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.
20. Magee DJ. Orthopedic physical assessment. WB Saunders Company; 1997. pp219-221.
21. Padula CA, Yeaw E. Inspiratory muscle training: integrative review. Research & Theory For Nursing Practice. 2006 Winter;20(4):291–304.
22. Kolar P, Neuwirth J, Sanda J, Suchanek V, Svata Z, Volejnik J, Pivec M. Analysis of diaphragm movement during tidal breathing and its during activation while breath holding using MRI synchronized with Spirometry. Physiol Res 2009;58:383-92
23. Kolar P, Sulc J, Kyncl M, Sanda J, Neuwirth J, Bokarius AV, Kriz J, Kobesova A. J Applied Physiol Aug 2010

To Tuck the Pelvis or Extend the Spine - That is the Question

To Tuck the Pelvis or Extend the Spine - That is the Question

Whether you are sitting in a chair all day long, lifting weights or pregnant, the position of your spine matters. In fact, in all three instances we want the same thing - a neutral spine. To tuck the pelvis or extend the spine - that is the question, but really, the answer is neither...we want a happy medium of both and here is why:

What is a neutral spine?

A neutral spine is when the position of the diaphragm is aligned with the pelvic floor. The spine is not flexed, extended, tilted or twisted.

Benefits of a neutral spine

The following is a list explaining why a neutral spine is beneficial:

• Maintains good posture
• Prevents or decreases muscular imbalances and strain on joints ⁽³⁾
• Supports and protects the spine
• Improved lung capacity
• Increased strength and mobility ⁽⁴⁾
• Maintains integrity of stabilizing complex (diaphragm, abdominal muscles, pelvic floor)
  • Antagonistic trunk flexor‐extensor muscle coactivation was present around the neutral spine posture in healthy individuals. ⁽¹⁾
• Decreases risk of pregnancy-related pain, including sciatica and low back pain ⁽³⁾
• Distributes load evenly through discs ⁽³⁾
• Relieves pelvic floor dysfunction including urinary incontinence ⁽³⁾

The Mechanics of Tucking the Pelvis vs. Lumbar Extension

Tilting the pelvis too far forward or tucking it too far backward can exaggerate or minimize the natural curve of the spine and cause pain, discomfort, or instability through the following mechanics:

Tucking:

Pelvic tucking is called a posterior pelvic tilt and is created when the pelvis rotates backwards (posteriorly). When this happens the coccyx (aka tailbone) moves down and forward. At the same time the pubic symphysis which is in the front of the pelvis moves forward and up towards the navel. By tucking, the lumbar spine actually moves into flexion and can pull the ribs down in a shearing motion that puts the abdominals almost into a crunch position by shortening the musculature. This movement also shortens the hamstrings while lengthening the quadriceps and back musculature. One reason people will tuck the spine is to activate the glutes, but this movement actually causes chronic tightening of the gluteal muscles and external hip rotators but this movement can pull the femur head back and externally rotate it causing widening of the pelvic floor and weakening the pelvic floor muscles.

Lumbar Flexion:

Lumbar flexion creates an anterior pelvic tilt and is created when the pelvis rotates forward (anteriorly). When this happens, the lumbar spine (low back) goes into hyper lordosis and the hamstrings and abdominals are lengthened while the quadriceps and back musculature are shortened causing the psoas and spinal erectors to be hyperactive. This position can also elevate the ribs and create a concentric abdominal wall while creating an oblique position of the diaphragm and pelvic floor, causing pelvic floor instability and an inability to optimally use the diaphragm.

How do I get to neutral?

