Diastasis Rectus- Navigating the Ins & Outs: Part 3

Diastasis Rectus- Navigating the Ins & Outs: Part 3 - Preventing & Treating a DRA

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Now that we know what diastasis rectus abdominis (DRA) is and the causes of DRA, it’s important to understand how DRA affects us and what we need to know before returning to the gym, studio, or running.

What can I do to prevent or heal DRA?

The movements and activities that heal a DRA are the same activities that prevent them. Here is a list of ways that may naturally prevent or heal DRA.

DNS, breathing, core exercises

1. BREATHE

   1. Creating appropriate intra-abdominal pressure (IAP) and using the diaphragm synergistically with abdominal musculature and the pelvic floor helps stabilize the body and decreases undue pressure on the abdomen that can cause DRA.

   2. It is through the breath and inhaling into all aspects of the abdomen including the lower pelvis, sides and low back that our core is stabilized. It is the stabilization with the breath and IAP and breathing into all aspects of the abdomen that creates a canister of stabilization.

   3. Another way to focus on the breath is to relax. Stop clinching your butt cheeks together, stop sucking in the abdomen and let the belly and butt relax and move freely with the breath.

1. Avoid movements that put undue stress on the abdominal musculature.

   1. This includes all exercises listed in the ineffective exercise section and it also includes any movement that causes tenting or coning of the abdomen (this is unique for each person)

   2. One thing that can cause unnecessary stress on the pelvic floor and abs is straining when you use the restroom. One way to avoid this stress is to avoid constipation. You may like to try the Squatty Potty to help ease the flow. If you are regularly constipated, please seek out medical advice.

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1. Mind your posture

   1. Neutral spine is key! We don’t want to be pulled into anterior pelvic tilt or posterior tilt as both put strain on the body in different ways.

   2. The goal is to keep your pelvic floor and your diaphragm aligned!

1. SLOW IS FAST

   1. Postpartum is forever and deserves to be respected. It’s not only OK to go slow, it is better in the long run! Going too fast too soon can actually slow down the healing process.

   2. Postpartum gives you an opportunity to slow down and allow your body to recover, rehabilitate, and rebuild.

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1. Restore your movements from childhood

   1. ALL babies are born with a DRA and it is through their normal childhood development that they naturally begin to close and close their DRA through movement.

   2. This is where Dynamic Neuromuscular Stabilization (DNS) in as it is based on ontogenesis- the natural growth & development we go through as children. We do purposeful movements that can naturally help to heal a DRA.

1. See a pelvic floor physical therapist

   1. Sometimes pain and discomfort can come from weak muscles and sometimes it comes from tight muscles. The key is knowing what you are working with so it can be treated appropriately. One great way to know what needs work is to see a women’s health physical therapist in your area!

   2. If you are in the Chicagoland area, reach out, I’d love to help!

*Disclaimer:

The information by Dr. Lauren Keller of Elemental Chiropractic, Inc. is provided for general information only and should in no way be considered as a substitute for medical advice or information about any particular condition. While every effort has been made to ensure that the information is accurate, Dr. Lauren Keller nor Elemental Chiropractic, Inc. make no warranties or representations as to its accuracy and accept no responsibility and cannot guarantee the consequences if individuals choose to rely upon these contents as their sole source of information about a condition and its rehabilitation. If you have any specific questions about any medical matter or think you may be suffering from any medical conditions, you should consult your doctor or other professional healthcare provider. You should never delay seeking medical advice, disregard medical advice, or discontinue medical treatment because of information on this website.

Diastasis Rectus- Navigating the Ins & Outs: Part 1

What is Diastasis Rectus Abdominis?

Diastasis Rectus Abdominis (DRA) is caused when the rectus abdominis muscles (two large, superficial, parallel bands of muscles commonly referred to as the 6-pack) become separated by a larger distance than normal. Diastasis recti occurs when the linea alba, a collagen structure of connective tissue, is no longer able to provide stability and appropriate tension.

