Dear Greg

Dear Greg,

Thanks for a well written and thought provoking response  to my Dear Coach blog. As you noted, “not an attack”, just an opportunity for a discussion. You brought up many great points, so let’s discuss! For those listening in to our conversation, please read Dear Coach, then Dear Julie to follow along. I think you will find that we are likely even more aligned than 90%.

First, I just wanted to address audience and goals for our blogs. You read my primary message as simply anti-crunch, stating “The big issue you had with your coach was his use of the crunch in his conditioning program”. The coaches comments provided me with the opportunity I have been looking for to address what, I believe, is a huge overfocus on abdominal use and training in many youth fitness, coaching, adult training/fitness, rehab settings and the impact that ab-overfocus has on other systems in the body. It is an oversimplification to water that down to simply an anti-crunch message. It is the volume of ab focused exercise in most programs, unbalanced by working any other muscle group with a similar volume that troubles me. I am not anti-ab, I am anti-ab only. Crunches just happen to be the primary way that ab-overfocus occurs in most programs. A variety of crunches seems to be in the arsenal of most coaches and trainers, but a similar arsenal of glute, lats, adductors, etc activities to create a balanced central stability system are not. Most coaches do not have your background. I would love it if a PT/DC, spinal biomechanist that trained with Stu McGill, and was a gymnast himself was my daughters gymnastics coach (any plans to open a gym here in California?), but that is not the experience of most youth coaches out there. I am not disparaging their commitment, willingness to step up and provide my kids with sport experience, their love of the game they coach, etc. But many do not have an educational or experiential background that helps them develop balanced programs, with judicious and effective use of strengthening exercises. So my “big issue” or rather my big goals were to take some of what we are learning in our fields, and give coaches, youth fitness, trainers, and rehab therapists some understanding of how the research is evolving, offer some alternative ideas to create a more balanced developmentally appropriate program and recognize the impact of abs-heavy programming on a more global level in terms of the impact on respiratory patterns and the pelvic floor. To offer ideas and reasoning behind thinking beyond the ubiquitous crunch. Much of the work I incorporate is ongoing in the 2000’s particularly as it relates to the role of the pelvic floor, the brain and movement, the brain and fitness, pain, and alignment not only the 90’s as you noted. I recognize that you are addressing a specific issue in your blog, and a response to mine was a vehicle to do that. But I do not want those other messages to get lost as simply a crunch vs anti-crunch discussion. The crunch is a symptom of a larger problem, which is abdominal overuse and the over-emphasis on abdominal training, particularly in the absence of training other muscular components.

My second overarching goal for my blog was to address developmentally appropriate activities in youth recreational sports, not in high-level athletics, older athletes and adults which seemed to be the population you were addressing in your blog. For me the gymnastics coaches “hard middle” comment was a vehicle to address this in all youth sports, not just gymnastics. As I noted as a sidebar at the end of my blog, this was a generalized blog based on multiple coach experiences. Of course, I picked the sport you are passionate about! Mine is soccer. I coached my son’s team this year, and saw other teams doing crunches during practice. I agree that repeated spinal flexion occurs in natural movement in soccer, but it doesn’t occur at the extremes in a loaded way in soccer as it does in some of the sport pictures you highlighted (gymnastics, rowing). Except for perhaps throw-ins, and at my sons level of competition (8-U) constantly looking down at their feet while dribbling. I was way more concerned about the need for more glutes and extension work for many of the boys on the team for a variety of reasons. But I didn’t work on it with high reps of donkey kicks or planks with hip extension. I tried to use obstacle course games that used the body as a whole but emphasized the glutes and were soccer relatable. In other words goal directed, developmentally appropriate activities for a bunch of 7-year old crazy boys! I also wanted to make it fun to engage the boys, and set them up for a positive experience and a lifetime of fitness and sport participation. John Ratey’s book “Spark” is an excellent look at exercise and the brain, and an alternative model for fitness and physical education in kids that supports these ideas.

Many of your pictures and well made points I think related to a much higher level of competition and likely older athletes. We seem to have lost sight of the YOUTH part of youth sports particularly in the U-12, which is the age group I was discussing in the blog. As you acknowledged, “It (the crunch) may be inappropriate at different times in a training cycle or there may be other exercises that are better for the specific goals of an athlete.” The appropriateness of the crunch in the population I was addressing is a large part of what you perceived as an anti-crunch position, so we may not be comparing apples to apples. And perhaps the better question should be: what populations is the crunch appropriate for? Should 7 year-olds do crunches?  I really don’t think so. Should a 20 year old training for the NCAA Division 1 Gymnastics do some in a balanced way with other muscle strengthening to prep specifically for V-snaps and extreme moves….maybe, but read on.