Here are a few tips to help you achieve a neutral spine:

• Toes/feet are pointed straight ahead or at a slightly outward direction (11 o’clock & 1 o’clock position) and feet are hip-width apart
  • You should feel equal pressure on the three points of your foot (see diagram) creating a tripod
• Stacking is the key to stability: your head should be above your shoulders, your shoulders should be above your pelvis, your pelvis should be above your knees and your knees should be above your feet
• Make sure your diaphragm and pelvic floor are on top of each other
  • Avoid “rib flare” by gently lowering your ribs down until the lower ribs move into the abdominal skin and musculature
  • Don’t tilt the pelvis forwards or backwards: the pelvis should be neutral and not tilted forward or tucked. To do this, think of a cup, you don’t want the pelvis tilted forward or backwards causing water to drip out of the cup
• Make sure your chin isn’t jutted out and your head is squarely on your shoulders
  • To do this you tuck the chin straight back while also elongating the neck
  • Sure, you may feel like you have a double chin but we almost all do and that’s ok because it helps maintain that neutral, stacked spine

What does a neutral spine look like?

A neutral spine/ pelvis is when the ASIS (aka the hip bones) is in line with the pubic crest and the lumbar spine is balanced atop the sacrum, the rib cage will be lifted and supported by both the abdominal and back musculature and the pelvic floor and the diaphragm should be stacked upon one another.

To Tuck or Extend: Is it black-and-white?

Nope. First off, not everyone is created equal so there will naturally be some variance in what is best for each person. Constantly arching the spine is not healthy just as constantly tucking the spine is not healthy. The key is to systematically move the spine through its full range of motion with load. Therefore, we need to focus on a neutral spine for both weight-bearing and non-weight-bearing movements to help build strength and create a strong stabilizing system.

Resources:

1. Cholewicki J, Panjabi MM, Khachatryan A. Stabilizing function of trunk flexor-extensor muscles around a neutral spine posture. Spine. 1997;22(19):2207–2212.
2. Wallden, Matt. The neutral spine principle. Journal of Bodywork and Movement Therapies, Volume 13 , Issue 4 , 350 - 361
3. Panjabi, Manohar. (1993). The Stabilizing System of the Spine. Part II. Neutral Zone and Instability Hypothesis. Journal of spinal disorders. 5. 390-6; discussion 397. 10.1097/00002517-199212000-00002.
4. Jagarinec, Tomi. (2017). Core Training in Football: Improve Your Players’ Posture and Unlock Their Play Potential.
5. Bendix, T & Biering-Sørensen, F. (1983). Posture of the trunk when sitting on forward inclined seals. Scandinavian journal of rehabilitation medicine. 15. 197-203.
6. Richardson, C, Jull, G, Hodges, P, Hides, J. Therapeutic exercises for spinal segmental stabilization in low back pain. Churchill Livingstone, Toronto; 1999.
7. Elia, DS, Bohannon, RW, Cameron, D, Albro, RC. Dynamic pelvic stabilization during hip flexion: a comparative study. J Orthop Sports Phys Ther. 1996;24:30–36.
8. Robinson, R. The new back school prescription: stabilization training part 1. Occup Med. 1992;7:17–31.
9. Dumas, GA, Reid, JG, Wolfe, LA, Griffin, MP, McGrath, MJ. Exercise posture and back pain during pregnancy: part 1. Exercise and posture. Clin Biomech. 1995;10:98–103.

Must I pee when I sneeze?

Must I pee when I sneeze?

We know that abdominal bracing and diaphragmatic breathing  is beneficial to core strength and stability because “as one inhales, the diaphragm moves downward in unison with the abdominal muscles and pelvic floor to eccentrically contract and regulate the volume of the abdominal cavity. By regulating the volume, the intra-abdominal pressure is also controlled.” Now, let’s focus on the other beneficial aspects of proper breathing and bracing, pelvic floor strength.

I commonly hear women say “I don’t like to do that movement because I will either pee my pants or fart.” Unfortunately, many women are told this is normal and to be expected because they gave birth. In fact, “at three months postpartum 34.3% of women admitted to some degree of urinary incontinence…” (Wilson, 1996). The thing is, it may be common but it is not normal. An article from 2001 stated that “the data are highly suggestive that leaking urine may be a barrier to physical activity, especially among mid-age women.” No woman should have to worry about exercising, sneezing, coughing, yoga or jumping rope for fear of losing control of their pelvic floor musculature and peeing their pants or farting.

