination of all the above. In this article we will go over some exercises and drills for common mobility restrictions that may contribute to shoulder impingement.

Pectoralis Major/Minor Tightness:

The way the pec muscles sit across the chest and attach to the upper humerus (pec major) and scapula (pec minor) can impact overall shoulder position, decreasing the available sub-acromion space. Decreased space here provides less “room to breathe” as we raise our arms past shoulder height. Check these out to help improve pec major and pec minor flexibility.

Latissimus Dorsi Tightness:

Although the lats are a “back” muscle, the muscle actually attaches towards the front part of the upper humerus. Therefore, along with restricted pecs, it can also pull the shoulder forward and decrease the available space. Here are few options to improve lat flexibility.

Thoracic Extension Restriction:

In Part 1 we discussed how the shoulder complex includes how the shoulder blade glides along the rib cage. The shoulder blade’s ability to do so partially depends on the thoracic spine’s ability to extend (bend upright/back). We oftentimes see patients and clients with more of a flexed forward posture and “stiff” going back. Here are a few of my favorites to improve thoracic extension.

Limited Shoulder Internal Rotation:

Internal rotation is the ability to rotate your hand towards your stomach or reaching for your back pocket. It can also indicate limited extensibility of the posterior (back) shoulder capsule. Restrictions can theoretically push the ball of the ball-and-socket joint forward, possibly creating irritation to the front shoulder structures. Here are some of our favorites to address this restriction.

Limited Shoulder External Rotation:

External rotation is the ability to rotate your hand out or cocking back as if throwing a ball. It is also responsible for being able to point your armpits forward and keeping elbows in when pressing overhead. Limited external rotation results in overhead movement dysfunction that can lead to shoulder impingement symptoms. Below are some exercises to work on this.

Everyone is unique, and not everyone will need the same flexibility exercises and mobility drills. If you feel you are “stiff” in an area or two, try out the associated exercises in the videos above and see how it feels. One way to assess if an exercise is beneficial is simply by testing and retesting a potential painful or “stiff” movement: try the movement (ex: overhead pressing), complete mobility work to address the restriction (ex: thoracic extension drills), then retest the movement. If the movement feels better, then it may be worth working on further.

If you feel you are restricted and dealing with some shoulder pain, I hope this post has been useful. The next part of this series will be geared towards shoulder strength and stability. Stay tuned!

Pat

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