The third “big issue” I tried to address in Dear Coach, was to highlight integrative activities vs isolation of just abs. If I had to put my stake in the ground on any issue it would not be anti-crunch (or anti-spinal flexion, which other than a mention of McGill’s contribution to our understanding of repeat load on spine health, was a very minor note in my blog) it would be that I am anti-isolationist for any and all muscle groups. I don’t even like giving out bicep curls, wait ‘til the lowly bicep curl defense blog comes my way! I do not think that in function (day-to-day or sport) muscle groups act alone or that we act with a rigid spine (Read here, and watch here). Nor do I think that function and movements simply add up to the strength of the muscles involved. The neuromuscular strategy of recruitment, motor planning and coordination are critical to consider. In the pictures you posted as evidence for spinal flexion in sport, none of them showed pure isolated spinal flexion (see below).

paddling.jpg

I know you know that. But my question would be does the movement, the activity of a crunch actually prepare them for that extreme loaded moment in their sport? Or does mimicking that multi-plane, multi-muscle group, neuromuscular-strategized movement with resistance actually prepare them for that moment? You suggested that the crunch might be a good progression. Perhaps at the early stages, but should high-volume or even low-volume crunches still be occurring as the athlete moves into higher and higher skill level complexity?

I would argue that for my son’s team our throw-in practice was purposeful and meaningful ab and spinal flexion work. I agree with your point that spinal flexion is a part of natural and athletic movements and does need to be trained. However, I would argue that “over-loading” a muscle group as you noted, may not be what I want to focus on with 7-year old neuromuscular systems or 17, 27 or 77 year old ones for that matter. I would rather “over-load” the muscle patterning. Such as in executing the throw-in: the abs in conjunction with the lower quarter anchoring the activity, and the upper quarter executing the motion.

Chris Powers supported this idea when he shared early results of a pilot study he had yet to publish as of March 2012 when I took his class. He compared brain activation pattern changes for an isolated vs movement patterned activity for the glutes. They were somehow able to isolate the brain mapping for glutes. Both groups had brain activity in that glute area with the isolation work (donkey kicks I think) and movement pattern group (single leg squat or step down – my apologies, it was a year ago and I have not seen the final study). More specifically he was looking at learning or, perhaps a better term, automation of activation of the muscle group. Both activities registered high activation patterns in the brains “glute area” during performance. After a period of training the isolated muscle work continued to show a high level of “glute area” noise. However, the movement pattern activity no longer showed much glute area noise. Powers interpretted that the lack of noise actually meant that the skill, the synching, the interplay of the glutes and its counterparts in the movement had been automated and the brain no longer needed to pay as much attention to the glutes. That is what I want to create for my patients, and my kids for their physical health and future. A sub-conscious activation strategy of the glutes, so the brain can activate the glutes (you can insert any muscle name here: abs, adductors, and my fave the pelvic floor) with its counterparts in multiple activities and movements throughout the game, day to day movements, unexpected perturbations in a school hallway or on the field, etc. If loaded spinal flexion is a part of the sport, which I agree is a part of gymnastics at a higher level, not as heavily in the elevated tumbling and balance setting my daughter is currently in, why not an activity that involves the abs in multiple sport specific patterns. Let’s repeat (“overload”) that, let’s add resistance to that. This will train the abs, the other muscles involved in the movement, provides skill refinement opportunities, and train the brain.

The other “big issue” I was trying to address or debunk for coaches, parents and fitness folk was the idea that strong abs = a strong core. This idea is pervasive in fitness culture and fails to take into account the other elements of the deep system, specifically the diaphragm and the pelvic floor. Introducing this faulty idea to girls at 9 is a concern for me. Not just as a mom, but as a practitioner who primarily treats women. The issue as it relates to women and future women is not just self-esteem related as you may have interpreted. The flat abs message that pervades not just fitness culture, but all culture, leads to conscious and eventually subconscious statically held abs in day to day movement and activities. This becomes their strategy for central stability reinforced in their movements. It is not simply when they do a few crunches once a week at recreational gymnastics. But as they grow-up into fitness crazed teen and college-age women who hold their bellies in all day and continue with high volume crunches. The overuse of superficial abs is a significant problem for those of us treating women. It is this chronic overuse, supported by abs-focused programming, that I was addressing with the picture of the balloons in my blog. This was the larger link I was making with incontinence, pain issues and disrupted breathing patterns.

I agree that complex moves in gymnastics can create higher IAP than the crunch. In fact, here is evidence of IAP unmatched by the pelvic floor in a moment for an elite gymnast during competition. The issue of incontinence common among elite female athletes (I discuss it here, and a great lit review is here) is beginning to get some much needed attention and it speaks directly to the issues I am attempting to address. The results of the study “Postural Response of the PF and Abdominal Muscles in Women With and Without Incontinence” by Smith et al (2007) showed that severely incontinent women had the greatest PF and External Oblique output in response to a postural perturbation when compared with continent and mildly incontinent subjects. This led the authors to suggest that “Differences in PF and EO EMG in incontinent women reinforce the need to consider the interaction between muscle groups, rather than the isolated evaluation of PF muscle activity.”