In the pregnant or postpartum mom, DRA is commonly noticed when the abdominal muscles are firing in a non-optimal pattern. This is seen as “tenting” or “coning” of the abdomen that is often seen when women are going from lying down to sitting up or when exercising. Even at rest, DRA may be noticeable as it is commonly nicknamed “mummy tummy” or “mommy pooch” as even after a mom has lost the baby weight her stomach may not appear skinny due to a DRA.

How common is DRA?

According to a study, the prevalence of DRA decreased from 100% at 35 weeks gestation to 39% at 6 months postpartum.¹That means that 100% of women have some level of DRA in their third trimester. One study showed the prevalence of DRA above the umbilicus was 68% and 32% below the umbilicus. While there was no difference the DRA above the umbilicus, the DRA below the umbilicus was greater in women who had given birth more than once.⁶

It’s important to note that at 6 weeks postpartum 60% of mothers had a DRA, 45.5% at 5 months postpartum and 32.5% at 12 months postpartum.⁷ A different study showed that 36% of postpartum mom’s rectus abdominis remained abnormally wide at 5–7 weeks postpartum.¹¹

Furthermore, diastasis recti and pelvic floor problems tense to go hand-in-hand and 66% of women with a diastasis recti have some level of pelvic floor dysfunction whether it be inconinence or pelvic pain.^5,7

When can I check for a Diastasis Rectus?

Since almost all moms have some degree of abdominal separation, it is important to act as if you have a separation until at least 6 weeks postpartum. Remember, 60% of mothers have a DRA at 6 weeks postpartum and 32.5% continue to have a DRA after one year. It is safe to assume (and act/exercise as though) you have an abdominal separation until 6 months postpartum.

How do I measure for a DRA and what is normal?

Mota found that “palpation has sufficient reliability to be used in clinical practice.”² The following is how to palpate for a DRA and what is considered “normal” for a diastasis rectus abdominis.

First, lay on your back with your knees bent to a 45 degree angle with your feet resting gently on the ground. Next, make sure you are in a neutral position so your low back has a gentle curve and your butt is untucked.  Then as you exhale, gently lift your head and shoulders off the floor, tucking your chin and use your index finger and middle finger to measure based on the following palpation:

1. Location and width - there are three locations to palpate for a DRA and width is measured from side-to-side in fingertip width:¹⁰
   1. Just above the umbilicus: 2.7cm is normal (at most 2 fingertip widths)
   2. Midway between the pubic symphysis and the umbilicus: .9cm is normal
   3. Midway between the umbilicus and xyphoid process: 1.0cm
2. Depth or tension of the linea alba
   1. The linea alba is connective tissue and should be both strong and taut. There should be some natural flexibility but the tissue should resist the pressure of your fingers.
   2. If the linea alba is not able to optimally contract, you will feel as if your fingers are sinking in deeper when light fingertip pressure is applied.
   3. Depth can be measured as fingertip, knuckle or even finger depth or more specifically:
      1. Shallow: 0-3cm
      2. Medium: 3-6cm
      3. Deep: 6-7cm

*One other thing to look for as you lift your head is tenting or coning of the abdominal musculature. Although this is not specific to a diastasis rectus abdominis, it is commonly a sign that you are recruiting the wrong abdominal musculature and indicates instability that may need to be addressed.

How frequently can I check my DRA?

Not too often!  Checking too frequently can actually damage the tissue and weaken the muscles which makes the gap worse! If you “have to know” the most frequently you should check for a DRA is 4-6 weeks....give yourself time to heal from the inside out!

Keep an eye out for Diastasis Rectus- Navigating the Ins & Outs: Part 2 - The Causes of DRA

References:

1. Mota P, Pascoal AG, Carita AI, et al. Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Man Ther 2015;20:200–5.
2. Reliability of the inter-rectus distance measured by palpation. Comparison of palpation and ultrasound measurements. Mota, Patrícia et al. Manual Therapy , Volume 18 , Issue 4 , 294 - 298
3. Corrêa MC, Corrêa MD. Puerpério. In: Corrêa MD, editor. Noções práticas de obstetrícia. 12ª ed. Rio de Janeiro: Medisi; 1999. p. 95-104.
4. Gilleard WL, Brown JM. Structure and function of the abdominal muscles in primigravid subjects during pregnancy and the immediate postbirth period. Phys Ther. 1996;76(7):750-62.
5. Spitznagle TM, Leong FC, Van Dillen LR. Prevalence of diastasis recti abdominis in a urogynecological patient population. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18(3):321-8.
6. Rett, MT, Braga, MD, Bernardes, NO, & Andrade, SC. (2009). Prevalence of diastasis of the rectus abdominis muscles immediately postpartum: comparison between primiparae and multiparae. Brazilian Journal of Physical Therapy, 13(4), 275-280. Epub August 21, 2009.https://dx.doi.org/10.1590/S1413-35552009005000037
7. Sperstad JB, et al. Br J Sports Med 2016;0:1–6. doi:10.1136/bjsports-2016-096065
8. Boissonnault JS, Kotarinos KR. Diastasis recti I. In: Wilder E. ed. Obstetric andgynecologic physical therapy. New York: Churchill Livingstone, 1988:63–81.
9. Boissonnault JS, Blaschak MJ. Incidence of diastasis recti abdominis during the childbearing year. Phys Ther 1988;68:1082–6.
10. Rath, A.M., Attali, P., Dumas, J.L., et al., 1996. The abdominal linea alba: an anatomo-radiologic and biomechanical study. Surgical Radiologic Anatomy 18, 281–288.
11. Coldron, Y., Stokes, M.J., Newham, D.J., Cook, K., 2007. Postpartum characteristics of rectus abdominis on ultrasound imaging. Manual Therapy. Epub.

*Disclaimer:

The information by Dr. Lauren Keller of Elemental Chiropractic, Inc. is provided for general information only and should in no way be considered as a substitute for medical advice or information about any particular condition. While every effort has been made to ensure that the information is accurate, Dr. Lauren Keller nor Elemental Chiropractic, Inc. make no warranties or representations as to its accuracy and accept no responsibility and cannot guarantee the consequences if individuals choose to rely upon these contents as their sole source of information about a condition and its rehabilitation. If you have any specific questions about any medical matter or think you may be suffering from any medical conditions, you should consult your doctor or other professional healthcare provider. You should never delay seeking medical advice, disregard medical advice, or discontinue medical treatment because of information on this website.

The Core Muscles of Core Exercise (aka…an Anatomy Lecture)

Understanding the Anatomy of Core Exercises

The Core Muscles of Core Exercise (aka…an Anatomy Lecture)

New Years is coming up so you are probably seeing the swarm of advertisements saying “New Year, New You” or “get your body beach ready”. When we talk about core exercises it’s important to remember what exactly makes up that core. When talking about the core a lot of  people think about the fancy six-pack muscles but there’s so much more than that. So here it goes…the core is comprised of the following:

Diaphragm

• What does it attach to?Lumbar vertebra (1-3)
  • Lower 6 ribs
  • Back of sternum & xiphoid process
• Function?
  • Concentrically contracts and lowers on inhalation
  • Eccentrically contracts and rises on exhalation
  • Helps mobilize the ribs, lumbar spine and thoracic spine

Multifidus

• What does it attach to?
  • Vertebra from sacrum to skull
• Function?
  • Important role in stabilizing the joints within the spine
  • Supports and protects the spine and pelvis to prepare movement of limbs
  • Commonly inhibited in pain

Abdominal Raphe (Linea Alba & Linea Semilunaris)

• What does it attach to?
  • Runs along anterior abdominal wall connecting xiphoid with pubic symphysis and crest
  • Receives attachment of obliques and transverse abdominis
  • Extends from cartilage of 9th rib to pubic bone
• Function?
  • Mostly collagen connective tissue

Rectus Abdominis (the six-pack…actually the eight-pack, but who is counting?)

