Could We Be Teaching ‘The Core’ Better’?
By Gill Smith
Background
There may be 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 maybe 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 over recruiting 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 as 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 form 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 play 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 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 in 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 exercise. 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 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.
More reading
Functional Pelvic Floor & Core Fitness information for the Fitness Industry
Do you or your clients pee when working out? Its more common than you think.
Scientific evidence shows women are experiencing pelvic floor dysfunction because of inappropriate exercise regimes. ‘The Core’ which the pelvic floor muscles play an important role is not being taught well. Do you really know how to teach “The Core” or Abdominal Cylinder Control or Neutral Spine? Did you know’ The Plank’ does not target these important core muscles. Yes, it is tricky because it’s the deepest lumbar pelvic muscles that contract together to provide core stability.
Contract these muscles correctly and your clients will be
- Supporting their pelvic organs
- Not leaking while exercising
- Keeping their lower back safe –no low back pain from exercise
Here are some interesting stats
- 43% of women bear down when instructed to squeeze and lift their pelvic floor muscle
- 1 in 3 women who have had a baby wet themselves
Urinary incontinence is quite common in women who work out in gyms or exercise. Yet only 15.2% of women are screened for pelvic floors issues when they join a gym. And less than half of fitness instructors cue their clients to engage their pelvic floor. Even a quarter of fitness instructors have reported to experience incontinence when working out! Int Urogynecol J. 2012 Dec;23(12)
A 2012 study showed that women who participate in high impact exercise, like running or aerobics, experience more incontinence symptoms than those who don’t exercise. And that’s regardless of the type of exercise they do. Int Urogynecol J. 2016 Aug;27(8):1175-84.2016
A study involving over 38,000 women has found that disorders of breathing and continence have a stronger association with back pain than obesity and physical activity. Aust J Physiotherapy. 2006;52(1):11-6
THE INSEPERABLE CONDITIONS:
Incontinence, pelvic organ prolapse, low back pain, respiratory issues, pelvic girdle pain in pregnancy and balance problems are fundamentally linked to a deficit in abdominal cylinder control ‘The Core’
Research suggests education is required to encourage fitness professionals to screen exercise participants and provide pelvic floor friendly exercise regimes contributing to holistic client care.
Core control (abdominal cylinder control) is widely believed to be healthy for female clients as it is supportive to the back, pelvic organs and important for the continence mechanism as well as all stages in pregnancy and beyond… Often referred to as foundation movement in the fitness industry.
The Core muscles are the Pelvic Floor, Transversus Abdominus, Multifidus and Diaphragm. These muscles love working together to provide lumbar pelvic stability.
Every fitness professional should understand and respect the important role these ‘Core Muscles’ play in maintenance of continence, support of pelvic organs, reduce low back pain and critical in all stages of pregnancy – foundation movement pattern for Functional Fitness.
If you could visualise these deep muscles contract on a screen and appreciate how to best cue them would that be helpful?
Using visual biofeedback on the Real-time Ultrasound you can now see these muscles working and no longer rely on guess work. When you know how to recruit these deep muscles on your body you will confidently be able to teach this important foundational movement pattern to your clients.
Advancing your anatomical knowledge enhances your duty of care to prevent harm to your client and assist in mitigating risk. Knowledge gained is fundamental to many Fitness Industry Guidelines.
Your aim as a Fitness Professional is to reduce risk of serious injury or incidents by creating an exercise plan specific to the client constantly referencing information from the Pre- exercise screening.
Being aware that the pelvic floor, multifidus, diaphragm, and abdominal cylinder muscles is essential for ideal lumbar pelvic posture (sitting, squatting, standing) –foundational for Functional Fitness and Pelvic Floor Safe exercise
Critical to enhance fitness professionals observational and cueing skills determining whether their clients are correctly recruiting pelvic floor, multifidus, diaphragm, and abdominal cylinder muscles ‘The Core’ before attempting any strengthening, cardio exercise workout in the fitness environment
With a little further education, you can begin to incorporate Functional Pelvic & Core Fitness into your fitness regime contributing to your clients’ health and fitness goals…. and, in doing so, help you build a successful and thriving business.
Our story:
Inspired by Pelvic Floor First
I attended the launch of the Pelvic Floor First campaign that was presented by the Continence Foundation of Victoria in November 2011. As a Women’s Health, and Musculoskeletal Physiotherapist I was delighted with the name of Pelvic Floor First. Inspired with the presentation I woke in the early hours writing a practical educational workshop called PELVIC FLOOR FITNESS targeting the Fitness Industry on the importance of the functional application of the pelvic floor muscles.