It is the neuromuscular interaction between the contributors to the IAP pressure system that control continence, not simply the pelvic floor acting alone. The study indicates that the pelvic floors of incontinent participants were acting valiantly to try to attenuate pressure from above, but could not match the equally high activity of the EO group. Can we pin that on a history of crunches for the study participants? Was the elite gymnast’s incontinence simply due to some crunches in practice? No, it is in no way that simple, nor is that what I have suggested. Instead I contend that our training programs do not balance the pressures or coordinate the efforts from the contributing muscle groups. The most common imbalance I see is that of overuse of superficial abdominals as static holds throughout the day, compounded by fitness regimens that provide a high volume of crunches without appropriate attention to other central stabilizer muscle groups.

We understand that men and women are different. In the last few years, we have come to understand that carbo loading isn’t as effective in women, women now have their own max heart rate formula, and heart attack symptoms. Is it crazy to imagine that the female musculoskeletal system may require an alternative training program to men? I have no pictures of men accidentally soiling themselves during elite competition. Where does this imbalance that contributes to incontinence begin for women? The studies highlighted above on incontinence in athletics are all on women who are in most cases nulliparous (not moms). So it is not pregnancy. I contend that puberty is where we begin to see a shift toward imbalance in girls. An example of that is the significantly greater incidence of female non-contact ACL injuries. Timothy Hewitt (1) called  a “lack of neuromuscular spurt” in girls at puberty that flat-lines their vertical leaps while boys continue to leap higher and higher. Studies (Zazulak et al, Shirey et al ) have shown that changes in central stability and control impact LQ frontal plane control and vulnerability to injury. Central stability (commonly communicated as core stability) requires a balance of all the muscular contributors and the capacity to create a subconscious neuromuscular strategy for graded engagement to meet the demands of the task at hand. Incontinence and lack of lower quarter control are both signals that the balance of the strategy and/or strength of the central stabilizer muscles is off. Should we consider the possibility that women may have a greater challenge to maintain this balance due to structural, musculoskeletal, or neuromuscular factors?  We need to figure the answer to that out, and modify our training regimens accordingly as we unpack this problem. Mine is a prevention and early intervention strategy, attempting to educate coaches on the impact of contributing to an unbalanced system early on with heavy abdominal work.

I also agree that alignment is poorly understood, not universally addressed or assessed in a uniform way and research on alignment is difficult. However, Scannel et al did note that posture is modifiable in response to conditioning and supported clinical practice to do so. You have articulated the opposite argument, with supportive research, that strengthening does not impact posture. Yet, you noted the anecdotal evidence that gymnasts tend toward a certain posture type, this is universally recognized. I can also spot a former ballerina a mile away. The idea that form follows function does seem to be supported by our clinical experience but the evidence seems to be contradictory as to why that occurs. Perhaps by understanding or treating posture from a purely strength or musculoskeletal mindset does not allow us to explain what we see clinically and the variability noted in the research. In the neurological rehab world the concept of “dynamic holding” (2) may help us understand the adaptive changes we see in common posture types. Dynamic holding is essentially excessive co-contraction for stability. This can be seen in a child with cerebral palsy who uses their adductor spasticity as a part of their strategy for upright postures and mobility. It is both their enemy and their friend. As we try to apply this in orthopedics and sports, this speaks to the neuromuscular control of posture versus thinking it through as a balance of the strength of muscle groups surrounding the center. To the topic at hand, I submit that altered muscular holding patterns become both friend and enemy, causing adaptive posturing rather than any true change in length of a muscle group. This may explain the difference between our clinical observations, and the conflict noted in the literature.

Alignment for me also translates to exercise form. In regard to the Sapsford study that showed optimized recruitment of the pelvic floor in what she called upright, unsupported posture, which others might refer to as a more neutral position. You stated: “So they (the pelvic floor) has less activity when your spine is flexed. Why is this a concern?” The concern is that if they are performing day to day tasks, strengthening activities, balance and athletic moves (not just crunches) in alignments that have a flattened lordosis, and tend toward posterior tilt the pelvic, the pelvic floor is less active to match the IAP from above. The Sapsford study also observed that the participants who were continent tended to have a deeper lumbar lordosis, supporting the form follows function idea we understand clinically, and that function seems to follow form as well. You noted that most gymnasts tend toward anterior tilt, and yes some do. However, this blanket assumption needs to be revisited by our community.