Vaginal vs. Casearaen 

There’s a thought that urinary incontinence must be more common in vaginal births because the baby is coming through the birth canal. In fact, a study from 2007 done by Press showed that “Although short-term occurrence of any degree of postpartum stress urinary incontinence is reduced with cesarean section, severe symptoms are equivalent. This begs the question of why is the rate of urinary incontinence the same among all women?

Breathing & Incontinence 

In 2006, an article was released in the Australian Journal of Physiotherapy that concluded “unlike obesity and physical activity, disorders of continence and respiration were strongly related to frequent back pain. This relationship may be explained by physiological limitations of co-ordination of postural, respiratory and continence functions of trunk muscles.” This relates back to the connection the diaphragm has with the pelvic floor and all abdominal musculature - they must work in unison to provide stabilization. This was further addressed when Smith found in 2014,  the “relationship between BP, incontinence, respiratory problems, and GI symptoms in which the presence of one symptom is associated with the development of another.” Difficulty with optimal breathing and pelvic floor control (urinary leakage or farting) actually go hand-in-hand.

The importance of the diaphragm

The diaphragm, which works with the pelvic floor and abdominal musculature is important when looking at the cause of urinary incontinence. In 2015, Park released an article stating that “Diaphragmatic motion and contraction of the PFM correlate with breathing.”

It is improper breathing patterns altering the pressure on the pelvic floor that leads to incontinence. You see, “during normal respiration, or in the event of coughing or any other physiologic diaphragmatic alteration, a symmetric change in the pelvic floor can be observed…it also ensures the steadiness of the human trunk and maintaining urinary continence during respiration and coughing” ( Bordoni, 2013)

In the Therapeutic Management of Incontinence and Pelvic Pain: Pelvic Organ Disorders by Laycook and Haslam, they focused on breathing in order to improve urinary incontinence. They state, “it is considered essential to maintain co-activation and breathe in a slow, relaxed manner” and the use of isolated breathing patters is dysfunctional.” They further stressed the need for intra-abdominal pressure by stating “co-activation of the abdominal, erector spinae, diaphragmatic and pelvic floor musculature is essential to developing the intra-abdominal pressure for spinal stability.”

Improving the leak

A study done by Hung in 2016 focused on treating urinary incontinence by retraining diaphragmatic, deep abdominal and pelvic floor muscle coordinated function. The results showed that “both amount of leakage and number of leaks were significantly lower in the training group (p < 0.05) but not in the control group. More aspects of quality of life improved significantly in the training group than in the control group.” This is great news for many women because it highlights the fact that many don't have to continue peeing their pants or farting if they do specific exercises to help strengthen the abdominal musculature, pelvic floor and diaphragm activation.

Dynamic Neuromuscular Stabilization (DNS) focuses on the inherent movement control system in the brain in order to activate the body’s stabilization system through proper use of the diaphragm. Functional progressions, which were created using DNS principles, focus on moving through a functional position. Laycook stated that “to improve performance, muscles are best trained with movements as similar as possible to the desired work. Therefore, exercise is most appropriate in a functional position.” This is important to remember because all exercises given to improve the pelvic floor should be done in movements that mimic ordinary function.

Results of exercise 

We know that peeing your pants when you exercise or sneeze is not normal and we know that the functional movements based off of DNS principles will improve the leakage. It’s also important to look at the long term effects because let’s be realistic, nobody wants to put in a ton of work and not see results. Dumoulin in 2014 released an article stating that, “the review provides support for the widespread recommendation that PFMT be included in first-line conservative management programmes for women with stress and any type of urinary incontinence.” In 2000, Morkved released a study showing there was not only statistically improvement in urinary leakage at 16 weeks postpartum, but exercise can improve leakage at 12 months postpartum too.

The gift of normalcy

While it may be common, peeing your pants when you exercise is not normal. In fact, it is a sign that you need to work on breathing and core stabilization. In order to find someone who can appropriately help you navigate this concern, it is important to find someone trained in DNS or a women’s health physical therapy.