• What does it attach to?
  • Arises from pubic symphysis and runs vertical to typhoid and costocartilage of 5th and 7th ribs
  • Contained in rectus sheath (which is derived from external obliques, internal obliques and transverse abdominis)
• Function?
  • Important in forced exhalation
  • Helps with strength termination

External Obliques

• What does it attach to?
  • 5th-12th ribs
  • Connects with fibers of serrates anterior and latissimus dorsi
  • Connects to iliac crest
  • Crosses the pubic symphysis
• Function?
  • Stabilize the pubic symphysis (with anterior pelvic floor muscles)

Internal Obliques

• What does it attach to?
  • Connects to thoracolumbar fascia posteriorly (via transverse abdominis tendon)
  • Connects to anterior iliac crest and lateral inguinal ligament
  • Posterior fibers connect to 11th and 10th ribs
• Function?
  • Accessory muscle of respiration
  • Forms inguinal ligament with transverse abdominis
  • Rotates and side-bends the trunk by pulling the rib cage and midline towards the hip and lower back, of the same side with contralateral external oblique

Transverse Abdominis

• What does it attach to?
  • Connects to thoracolumbar fascia with tendon and iliac crest
  • Connects to the lower 6 ribs and lateral aspect of inguinal ligament
  • Inserts into linea alba
• Function?
  • Forms inguinal ligament with internal obliques
  • Helps support the spine and internal organs

Psoas

• What does it attach to?
  • All lumbar vertebra bilaterally
  • Lateral edges of vertebra from T12-L4 (and intervertebral discs!)
  • Lesser trochanter of femur
• Function?
  • Stress response shortens the psoas
  • Affects structural balance
    • Commonly seen in an anteriorly tilted pelvis and/or rib thrusting

Pelvic Floor

• Function?
  • During breathing, raises and lowers synergistically with the diaphragm
  • Works to control the spine and pelvis by offering support for abdominal and pelvic organs
  • Supports the urethral and anal sphincters (what you pee and poop out of)

Superficial Pelvic Floor

• Composed of bulbocavernosus, ischiocavernosus, superficial transverse perineal, external anal sphincter
• Function?
  • In women, it contributes to clitoral erection and orgasm
  • Helps empty the canal of the urethra

Deep Urogenital Diaphragm Layer

• Composed of deep transverse perineal
• Function? Supports central tendon of perineum through perineal body

Pelvic diaphragm

• Composed of levator ani (pubocococcygeus, iliococcygeus, coccygeus), piriformis, obturator internus
• Function?
  • Support pelvic viscera
  • Closes back part of pelvic outlet
  • Keeps vagina and rectum closed
  • Facilitates birth

Up Next? Learn about the The Hows and Whys to Working that Sexy Core!

Dysfunctional Breathing: The Whys

Dysfunctional Breathing

“Breathing becomes dysfunctional when the person is unable to breathe efficiently or when breathing is inappropriate, unhelpful or inefficient in responding to environmental conditions and the changing needs of the individual.” (4)  Dysfunctional breathing and it's effects can be found:

• For the love of all things good, stop sucking in
• Must I pee when I sneeze?
• Understanding the Different Breathing Options

BUT WHY?

But one thing in health that is sometimes over-looked is the why. Why do we have dysfunctional breathing or what are the causes? There are three main causes of dysfunctional breathing:

1. Developmental Adaptations

During the first year of life, our bodies should go through an ideal developmental pattern that helps create a stabilization system and helps form posture. Two studies (Vjota and Prechtl) both indicated that 69.7-72% of children develop normally while ~30% have abnormal development. (5) 

This is one reason developmental kinesiology and the work of Dynamic Neuromuscular Stabilization (DNS) are important. Both address the ideal developmental pattern that can be adapted as an adult for the 30% of the population that may not have developed a strong stabilizing system in infancy.

2. Physiological / Medical

Hyperinflation of the lungs causes air to get trapped in the lungs. This hyperinfalation, often seen in COPD, asthma or emphysema and severe pneumonia, and congestive heart failure causes the diaphragm to shorten and lose its power and efficiency. (3)

In 2001, Hodges et al stated that the coordinating function between the diaphragm and transverse abdominis are frequently reduced in respiratory disease. (2) When the diaphragm contracts it is unable to properly lift and expand the lower ribcage and instead the lower ribs are pulled inward during inspiration creating what's called a Hoover's sign.

2. Emotional / Psychological

Both psychological and emotional stress can alter the diaphragm’s control. Dysfunctional breathing has been shown to be present in 11% of the normal population, 30% of asthma sufferers and 83% in people suffering from anxiety. (4) It has been reported that voluntary breath modulation accounts for 40% of the variance in positive feelings such as joy and negative feelings such as fear, sadness and anger (7).