gymnast-apt.png

In the image you used (above) to demonstrate this tendency I would argue that she is not in a hyperlordosis/anterior tilt. In hyperlordosis we should see an exaggerated apex of the curve at L4-5, where we  absorb shock. I would argue that the apex of the curve in your example is much higher toward her upper lumbar and lower T-spine. She is achieving that extreme position through the posterior translation of her ribcage. The lumbar spine and pelvis must alter their position to allow her to continue to balance that position, which  ultimately causes a flattening of the lumbar spine and posteriorly tilting of the pelvis (look again). A postion similar to that of the incontinent women in Sapsford’s study. (Great study demonstrating the impact of ribcage position on lumbar and pelvic position here). If she tends toward this “form” in her day to day movements and as she stabilizes in exercise, are she and her pelvic floor gradually being set up for that same elite gymnasts incontinence moment? Hard to say but it may be a place to start as we begin to try to decode this issue for our female athletes. Another commonly held notion is that pregnant women also tend toward hyperlordosis, and anterior tilt. This has also come under the microscope, with a similar conclusion that the majority of the study participants actually had a flattened lumbar spine and posteriorly inclined sacrum. That is the lumbo-pelvic position they then take to pregnancy fitness classes and it follows them to their post-partum stroller fitness classes as well. This is why the application and understanding of the impact on alignment on recruitment of the pelvic floor is a “concern” for me.  This attention to form is not on the radar of most coaches, many fitness folk, and practitioners which is why I hoped to draw attention to it in the blog.

Lots of layers for us to consider as we approach patient care and training. Thanks for the discussion. All the best.

Julie Wiebe, PT

 

  1. Hewett TE, Zazulak BT, The Importance of Trunk Neuromuscular Control in Knee Rehabilitation and Injury Prevention: The Core of Evidence. Annual Conference and Exposition of the American Physical Therapy Association. Boston, Massachusetts; 2010.
  2. Stamer M.  Posture and movement in the child with cerebral palsy.  Arizona, Therapy Skill Builders, 2000.

 

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24 thoughts on “Dear Greg”

  1. Stacy says:

    Great response Julie and wonderful dialogue! I wanted to give my perspective, as a former gymnast (I competed at fairly high levels) who had stress incontinence at the age of 15. I did loads and loads of crunches, sit-ups, v-sits, leg pulls, etc throughout my gymnastics career. I had beautiful abs and was one of the strongest on my team in regards to my core and moves that involved pure core strength. These kind of exercises may very well overtrain the core and lead to improved performance in the sport. (Although I do question that esp with gymnastics- are there studies that show that overloading the abs beyond what they are already doing improves performance ?) But as you stated, training for sport performance can lead to problems with imbalanced muscle activity and poor function of what those muscles are actually supposed to be doing in every day life. It is not just the additional ab training, but what is happening in the sport itself. You made excellent points about how this carries on into adulthood for these women- how they hold their bodies, and the constant gut holding and believing more ab work is what is needed when they start to notice problems- that has been me. And it led to further stress incontinence and diastasis after having children. It would be nice for these young athletes to be taught that the way they move and hold themselves for their sport should stop when they walk out the door. The thorax thrust forward gymnast posture with abs pulled in tight does not have to look like that the rest of the day. And that the conditioning they are doing may be good for the sport but not for their long term health. Yes, loaded spinal flexion and increased IAP may be necessary for their sport, and they may handle it just fine as children, but why are they still training that way at the age of 40 or 50 when they are no longer training for their sport? It certainly isn’t good for their spinal health when done over decades into adulthood and combined with more sitting. And awareness for these girls and their moms that this is a big issue so they can seek help when needed- I didn’t know about incontinence among female athletes until recently and hid it with alot of embarrassment, worry and trips to the bathroom.

    Also, even though you don’t see the stress incontinence with boys I do think the overtrained abs and habitual dynamic holding could lead to different types of problems. I’m sure the research isn’t there yet, but I wonder if men in their 50s with prostatitis or pelvic pain have similar kinds of habitual holding patterns. Or at younger ages, non-optimal breathing patterns that can cause all kinds of issues….

    1. Julie Wiebe says:

      Hi Stacy,

      Thanks for weighing in. Your experience is so common, and is partly why I wrote the blog. We have so much more to learn and as we raise more questions I hope we can build better training models that may not lead to a sacrifice of continence for girls and set them up for issues as adults.

      You raised a great question ” are there studies that show that overloading the abs beyond what they are already doing improves performance ?” . I do not know of any, but that is an assumption that seems to underly a lot of training principles/programs.

      Looking at these issues across the lifespan is really critical as we consider training regimens in youth programs.

      Thanks for your comment. Julie

  2. Kristine says:

    This is fantastic, Julie, on so many levels. As both a mom of girls and an instructor of both pregnant and postpartum moms in one of those stroller classes, I will be thinking on this one awhile. Thanks for taking the time to address Greg’s response.

