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.

Fat is not the enemy

Mainstream media is finally losing steam on their war against fat as more and more people are learning that fat is not the enemy.  The thing is, most people understand they need “good fats” but they don’t know what is a good fat, how much they need, or even why it is beneficial.

Why is fat beneficial?

Whether you are pregnant, nursing, thinking of getting pregnant, or a man, you need fats in your diet. Here is a list of ways dietary fat may be beneficial:

1. Increases muscle mass
2. Reduces your risk of heart disease
   1. Raises HDL and improves your TC/HDL ratio
   2. May help prevent lethal heart rhythms from arising
3. Stabilizes energy and mood
4. Lowers blood sugar and insulin levels
5. Decreases achy and stiff joints
   1. May help reduce the need for corticosteroid medications in people with rheumatoid arthritis
6. Relieves dry, itchy, or cracked skin and nails
7. Helps absorb fat soluble vitamins and nutrients including: A, D, E, K, CoQ10
8. Improves brain and memory function
   1. Decreases risk of Alzheimer’s disease as well as overall cognitive decline

What are the “good fats” and how much fat do we need?

There are four main types of good fats that everyone needs to properly thrive. It’s recommended you consume 35-40% of calories from fat. For a 2,000 calorie diet that is 78-89 grams of fat per day (remember if you are breastfeeding you need an EXTRA 500 calories or an extra 17.5-30 grams of fat.

Monounsaturated fats: Monounsaturated fats have been shown to decrease risk of heart disease and helps stabilize insulin.

Sources include: Oils: extra virgin olive oil, safflower oil, sunflower oil; avocado; red meat: pork and beef; nuts:  cashews, macadamia, almonds, pecans, hazelnuts; lard; olives, and eggs

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Long-chain saturated fats: Long-chain saturated fats create the structural foundation of fats and make up 75-80% of fatty acids in most cells. This type of fat is great for energy storage.

Sources include: animal meat: beef, pork, lamb; dairy: cheese, whole or reduced-fat milk and dairy products

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Medium-chain triglycerides: A great source of easily digestible energy that is not stored as fat by the body.(1,3) MCTs are great for immediate energy needs.

Sources include:  coconut milk and coconut oil, butter, milk, yogurt and cheese

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Polyunsaturated fats: These fats are broken into two categories being omega-6 and omega-3 fatty acids. Ideally these fats should be consumed in a 1:1 up to 4:1 ration but the Standard American Diet (SAD) tends to be heavy on omega-6 and lacking on omega-3s. These fats are essential, meaning you need them from your diet as your body is unable to produce them itself. Try to eat ~9g of polyunsaturated fat per day.(1)

Omega-6 sources include: refined oils: soybean, cottonseed, corn, safflower and sunflower; nuts; poultry and eggs; whole grain wheat

Omega-3 sources include: fish: salmon, herring, mackerel, sardines, anchovies, lake trout (DHA); meat and fat from ruminant animals: cattle, sheep, goats, buffalo, deer, elk, bison (DHA); eggs (DHA); walnut (EPA); flaxseeds and chia seeds (EPA); vegetables: Brussels sprouts, kale, spinach and watercress (EPA)

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Ideally, the majority of your fat will come from monounsaturated fats, long-chain saturated fats and medium-chain triglycerides. These fats have not been shown to have a toxicity level so you can safely consume the daily recommendation of 78-89 grams without concern. Polyunsaturated fats should also be consumed daily but use caution in consuming too many omega-6 and not enough omega-3.

Previously shared on the BIRTHFIT blog.

