Lengthen Before You Strengthen The CORE!
Last week's blog topic addressed what it means to have a healthy core. The deep core muscles have to be working optimally or other compensations will occur that lead to pain and dysfunction. Dr. Vladimir Janda, a 20th century Czech physician who studied muscular imbalances after he contracted polio at age 15, summed up this compensation process: in the presence of dysfunction or inflammation, there is a systematic, predictable and full body response in which certain muscles will become tight and others will become weak or inhibited. He coined the term "cross patterning" and described what happens in the lumbopelvic region. This is the typical pattern seen in most individuals regardless of pain.
For example, pain in the LEFT sacroiliac joint/ buttock area can be caused by trigger points in the RIGHT inner thigh/ adductor muscles. In the cervical region, pain on the RIGHT side of the head and neck can be caused by trigger points on the LEFT side of the neck and shoulder. Since muscles have "memory", they remain tight and dysfunctional, unless there is intervention or treatment. Most of us are so imbalanced and unaware since our only frame of reference is ourselves...so how do you know what "normal" even is?
In the pelvis, muscles that become WEAK or disrupted in function and need to be retrained:
Transversus abdominus (deepest abdominal muscle)
Gluteus maximus, medius and minimus
Multifidus (back muscles)
Adductors (long inner thigh muscles)
Hamstrings (eccentric or lengthening action)
Exercise and rehab should focus on lengthening the tight muscles and strengthening or retraining the weak muscles. However, trigger points and dysfunction need to be addressed first, or strengthening can worsen the problem. For example, doing yoga or stretching exercises with muscles that have trigger points can cause or worsen pain. Imagine a rope that has a knot in it. Does it make any sense to pull the rope from both ends to eliminate the knot? In the same way, muscles that have trigger points, or muscle knots, have to be “untied” first before they can be stretched or strengthened. It is important to 1) Remove the knots and 2) Lengthen before you strengthen!
At our clinic, we teach individuals to do this with therapeutic exercise and tools such as foam rollers or balls in addition to Integrative Dry Needling therapy. Muscles that become TIGHT or hypertonic and need to be lengthened:
Pelvic floor muscles
Hip adductors (short groin muscles)
This is the problem I see with so many women in boot camps, Insanity or P90x workout routines before doing the proper rehab first, especially after having a baby or surgery. (Remember, "once postpartum, always postpartum"). I understand the need to lose weight and gain muscle, but impact exercise should really be avoided until the core is sufficiently strong. Otherwise, the abdominal wall can be like “wet toilet paper”, which is what one of my postpartum patients was told by her surgeon after surgery for stress incontinence. I wonder if she had gained proper core control and avoided running if she really would have needed surgery. Ladies, IT IS NOT NORMAL to leak even a few drops of urine with exercise! Small problems turn into bigger problems!
Following Janda's principles and observing clinical findings in over 20 years as a physical therapist, a disruption in the core muscles can lead to the following problems:
Sciatica (radiating pain down one leg)
Sacroiliac (SI) dysfunction
Pelvic organ prolapse (POP): bladder, vagina, urethra or rectum
Urinary incontinence (involuntary loss of urine)
Fecal incontinence (involuntary loss of stool)
Urinary frequency, urgency or nighttime voiding (nocturia)
Constipation or difficulty eliminating stool
Hip pain or tightness
Menstrual or abdominal cramps
Abnormal breathing patterns
Painful penetration (dyspareunia)
Inability to achieve orgasm (anorgasmia)
Pelvic floor cramps or spasms
Pain with sitting
Pain with lying or sleeping
Inability to exercise
Many individuals have several of these problems and others have just a few. By not addressing one problem, it can lead to other problems. I have had several patients come in for treatment years after having a hysterectomy or abdominal surgery who didn’t realize that the pain that developed in the hip after surgery was part of their current pelvic floor problem. Or what started as “piriformis syndrome” or buttock pain later spread to the pelvic floor and caused pelvic pain. If the hip issue was addressed postsurgically or at the time the symptoms first developed, the pelvic floor problem could have been prevented.
In the case of urinary issues, a woman might start with a small problem of leaking a few drops of urine with a cough or sneeze. She soon begins to restrict her fluid intake or stops at every bathroom in order to keep from leaking. This leads to even more frequent urination to the point that her bladder does not expand during the night and sleep is disrupted. This might worsen when she reaches menopause and estrogen is further depleted which is needed to fluff up or support the lining of the urethra. A little problem can lead to a bigger problem...this can be prevented if addressed early on.
Older women often comment they wish help had been available years ago. That is understandable as very few therapists were trained in women's health to treat these issues. Now we really have no excuse for not getting the help we need other than not being informed. This really is a public health issue, costing millions and maybe even billions of dollars in unnecessary surgeries, medication and protective pads each year in the United States. The fact there is an aisle in the drug stores named "incontinence" should be enough to prompt a change. But unfortunately, there are not commercials or advertisements encouraging us to seek the help of a physical therapist, but rather telling us to put a pad on it to celebrate that “pee happens.” Really? Is this what we should accept? I don’t think so!
How many women do you know that lost their butt muscles after pregnancy? I experienced this after my first delivery despite walking almost every day. If I had to pick something up from the floor or climb stairs, I felt like I was 80 years old. I had to specifically train my gluteal muscles in order to care for my baby and do daily chores. I found myself doing "buns of steel" step aerobics workouts, incorporating lunges and stair stepping even though at the time I didn't realize it wasn't the best exercise for a postpartum woman with an SI joint dysfunction. I also found myself trying to retrain my inner thighs on the adductor machine at the gym, another exercise I now know to wreak havoc on women with core dysfunction. By the way, every woman after pregnancy has a core dysfunction, regardless of obvious symptoms!
I also witnessed gluteal and core weakness in my 12 year old daughter after she had a laparoscopic appendectomy. She struggled to lift her hips off the bed and lost her core strength within the first few weeks after surgery. And when she attempted to run with the cross country team, she developed incisional pain that limited her ability to finish the race. She needed specific rehabilitation to retrain the muscles that became inhibited, in addition to manual therapy to free up adhesions she developed (surgery increases risk of adhesions by 93%). Once she strengthened the correct muscles, she was able to practice and fully participate in meets without pain. Prior to surgery, she had amazing core strength, did advanced Pilates exercises and had no pain or difficulty running. After surgery, she lost her innate control of her muscles. I have to say I was surprised that a young pre-adolescent girl would struggle in her recovery. My 12 year old had the same issues my older women had!
In summary, the following exercises should be avoided until the core is stronger:
1. Sit-ups or crunches
2. Pilates 100s or V sits
3. Adductor machine
4. Running, jogging, jumping or Burpees
5. Repetitive lunging or asymmetrical motions such as bleacher climbing
Once core motor control is regained, I recommend gradually returning to impact and the above exercises with the exception of the adductor machine, which is not a functional exercise (legs spread apart against resistance) and can cause injury to the pelvis and further muscle dysfunction. There are also alternatives to sit-ups and crunches, including Pilates exercises on a mat or Reformer. Dr. Janda discovered this important phenomenom years ago and is an important key to rehabilitation, especially of the pelvis. The deep core must be retrained first and should be the foundation of any exercise program!