    I am presently struggling with whether to enroll my 4 year old in ballet classes. She is *dying* to take them, but you’re “I can spot a former ballerina a mile away” bit? … man oh man, I just cringe at the thought of what I feel like I would be training her little body to be. It’s one of those tough parenting moments where sometimes I wish I didn’t know quite so much!

    1. Julie Wiebe says:

      Hi Kristine,
      Thanks for weighing in. There IS a lot for us to think on and consider for girls and women in regards to these.
      But please don’t let restricting participation for girls be one of the take away’s from this dialogue! One of the pieces of the puzzle I left out of the post, b/c it was full enough, is the impact of early sport specialization. We are seeing more overuse injuries in youth athletes these days in part b.c. they focus very young on one sport, and one way to move and use their bodies. They have lost the protection of participating in multiple sports over the course of the year. The 3-season athlete got to use muscles in a different way with each new sport, which is a great way to develop gross motor skills in general.
      So ballet, or gymnastics aren’t bad….bodies just need balance, which a major point I am trying to make in both of these blogs. If your daughter is balancing ballet with climbing on the monkey bars, swimming, skipping, hopscotch, and running. I think she is good to go! And she has you to guide her!
      All the best! Julie

  3. Greg Lehman says:

    Hi Julie,

    Thanks for this. Just a few brief comments. Again we agree on much of this. Thanks for clarifying your points.

    To summarize our similarities:

    1. Variety in training is good – train more than ABs – no issue there

    2. Core strength/control/health is more than abdominal strength. On board for a long time.

    3.We should have age appropriate conditioning

    4. Anti-isolation training – I agree to an extent but still believe there is carryover. The movement and velocity specific training still supports this. But, this is a big debate in the strength field so I will stay out of it for now.

    5. Joan Scannel’s paper: the changes were quite minor and not all that robust. I reviewed Joan’s paper in the blog I linked to.

    6. Posture can be changed but it is certainly more than tightening up a muscle with strength. This is neurologically driven, may be habitually and can also be defensive

    Now where we differ 🙂 but not so much.

    A. You wrote “The most common imbalance I see is that of overuse of superficial abdominals as static holds throughout the day, compounded by fitness regimens that provide a high volume of crunches without appropriate attention to other central stabilizer muscle groups”

    I can’t argue this because it is a clinical observation that assumes a lot. We can’t accurately see superficial abdominal activity. Especially, since the research does not strongly support this. In the studies that show more supercial activity (probably due to differences in posture like the Sapsford study shows) the differences are 3-10% MVC. You can’t see this with the naked eye. I worked with EMG for 10 years and I am the first to recognize its limitations.

    B. In regard to the Sapsford study I think this is where we diverge the most. That study seems to guide a lot of your clinical thinking. I think the study has a few limitation in how it is clinically applied.

    You wrote “In regard to the Sapsford study that showed optimized recruitment of the pelvic floor in what she called upright, unsupported posture, which others might refer to as a more neutral position. You stated: “So they (the pelvic floor) has less activity when your spine is flexed. Why is this a concern?” The concern is that if they are performing day to day tasks, strengthening activities, balance and athletic moves (not just crunches) in alignments that have a flattened lordosis, and tend toward posterior tilt the pelvic, the pelvic floor is less active to match the IAP from above. The Sapsford study also observed that the participants who were continent tended to have a deeper lumbar lordosis, supporting the form follows function idea we understand clinically, and that function seems to follow form as well

    My concerns are:

    1. There are a few assumptions in here and the authors make some conclusions but don’t consider that their data can lead us to completely different conclusions.

    2. This study was just done with subjects sitting in different positions. There was less activity in the pelvic floor when the participants slumped. Some might think that this is a negative thing. I would ask why? Perhaps there is less activity at this position because there is no need to have more activity. So you might interpret less activity while slumped (aka posterior pelvic tilt) as a bad thing I just interpret as a “thing” that the body chooses to do to satisfy the demands on the neuromuscular system. Further,the authors did not investigate PFM activity during loaded flexion. We can’t extend a decreased amount of PFM activity in unsupported sitting to the performance of crunches or flexion. It is a completely different task.

    Further, look at the work out of Linda McLean’s lab (another former supervisor of mine, :)) http://www.ncbi.nlm.nih.gov/pubmed/20833070 They also found less activity during a hypolordotic position. But because they collected more data they were able to make a conclusion about the signficance of less activity.

    They wrote “Despite optimal PFM EMG activation being found in the neutral posture, this posture was not the ideal position for the generation of intra-vaginal pressure. Higher pressures may be produced in the hypolordotic position due to the orientation of the PFMs relative to the vaginal lumen. In hypolordosis, the PFMs are oriented approximately perpendicular to the vaginal canal. Although the PFMs are not contracting as strongly in this position, intra-vaginal pressure may be maximized due to optimal transmission of the anterior forces generated through PFM contraction squeezing the vaginal lumen between the pubic symphysis and the PFMs. In a normal or hyperlordotic posture, the PFM contraction may create lower resultant closure forces because the force vector is further away from being perpendicular to the vaginal lumen in these postures”.