In clinical practice using the Real Time Ultrasound for biofeedback I became aware that women’s pelvic floor muscles were not being acknowledged and recruited with exercise. Observations using the real time ultrasound revealed that women were not recruiting the pelvic floor muscles instead were pushing down upon the pelvic floor risking pelvic organ prolapse.
Women were trying hard to improve their physical fitness, placing great trust in their personal trainers and fitness instructors. However, were saddened to hear they were not being properly guided on how to best recruit their pelvic floor muscles for exercise. I became aware of the gap in knowledge regarding the correct recruitment of the “core” of which the pelvic floor muscles are an essential component.
Pelvic Floor First was a brilliant choice to encourage the pelvic floor muscles to be well elevated in the pelvic cavity to counteract the inevitable increase in intra-abdominal pressure in fitness-based exercise.
This repetition of intra-abdominal pressure and constant loading of an unrecruited pelvic floor has the negative consequence of pelvic organ prolapse and/or stress urinary incontinence.
Mandy’s Story:
Mandy returned to her local gym 8 months after the birth of her third child. After 3 months of enjoying multi weekly gym visits Mandy presented frustrated that she still looked 6 months pregnant. Mandy experienced mild stress urinary incontinence and abdominal discomfort with exercise.
Mandy’s typical abdominal routine included sit ups which she enjoyed doing. Mandy performed these sit ups with her abdomen swelling outwards and on real time ultrasound observation her bladder descended downwards into her vagina.
Mandy was horrified that she had been working out for the past 3 months potentially developing a prolapse and worsening her stress urinary incontinence. She was upset that the fitness instructors had not corrected her poor technique and wondered why her pelvic floor muscles were not discussed considering she was recovering from the birth of her third child.
Mandy was then taught, in physiotherapy, how to correctly recruit her pelvic floor muscles and perform an appropriate and partial sit-up. When viewing on real time ultrasound, whilst doing this exercise, Mandy maintained an elevated pelvic floor with minimal downward movement of her bladder.
Mandy left with the motto “Pelvic Floor First” before exercise.
Information:
Real Time Ultrasound is a wonderful biofeedback tool where you get to see your deep core muscles work on the screen.
It is vital for all fitness professionals to see and feel how their core muscles are recruited so they can teach this to their clients.
Abdominal muscle cylinder (core) includes the transversus abdominus, pelvic floor muscles, deep lower back muscles (multifidus) and diaphragm. The four parts of the abdominal cylinder work synergistically together to best support the spine. This is referred to lumber pelvic stability in the literature and often spoken of as “neutral” spine.
The deep abdominal muscle transversus abdominus, surrounds the trunk and acts like a natural back brace. The pelvic floor works to regulate bladder and bowel control, support the pelvic organs and is important in sexual function. These muscles work in unison with the diaphragm and other spinal stabilising muscles to provide core stability.
Scientific research has shown that during an episode of low back pain these important deep stabilising muscles, the multifidus, can switch off and waste away long after the pain has settled. They do not automatically return to ideal function on resolution of pain. This is why it is vital after an episode of low back pain that your deep stabilising muscles are assessed. This information should empower fitness professionals that if they are able to teach neutral spine and cue clients correctly recruiting their pelvic floor muscles before exercise, they may be reducing recurring episodes of low back pain, stress urinary incontinence and prolapse symptoms.
This information below about Pelvic floor muscle strength training should EMPOWER all Fitness professionals to be comfortable about discussing with clients the pelvic floor muscles and possible associated pelvic floor dysfunctions such as incontinence and prolapse symptoms.
Did you know that
- 65% of women sitting in a GP’s waiting room have some type of incontinence – less than a third will seek your help
- 1 in 3 Australian women suffer from urinary incontinence
- 43% of subjects with incontinence and prolapse depressed their pelvic floor on ultrasound when instructed to lift (straining strategy)
There is:
- Level 1A evidence, Grade A recommendation, Fourth International Consultation on Incontinence (Abrams et al, 2009)
“Pelvic floor muscle training should be offered as first-line therapy to all women with stress, urge or mixed urinary incontinence”
Morphological changes after pelvic floor muscle strength training (RCT):
- Increased muscle thickness, 1.9mm
- Decreased hiatal area by 1.8cm squared
- Shortened muscle length by 6.1mm
- Elevated the position of the bladder by 4.3mm
- Rectum elevated by 6.7mm
- Increase maximal urethra closure by 11.1 mm2.
- Reduced hiatal area and muscle length at maximum Valsalva indicating increased pelvic floor muscle stiffness
- Inhibition of detrusor contraction
Obstetrics & Gynaecology (2010), Hoff Braekken