References:

1. https://chriskresser.com/9-steps-to-perfect-health-2-nourish-your-body/
2. http://drhyman.com/blog/2016/11/18/heres-determine-healthiest-fats-cook/
3. https://draxe.com/healthy-fats/
4. http://www.eatright.org/resource/food/nutrition/dietary-guidelines-and-myplate/choose-healthy-fats
5. http://www.health.harvard.edu/staying-healthy/the-truth-about-fats-bad-and-good
6. http://www.clevelandclinicwellness.com/food/GoodFats/Pages/BoostBrainPowerwithGoodFats.aspx
7. http://www.med.umich.edu/umim/food-pyramid/fats.html

For the love of all things good, stop sucking in

Two weeks ago NPR posted an article on how to quickly fix "Mummy Tummy" (what they actually meant was diastasis recti) in 10 minutes a day.  There have been a lot of quick fixes for correcting and flattening diastasis recti going around the internet and this article even stated "You can easily expect to see 2 inches off your waist in three weeks of time".  The article went as far as stating the exercise, which is abdominal hollowing, is backed by research and physicians. Two days later NPR released another article stated that yogis knew all about this method long before but stated "you want to make sure your pelvic floor is strengthened and recovered before doing Kapalbhati, Allen says. "Otherwise, it could make things worse.""Now, two weeks later, NPR has released a third article stating "Unfortunately, there hasn't been much research that looks at how effective any particular exercise is — or is not — in fixing diastasis recti." and that the creator "thinks the "breath-in" exercise can strengthen abdominal muscles".

To recap, NPR first stated that the exercise is backed by research, then stated it has been in practice a long time and to use caution because it can worsen pelvic floor control (ah-hem, urinary incontinence) and now they are saying that we need more research (there is no disputing that!) and the method they were promoting is only thought to be beneficial. The thing is, critical evaluation of currentresearch does not support these methods and actually contradicts their use in treating diastasis recti and the pelvic floor and here is why:

Abdominal Hollowing

When breathing is discussed most people think of sucking or drawing in their stomach or pulling their belly button inward to support their body. This movement, called abdominal hollowing, became the gold standard in 1996 after Paul Hodges and Carol Richardson released an article in Spine stating “the delayed onset of contraction of transverse abdominis indicates a deficit of motor control and is hypothesized to result in inefficient muscular stabilization of the spine.” Abdominal hollowing became popular because it creates concentric contraction of the transverse abdominis and should theoretically help stabilize the spine. In reality, a study released in 2009 showed that all the muscles have a delayed contraction and not just the transverses abdominis in people with low back pain.

Research has since evolved and grown since 1996 but exercise practices have not kept up with the research in regards to core strength and stability. Concentric contractions, like those created by abdominal hollowing, create a force that is always less than the muscle’s maximum potential. Dr. Stuart McGill released a study in 2001 showing that activation of the transverse abdominis along does not improve spinal stability as it can inhibit activation of the external and internal obliques. Therefore, even though a person is strengthening the transverse abdominis, abdominal hollowing focuses on strengthening the muscle to its suboptimal potential and can actually decrease core stabilization.

Abdominal hollowing also activates the abdominal wall without co-activation of the diaphragm. This causes the transverse abdominis to activate independently and does not create intra-abdominal pressure to help stabilize the spine. In fact, the biomechanics created when a person does abdominal hollowing causes instability throughout the spine and system. The act of hollowing will create an oblique position of the diaphragm and pelvic floor, increases lumbar lordosis and creates hyperactive spinal erectors and stresses the psoas. This is important in people who have chronic low back pain and "tight hip flexors".

Furthermore, abdominal hollowing does not create a movement that is replicated in function…one would not suck in their belly prior to lifting a grand piano as this would create instability.

So what is important in "Core Stabilization"?

In 2012 Kolar released two articles in the Journal of Applied Physiology and the Journal of Orthopedic Sports Physical Therapy showing the importance of the diaphragm. He found that respiration and stability are inseparable as we cannot stabilize without proper breathing mechanics. “It is through respiration that continuous activation of the diaphragm, abdominal wall and pelvic floor are maintained”.

Intra-abdominal Pressure - is it really a bad thing?

diaphragmatic breathing

The ideal Gas Law (PV=nRT) helps us understand that pressure and volume are inversely related and therefore must work in unison to create a stable environment. Volume is controlled by the contractile nature of the core because our bodies are able to expand and contract in relation to outside forces. 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.