    That in a nutshell is the limitation of EMG. It does not tell us the whole picture. It tells how active a muscle is. We assign value to this activity and often we might want to reserve our judgement.

    3. The increased lordosis in the asymptomatic group tells us very little. The sample size was small (now down to 13 total for both groups). The lordosis difference was 5 mm. That is nothing.

    4. The authors try to force the belief that there is more superficial muscle activity in the asymptomatic group by saying there is a trend. That is not what their results showed. A trend is not significance. They are forcing this issue. Further, if you take a look at their results we see that the trend is really force and we can even argue the opposite. Look at all five superficial muscles during unsupported upright sitting. Three out of the five have less activity in the asymptomatic group. In unsupported sitting both the right external and left internal oblique have less activity whereas the opposite is seen on the other sides of body. To me, they are forcing the idea that the superficial muscles are overactive. Their results did not support this yet they put it in the discussion. Clinicians then take these discussion points that are unsupported and tout them like evidence.

    5. Last, why is less activity during a hypolordosis a bad thing? It gives the muscles a break. They work less at this range. No one has shown they are dysfunctional in this posture, just less activity.

    It would be very interesting if future research actually shows that hypolordosis prediposes women to incontinence. We might also want to question whether the reduced lordosis(remember, it was a reduced lordosis not a hypolordosis, and at that only minimally different by 5 mm) seen in the incontinent women in the Sapsford study is a defense and not a defect. With McLean’s study showing this might be a better position perhaps they adopt this posture protectively.

    All the best,

    Greg

    Greg

    1. Julie Wiebe says:

      Thanks Greg. Briefly in response to the research you cited. There is very little literature in regards to activation of the pelvic floor and its relationship to alignment. So we try to create programs that adhere to what little evidence we do have. I am familiar with the McLean study and my primary concern with it was that while they measured lumbo-pelvic angles they did not take into account the impact of the UQ (and thoracic position) on the angle of the lumbar curve. In the picture they provided to show the test set-up…it is unclear to me if this is their definition of hypolordosis? Or neutral? I am unable to rectify that with what I see in her thoracic cage position. They called hyperlordotic a “normal” posture, does that mean that in assuming a hypolordotic position they had actually moved into neutral? Are we comparing apples to apples? They acknowledged that their findings were different than Sapsfords, could this be the explaination? Sapsford’s positioning did alter thoracic position and take its influence into account. They looked at standing and had everyone slightly bend knees which would alter their “habitual posture”, pelvic and lumbar position. But habitual posture was deemed the best, were those positions their true “habits”. Our collective understanding and definitions of alignment are murky, in part b/c we name it based on one area of the body (lumbo-pelvic) when LQ and UQ influences can have a significant impact on the lumbo-pelvic position. The McLean study also only looked at continent women.

      Thanks again for the dialogue! Julie

  4. Meredith says:

    Can I ask a question from a patient perspective? I’ve been told lots of different things about where my pelvis should be to deal with minor stress incontinence (yes, I know the upper half should also be aligned, that advice seems consistent across advise givers). I read a lot that suggested lordosis and the dangers of a tucked pelvis (aka Christine Kent and the whole woman) so lordosis I went, then I went to PT and my therapist said I was too lordotic, so tucked I went, then I read that neutral was right, so untucked I went, but not as lordotic as Kent suggests (plus, Kent’s science seems odd and her one lordosis fits all description of treating prolapse doesn’t feel sound, as in literally, my back hurts). I’ve been trying to find neutral, but frankly all these blog posts and different opinions hurt my head. The more I delve into the inner world of physical therapy, the more I realize much of the time everyone has a different I’m positive this is right guess. If you were to give advice to the average woman who just wants to walk around and live her life in a way that won’t aggravate things, when looking in the mirror, how does one find the right position of the pelvis? And what are your thoughts on the hyperlordosis of the whole woman program? Thanks!

    1. Julie Wiebe says:

      Hi Meredith,

      I am really glad you asked that question. As this conversation demonstrates, and you have experienced, even though there is agreement on a majority of the evidence/issues, how we apply that clinically has variability. Patients get caught in the middle. In addition, alignment in particular is very difficult to study b/c there are so many variables that play into it, so this area of research is evolving. As I noted in the blog and my response to Greg’s comment above is that we have defined posture by the position of the pelvis and lumbar spine. But this fails to take into account the position of the upper quarter (UQ) meaning the upper body. The position of that UQ will influence your attempts to tuck, untuck or neutral-fy your pelvis. If this wasn’t considered as you made your attempts to change alignment, it may have added to your difficulty, inability to hold any alignment alterations and irritated your new and old, unresolved symptoms. What I suggest is taking a look at my Fit Floor 1 – 3 videos on my You Tube channel http://www.youtube.com/user/JulieWiebePT?feature=mhee . The videos have some practical how-to’s to try to find the right position of the pelvis and ribcage and the relationship that realigning those components has on pelvic floor function.

