Background
There may be a misinterpretation of the information in the education of fitness professionals on how to recruit the abdominal cylinder (pelvic floor and core muscles). The Pelvic Floor First campaign which was launched in November 2011 by the Continence Foundation of Australia (CFA) aimed to reduce the number of men and women who experience pelvic floor dysfunction as a result of inappropriate exercise.
As a Pelvic Health & Musculoskeletal Physiotherapist with over 30 years in clinical practice and using Real-time Ultrasound (RTUS) observation suggests fitness professionals may be using a bracing, bearing down strategy when teaching “core control”. Repeatedly women presenting to me clinically who have reported being taught “core abdominal muscle activation” by their Fitness Professional were bearing down on their pelvic floor and overrecruiting all their abdominal muscles when instructed to squeeze and lift their PFM. This bearing-down pattern was encouraged in the fitness environment as the correct way to recruit the PFM and core muscles.
Women were trying to improve their physical fitness, placing great trust in their Fitness Professional, and were frustrated to hear that they were not being properly guided to best recruit their pelvic floor and core muscles during exercise. There appeared to be a gap in knowledge regarding the correct recruitment of the “core,” of which pelvic floor muscle activation is an essential component. The CFA ‘Pelvic Floor First’ campaign information handout on “The pelvic floor and core exercises” explains that the PFM forms the base of the group of muscles commonly called the core. These PFM muscles work with the deep abdominal and back muscles and the diaphragm to support the spine and control the pressure inside the abdomen. The PFM plays an important role in supporting the pelvic organs and bladder and bowel control. If any of the muscles of the core, including the pelvic floor, are weakened, or damaged this coordinated automatic action may be altered. In this situation, during exercise that increases intra-abdominal pressure (IAP), there is the potential to overload the pelvic floor, causing downward pressure. When this happens repeatedly during each exercise session, over time this may place a downward strain on the pelvic organs and may result in loss of bladder or bowel control, pelvic organ prolapse (POP), and or low back pain.
Kari Bo et al 2011 found that urinary incontinence (UI) is prevalent amongst female fitness instructors and that more information about this topic seems to be important in the basic education of fitness instructors. Stephen K et al 2018 found there was a 28.2% prevalence of urinary incontinence among fitness instructors similar to Bo et al 2011 who found 26.3%. Stephen K et al 2018 found a significant proportion of fitness instructors are in need of “pelvic floor muscle exercise” and those who perform pelvic floor muscle exercise do so at a level below that which is recommended. However, many have had some training on pelvic floor muscle exercise or are willing to provide this.
Nygaard IE et al 2016 found that urinary incontinence during exercise is more prevalent in women participating in high-impact sports. Mild to moderate physical activity such as brisk walking appeared to decrease the risk of getting UI. Fozzatti C et al 2012 found women who attend a gym and perform high-impact exercises have a higher prevalence of UI symptoms, independent of exercise modality than women who do not perform any high-impact exercises. McKenzie et al 2016 found urinary incontinence is common in women attending gyms and exercise classes but is rarely screened for. More education is required to encourage fitness leaders to screen exercise participants and to provide pelvic floor-friendly modifications.
Julie Hides et al 2001 RCT investigated long-term effects of specific stabilizing exercises for first-episode low back pain. Hides rehabilitation (specific exercise group) focused on deep multifidus co-contracting with the transversus abdominis muscle. The control group received medical intervention including advice and the use of medications. Three-year follow-up after treatment showed specific exercise group reoccurrence was 35%, and control was 75%. Hides research brought the importance of the deep spinal stability muscles to public attention and transversus abdominus became associated with ‘core control’ in the fitness industry.
Neumann P et al 2002 found that the transversus abdominis (TA) and the obliquus internus (OI) were recruited during all pelvic floor muscle contraction and it was not possible for these subjects to contract the pelvic floor effectively while maintaining relaxation of the deep abdominal muscles.
Ferla L et al 2006 results from a systematic review concluded there is synergy between the muscles of the abdomen and the pelvic floor in healthy women.
Thompson JA et al 2006 demonstrated a difference in abdominal muscle activation patterns between a correct PFM contraction and Valsalva manoeuvre. They concluded abdominal wall bracing combined with an increase in chest wall activity may cause rises in intra-abdominal pressure (IAP) and PFM descent.
Junginger B 2010 investigated the relationship between bladder neck displacement, EMG activity of the pelvic floor and abdominal muscles, and IAP during different pelvic floor and abdominal contractions. Bladder neck elevation only occurred during PFM and (TA) contractions. Bladder neck elevation was only observed when the activity of PFM EMG was high relative to the IAP increase.
Smith MD et al 2006 study aim was to establish the association between back pain and disorders of continence and respiration in women. Analysing a cross-sectional analysis of self-report of 30,050 women, they found mid-aged and older women had higher odds of having back pain often when they experienced breathing difficulties compared to women with no breathing problems. 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. Smith M.D. et al (2007) further found women with stress urinary incontinence demonstrated decreased balance ability when compared to continent women.
Clinical observation suggests fitness professionals maybe using a bracing strategy related more to a bearing down pattern when teaching “core control.” This pattern will promote increased IAP and downward movement of the pelvic organs. It will not provide the physiological benefits as when the pelvic floor muscles synergistically contracts with the deep abdominals, deep back muscles, and diaphragm. This abdominal cylinder motor control pattern ‘the core’ (as evident with scientific research ) is critical for the continence mechanism, essential support for the pelvic organs, reduces episodes of low back pain, enhances ideal breathing patterns, associated with increased balance ability, and essential for ideal posture.
Reference
Bø, K., Bratland-Sanda, S., & Sundgot-Borgen, J. (2011). Urinary incontinence among group fitness instructors including yoga and pilates teachers. Neurourology And Urodynamics, 30(3), 370-373.
Nygaard, I. E., & Shaw, J. M. (2016). Physical activity and the pelvic floor. American Journal Of Obstetrics & Gynecology, 214(2), 164.
Fozzatti, C., Riccetto, C., Herrmann, V., Brancalion, M. F., Raimondi, M., Nascif, C. H., & … Palma, P. P. (2012). Prevalence study of stress urinary incontinence in women who perform high-impact exercises. International Urogynecology Journal, 23(12), 1687-1691.
McKenzie, S., Watson, T., Thompson, J., & Briffa, K. (2016). Stress urinary incontinence is highly prevalent in recreationally active women attending gyms or exercise classes. International Urogynecology Journal, 27(8), 1175-1184.
One thought on “Could we be teaching ‘The Core’ better’?”
Great work Gill