During inspiration the abdominal wall expands to maintain volume (and pressure) if no additional stability is needed. However, when additional stabilization is needed, the abdominal wall maximizes its expansion causing a decrease in volume of the abdominal cavity thereby increasing intra-abdominal pressure to stabilize the system. It is a deep, stabilizing breath that allows the abdominal wall and pelvic floor to be fully activated, specifically the anterior, lateral and posterior aspects of the abdomen creating increased intra-abdominal pressure. This pressure is what creates proper and efficient stabilization of the spine.

Abdominal Bracing

The research and work done by Dynamic Neuromuscular Stabilization, focus on creating intra-abdominal pressure through abdominal bracing. Abdominal bracing creates an eccentric contraction of the abdominal wall (including the transverse abdominis) while co-contracting the diaphragm and pelvic floor. The eccentric contraction is beneficial because it strengthens the muscle as it lengthens, which is when much of a muscles normal activity occurs. Therefore, the greatest muscle strengthening is gained  during the eccentric contraction which is why abdominal bracing is important.

Abdominal bracing helps maximize intra-abdominal pressure in a way that is natural to how humans function.  Bracing creates a neutral posture through joint centration that helps stabilize the spine for all movements. Without proper breathing mechanics a person cannot stabilize using proper patterns and compensatory movement patterns will be created resulting in instability. It is through joint centration and abdominal bracing that ideal movement patterns can be utilized that enhance performance while decreasing the risk of injury.

Abdominal Bracing & Pregnancy/Postpartum

It is common for postpartum women to have areas of concern such as incontinence or diastasis recti. These signs and symptoms are created when one can’t appropriately react to pressure or volume and indicate the need to maintain appropriate intra-abdominal pressureby integrating the breath (diaphragm) with the abdominal wall and pelvic floor. It is through intra-abdominal pressure that stability is created and the pelvic floor and abdominal muscles can heal.

Abdominal Bracing & The Athlete

Abdominal bracing is a huge component of lifting. As Dr. Richard Ulm stating, "In both training and sport, we must remember that movement is preceded by stabilization of the spine." For more information on the importance of breathing in the athlete, please check out Dr. Ulm's article in NSCA, STABILITY AND WEIGHTLIFTING—MECHANICS OF STABILIZATION—PART 1 .

If you are looking for more information in regards to athletes and the importance of the breath, check out Dr. Ulm's information at Athlete Enhancement or his youtube site.

Resources:

-Richard Ulm’s “Stability” course at National University of Health Sciences -Bordoni, B, and Zanier, E. Anatomic connections of the diaphragm: Influence of respiration on the body system. Journal of Multidsciplinary Healthcare (6): 281-291, 2013. -Hodges, PW, Eriksson, AE, Shirley, D, and Gandevia, SC. Intra-abdominal pressure increases stiffness of the lumbar spine. Journal of Biomechanics 38(9): 1873-1880, 2005. -Hodges, PW, and Gandevia, SC. Changes in intra-abdominal pressure during postural activation of the human diaphragm. Journal of Applied Physiology 89(3): 967-976, 2000. -Kolar, P, and Andelova, V. Clinical Rehabilitation. Prague: Rehabilitation Prague School, 2013. N. pag. Print.Dynamic MRI and synchronized spirometric assessment. Journal of Applied Physiology 109(4): 1064-1071, 2010. -Kolar, P, Sulc, J, Kyncl, M, Sanda, J, Cakrt, O, Andel, R, et al. Postural function of the diaphragm in persons with and without chronic low back pain. Journal of Orthopedic and Sports Physical Therapy 42(4): 352-362, 2012.

Goals

Goals...why set them? Whether you are coming in with low back pain and want to be able to sleep at night or you want to play volleyball or football without medial knee pain, goals matter. Without specific goals we may stray away from what is important.

Why are goals important?

In every form of treatment we do, we focus on your goals and how to accomplish them. We will constantly discuss how each treatment, movement, or exercise is serving your goals.

Performing an adjustment or exercise for the sake of "doing something" will not help you reach your goals. Each treatment component needs to be centered around your needs and wants.

What are my goals as the doctor?

My goals is for you to be informed on why we are doing each exercise/adjustment and how it will help you accomplish your goals. If you are interested in letting me help you reach your goals, please call (331) 307-7110 to schedule an appointment today.