      Regarding the whole woman program. I have only read a little bit of Kent’s info so I may not be the best person to comment on her program. I will say that what I did read promoted a hyperlordosis, which I don’t agree with as a “normal” or ideal. And I too was unclear on her science. One thing that was clear though, she is pretty anti-physical therapy. Sorry I can’t really comment more on her work.

      Thanks for weighing in. Julie

  5. Meredith says:

    Thanks for responding. I’m going to watch those videos tonight.

    1. Julie Wiebe says:

      Sure! Let me know how it goes. Julie

      1. Hi Julie,

        First of all thanks very much for sharing your discussion with Greg Lehman. So much valuable information comes from seeing two great minds debating issues and comparing points of views.
        I have just watched the three videos you mentioned above to Meredith and have a couple of questions:
        1. The inefficient alignment you talk about in the third video involves a combination of a bum tuck, i.e. posterior pelvic tilt, with in your words “a shifting of the ribcage up and back.” I am trying to see what would cause this shift as, in my own experience, I see posterior pelvic tilt typically accompanied by forward shoulders and curvature of the thoracic spine, which in essence brings the ribcage forwards and down?
        2. The ski jump maneuvre you describe to correct the alignment – is this accompanied by a conscious anterior tilting of the pelvis to bring it out of posterior tilt, or are you suggesting that the forward shifting of the rib cage (by leaning forwards) will alone “untuck the bum”?
        Thanks again for sharing your knowledge. Much appreciated,
        Matt.

        1. Julie Wiebe says:

          Hi Matt,

          Thanks for the kind words. Great questions. Regarding number one, yes, there is more to it than I could give in the short video. We have always understood pelvic tilt in the extremes, and in an isolated way. This rib cage movement idea is a new one to layer on top and name. I think of the ribcage as a bell ringing on the spine, swinging from the shoulder girdle (and name it by the lower ribcage position). If we swing the bell anteriorly and superiorly we see the shift toward posterior pelvic tilt, flattened lordosis with the ribcage translated posteriorly and the lower rib cage tilted up that I noted in the picture that Greg posted. This is a common post-partum presentation, that is frequently confused for anterior tilt (check it out on a few of your patients, where is that lumbar apex?). I focused on this in the video.

          But the bell can also ring the other way. If we swing the bell posteriorly and inferiorly (again I am naming by the lower rib cage), we see a different looking posture type. I think this is what you are calling ribcage forwards and down ( you named by the upper ribcage position). However, we still get a relative translation of the ribcage posterior to the pelvis in terms of COM displacement which exaggerates the posterior tilt. These are the folks with the super flat bums, that we have always thought of as posterior titled hypolordosis! The first set of bell ringers (anterior/superior, noted in the video and blog pic) are misunderstood and treated like anterior tilters. This group also has forward head, rounded shoulders, it is just masked by the position of the thorax. When you stack them back up ribs over pelvis, you can see how rounded they really are. Thinking this thru as a bell ringing of ribs on spine, also helps to explain those folks that look kyphotic, have rounded shoulders and forward head but T2-T7 is flat as a board.

          Regarding number two. The ski jump is a great tool for patient awareness. But it is only a tool that does need to be tweaked for some. When I use that “trick” during a talk with a crowd, I let them feel the activation pattern of the pelvic floor that a shift in their posture creates, front vs back. Inevitably, there are a few that do not feel a change as they shift. They used to stump me! Until I realized they shifted forward, but the ribcage stayed behind the pelvis, thus the pelvic didn’t naturally untuck. Those folks need some hands-on cueing and/or more visual feedback. Or a different cue entirely.

          Hope that helps, thanks for your questions and taking the time to view the videos. Julie

  6. Greg Lehman says:

    Hi Julie,

    Two quick points/questions that are unrelated:

    1. You are anti-isolationist and wish for all conditioniing to close match (i.e be specific) to the goal task. I would suggest that no exercise can isolate any muscle. A curl up activates the RA, EO, IO, Tranny, Rec Fem, PFM, Diaghragm, Psoas, hamstrings etc. A plank would do much the same (and you advocated)I don’t see the plank being any less of an isolation activity. Glut Bridge, Bird dog, side bridge, squat, deadlift. All of these bias certain muscle groups. Further, we think that if we just add load to movement than that movement is now specific and thus better. As soon as you add load you change how are nervous system works. It is no longer specific as kinematics, force profiles and kinetics change. Hence, my defense for simple exercises. We can’t just train the exact task we want to do. Otherwise, why would any athlete other than an olympic lifter do Olympic lifting, or deadlifting, heavy squatting.