In 2001, Umezawa found that breathing modification is the most common self-regulation strategy for relaxation and stress management. (6) Chaitow stated that in “Overbreathing: A Mind-Body Vicious Circle” that over-breathing and anxiety go hand-in-hand as anxiety increases the sympathetic system which causes an increase in breathing rate which leads to excessive carbon dioxide loss and in the end lead to a decreased pain threshold and more anxiety and overbreathing. (9) In 2010, Meuret stated that reducing hyperventilation “has emerged as a potent mediator for reductions in panic symptom severity and treatment success.” (8) Furthermore, studies have shown that conscious control of ones breathing can improve anxiety, depression and panic disorders. (11)

References

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2546439/
2. Hodges et al. Postural activity of the diaphragm is reduced in humans when respiratory demand increases. J. Physiol. 2001 Dec 15; 537(Pt3): 999-1008. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2278995/)
3. Hoover CF. The diagnostic significance of inspiratory movements of the costal margin. J Am Clin Sci 1920: 633-46
4. Courtney R. The function of breathing and its dysfunctions and their relationship to breathing therapy. Int J of Osteo Med. 2009;12:78-8
5. H. F. R. Prechtl and B. Hopkins, “Developmental transformations of spontaneous movements in early infants,” Early Human Development, vol. 14, no. 3-4, pp. 233–238, 1986.
6. Umezawa A. (2001) Facilitation and Inhibition of Breathing During Changes in Emotion. In: Haruki Y., Homma I., Umezawa A., Masaoka Y. (eds) Respiration and Emotion. Springer, Tokyo
7. Respiratory feedback in the generation of emotion. Pierre Philippot, Gaëtane Chapelle & Sylvie Blairy. Cognition and Emotion. Vol. 16, lss. 5, 2002.
8. Meuret AE, Ritz T. Hyperventilation in Panic Disorder and Asthma: Empirical Evidence and Clinical Strategies. International journal of psychophysiology : official journal of the International Organization of Psychophysiology. 2010;78(1):68-79. doi:10.1016/j.ijpsycho.2010.05.006.
9. Chaitow L Gilbert C Bradley D. Recognizing and Treating Breathing Disorders. Elsevier Health Sciences; 2013.
10. Ley R. The Modification of Breathing Behavior Pavlovian and Operant Control in Emotion and Cognition. Behav Modif. 1999;23(3):441-479.

Understanding the Different Breathing Options

Understanding the Different Breathing Options

When researching pregnancy and postpartum breathing as well as proper breathing when lifting, we run across three main types of breathing- abdominal hallowing, piston breathing, and diaphragmatic breathing. Each have their pros and cons and which is why understanding the different breathing options is an important aspect in knowing WHY we are doing something (#knowbetterdobetter).

Why the breath matters

Breathing matters because the breath is the key to a strong and stable core and body is the ability to create pressure, specifically intra-abdominal pressure (IAP), within the abdomen. IAP is fundamental in the initiation, control and prevention of movement.

Want the science on why Intra-Abdominal pressure is a GOOD thing, check the previous blog post, "For the love of all things good, stop sucking in."

Abdominal Hallowing / Sucking-In / Belly Button to Spine

Abdominal hallowing was previously mentioned in this blog but here's a quick breakdown...

Pros:

• Activates the transverse abdominis

Cons:

• Isolates the transverse abdominis through concentric contraction and separates the diaphragm and pelvic floor
• Inhibits activation of abdominal oblique musculature
• Sub-optimally strengthens the abdominal musculature through concentric contraction
• Creates oblique position of diaphragm and pelvic floor (see consequences of less than optimal breathing below)
• Not replicated in any functional movement

Piston Breathing

Pros:

• Helps one connect with the pelvic floor
• A great start: more beneficial long-term than abdominal hallowing and chest breathing as it focuses on trying to connect the diaphragm and pelvic floor
• Focuses on proper posture/alignment as well as breathing
• Pulls the breath out of the chest and into the belly, which is where one wants/needs to breath

Cons:

• Piston breathing implies unidirectional pressure with tight sides...when taught it typically includes something along the lines of "we quickly and forcefully draw the breath into the belly"
  • This is not functional as one does not isometrically contract to breathe and move throughout the day
  • The breath should never be "forceful"
• The pelvic floor and diaphragm should never be working separate of the abdominal musculature as this can create additional dysfunction
  • One does not want to tighten the abdominal musculature in preparation of the inhalation as this separates the co-contraction activation that should occur
  • The breath should create an eccentric activation of the abdominal muscles which then allows the muscles to tighten/loosen as they need in order to regulate the internal pressure

Diaphragmatic Breathing

Pros:

• The diaphragm, all abdominal musculature and the pelvic floor co-contract in coordination to create appropriate intra-abdominal pressure (IAP)
  • IAP is what gives one strength and stabilizes the core to protect the spine from injury
  • Coordinated co-contraction keeps the pelvic floor, diaphragm and musculature working in unison, which is the basis for optimal breathing (see below consequences of less than optimal breathing) (6, 7)
  • Optimal movements - if you want to strengthen the glute med you would pick a single-leg deadlift over a clam shell, the diaphragm is no different
• Creates 360 degrees of expansion to stabilize the abdominal musculature, back musculature and pelvic floor
• Focuses on proper posture in both standing and seated position (4, 5, 13)
• Replicated in day-to-day function

Cons:

• It may initially feel forced until the proper breathing patterns are learned
  • The goal is to make the breath more automatic/reflexive and a habit...when initially learning to do diaphragmatic breathing, it may feel a little forced as one is not accustomed to breathing in this manner and it takes time to train the proper breathing mechanics
• It may be difficult to learn due to compensation that has been trained throughout the years
  • One way to help learn the breathing easier is to utilize the Core360 belt which helps one activate their core correctly and consistently

Consequences of less than optimal breathing

Less than optimal breathing often leads to a functional cascade of complications/pain or faulty movement patterns. Some of those consequences include:

1. Oblique position of diaphragm & pelvic floor which can create/may lead to:

   

   • Increased lumbar lordosis and increased intra-fiscal pressure: more likely to  ave back pain or disc injury, chronic back tightness and hyperactivity of lumbar erectors
   • Lumbopelvic and hip instability : hamstring pain with bending and sitting, trigger points in low back, buttock and upper hamstring (14, 15, 16)
   • Anteverted pelvis: can lead to butt-wink in squat (8, 9, 10)
   • Poor thoracic extension and scapular stability: more likely to have shoulder and upper back/neck pain
2. Non-coordinated co-contraction of diaphragm, pelvic floor and abdominal musculature:Weak abdominals: the abdominal wall does not offer resistance to the diaphragm contraction which does not allow for appropriate IAP
   • Tight abdominals: the abdominal wall is too tight and the diaphragm and lower ribs cannot move downward to create ideal diaphragm activation and IAP
3. Secondary effects:
   • Pelvic organ prolapse and urinary/fecal incontinence (3, 11)
     • Often caused by a lack of tonic support and muscular strength of the pelvic floor, core and surrounding pelvic girdle musculature (1)
   • Increased risk of diastasis recti
   • Increased risk of disc herniation (14, 15)
   • Upper back and neck pain (18)

Benefits of proper diaphragmatic breathing

1. Improves core stability 
   • Coordinates and strengthens all components of the deep core musculature – pelvic floor muscles, transverse abdominals, multifidi, and diaphragm (2)
   • Contracting the diaphragm increases intra-abdominal pressure and generates a co-contraction of the pelvic floor muscles (pubococcygeus, puborectalis, and iliococcygeus) and transverse abdomens (17)
2. Decreased neck and shoulder pain (21)
   • Improved function of Sternocleidomastoid muscle which may decrease ringing in the ear (19)
   • Decreased use of pectoralis and scalenes which are commonly recruited in faulty breathing patterns (20)
3. Improved ventilation of the lungs (22, 23)
   • Increasing the inspiratory volume naturally increases the level of oxygen in the blood
   • Maximize the diaphragm's efficiency in performing breathing activity

References:

1. Sapsford R. Rehabilitation of pelvic floor muscles utilizing trunk stabilization. Man Ther. 2004;9(1):3-12.
2. Lee DG. The Pelvic Girdle: An integration of clinical expertise and research, 4e. Churchill Livingstone; 2010.
3. Wei, J.T. and DeLancey, J.O. Functional anatomy of the pelvic floor and lower urinary tract. Clin Obstet Gynecol. 2004; 47: 3–17
4. Sapsford RR, Richardson CA, Maher CF, Hodges PW. Pelvic floor muscle activity in different sitting postures in continent and incontinent women. Arch Phys Med Rehabil. 2008;89(9):1741-1747.15.
5. Sapsford R. R., Hodges P. W., Richardson C. A., et al. Co-activation of the abdominal and pelvic floor muscles during voluntary exercises. Neurourology and Urodynamics. 2001;20(1):31–42.
6. Bø K. Urinary incontinence, pelvic floor dysfunction, exercise and sport. Sports Medicine. 2004;34(7):451–464. doi: 10.2165/00007256-200434070-00004.
7. Pereira L. C., Botelho S., Marques J., et al. Are transversus abdominis/oblique internal and pelvic floor muscles coactivated during pregnancy and postpartum? Neurourology and Urodynamics. 2013;32(5):416–419. doi: 10.1002/nau.22315.
8. Soljanik I., Janssen U., May F., et al. Functional interactions between the fossa ischioanalis, levator ani and gluteus maximus muscles of the female pelvic floor: a prospective study in nulliparous women. Archives of Gynecology and Obstetrics. 2012;286(4):931–938. doi: 10.1007/s00404-012-2377-4.
9. Capson A. C., Nashed J., Mclean L. The role of lumbopelvic posture in pelvic floor muscle activation in continent women. Journal of Electromyography and Kinesiology. 2011;21(1):166–177. doi: 10.1016/j.jelekin.2010.07.017.
10. Cerruto M. A., Vedovi E., Mantovani W., D'Elia C., Artibani W. Effects of ankle position on pelvic floor muscle electromyographic activity in female stress urinary incontinence: preliminary results from a pilot study. Archivio Italiano di Urologia e Andrologia. 2012;84(4):184–188.
11. Halski T., Słupska L., Dymarek R., et al. Evaluation of bioelectrical activity of pelvic floor muscles and synergistic muscles depending on orientation of pelvis in menopausal women with symptoms of stress urinary incontinence: a preliminary observational study. BioMed Research International. 2014;2014:8. doi: 10.1155/2014/274938.274938
12. Devreese A., Staes F., Janssens L., Penninckx F., Vereecken R., de Weerdt W. Incontinent women have altered pelvic floor muscle contraction patterns. The Journal of Urology. 2007;178(2):558–562. doi: 10.1016/j.juro.2007.03.097.
13. Chmielewska D, Stania M, Sobota G, et al. Impact of Different Body Positions on Bioelectrical Activity of the Pelvic Floor Muscles in Nulliparous Continent Women. BioMed Research International. 2015;2015:905897. doi:10.1155/2015/905897.
14. Hebert JJ, Koppenhaver SL, Magel JS, Fritz JM. The relationship of transversus abdominis and lumbar multifidus activation and prognostic factors for clinical success with a stabilization exercise program: a cross-sectional study. Arch Phys Med Rehabil. 2010;91(1):78-85
15. Cholewicki J, Silfies SP, Shah RA, et al. Delayed trunk muscle reflex responses increase the risk of low back injuries. Spine (Phila Pa 1976). 2005;30:2614-2620
16. Holmich P, Larsen K, Krogsgaard K, Gluud C. Exercise program for prevention of groin pain in football players: a cluster-randomized trial. Scand J Med Sci Sports. 2010;20:814-821
17. Akuthota V, Nadler SF. Core strengthening. Arch Phys Med Rehabil. 2004;85(3)(suppl 1):S86-S92
18. Ingraham, Paul. The Respiration Connection: How breathing might be a root cause of a variety of common upper body pain problems and injuries. PainScience.com. updated September 13, 2016 (published 2005).
19. Travell J, Simons D, Simons L. Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd ed. Lippincott, Williams & Wilkins; 1999. p314.
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