    2. More of a question about posture: Do you think that those with incontinence tend to do all of their tasks in posterior pelvic tilt? If so, is your recommendation that they try to always maintain a neutral spine? What about all of the other wonderful movements that the spine can undergo? No more flexion, arcing twisting, bending? Why ignore this variability? I have an issue not with one specific posture being “bad” but with the lack fo variability we have in our postures…neutral spine included.

    Do you know of any data that shows that those with incontinence are generally deviated from neutral. Would not a great study be to assess spine posture over the course of day? My guess is that any tendency you see toward a static or time limited dynamic assessment of spine posture will wash out with all of the movement demands that normal life places on our spine.

    Greg

    1. Julie Wiebe says:

      Hey Greg
      I think we agree that no activity isolates any one muscle group, but the activity trains them differently. My preference for a plank is that it challenges all the muscles you mentioned to activate together toward a common goal. But within that I tried to communicate that my integrative goal with any exercise, simple or complex, is to first build the neuromotor program and pattern. I don’t want to layer strength on a dysfunctional pattern. You mentioned the pelvic floor above, I think we have assumed for far too long that the pelvic floor is just coming along properly for the ride through general conditioning work. I think the incontinence of elite female athletes is a prime example that this is a faulty assumption. Patterning that pelvic floor into activity will encourage its participation. @neuromater posted a great link in this regard http://www.ncbi.nlm.nih.gov/m/pubmed/23122895/?i=3&from=pressure%20on%20pelvic%20floor%20muscles

      I do think that alignment supports building and optimizing that neuromotor program. And your right we need more research to support this idea. My concern for our attention to the UQ and its impact on the position of the lumbar spine and pelvis is because of the relationship between the diaphragm and pelvic floor. That interrelationship is part of the neuromotor program/strategy and pressure regulation that balances the central stability system and promotes pelvic floor activation. Once I have built that neuromotor program in an optimized alignment, which I do think is neutral, I challenge it. But as I previously stated I cannot in my finite abilities train my patient or athlete for every moment, every natural movement, or loaded moment in life or sport. (I do not ignore these other moments, nor do I expect my basketball player to maintain neutral spine while scrambling for a loose ball, nor do I think you would want your dead lifter to perform that lift with rounded spine and locked knees). My goal is that by building on the strategy the brain will apply an appropriate, graded response to meet the task with all the components of the stability system online and at its disposal. The “balance” of activation and pressures required for that moment. The demands of the moment will not always be equal, it depends on the position (alignment) the activity is performed in or load. But the brain is a better judge of what that balance needs to be than I. My initial assertion was that overtraining the abs, builds a faulty neuromotor and pressure regulating strategy for stability. My suggestion is a different starting point: rebuild that neuromotor program, restore the balance and keep that in mind as we then layer a dead lift or a glute bridge or sport specific activity on top of that. Then we have built an integrative activity out of any exercise.

      I appreciate the dialogue. Neither of us has all the answers, I know I have way more questions than answers. But I hope the questions we’ve both raised will keep moving us toward better and better programming for those in our care. I am glad to say we can end our dialogue on a note of agreement…yes, please let’s do lots of studies on alignment! These types of clinical questions and patient needs (like Stacy and Meredith above) drive both clinical innovation to find real time solutions and future research pursuits.
      All the best-Julie

      1. Greg Lehman says:

        Hi Julie,

        Found some old (but new to me) research that I thought was relevant. First, a clarification on the Capson study which I consider superior to the Sapsford study. They used markers opto markers over L5 and L2 according to a protocol by Hodges to measure lumbar displacement. They measured habitual posture (neutral), hypolordosis and hyperlordosis. Their hypolordosis is not their neutral. This is stated in the methods section. Last, measuring this angle of lordosis does take into account the position of the thorax. How the thorax moves is reflected in changes in the lordotic angle.

        These authors showed that hypolordosis (a flexed spine, a deviation from neutral) showed no negative effects on pelvic function. I think this is extremely important because it suggests we need to question the idea that neutral is supreme. We need to stop fearing flexion. Eliminating this fear may be important in eliminating the kinesiophobia that so many have that contributes to their pain.

        Last. Here are two papers showing that gymnasts do not develop hypolordosis over time. While I personal don’t think posture is extremely important for pain or dysfunction these studies certainly suggest that this flexion related sport does not lead to a flexion related habit.

        http://www.ncbi.nlm.nih.gov/pubmed/10921639

        http://www.ncbi.nlm.nih.gov/pubmed/8316886

        The irony of all this is that I used to be a huge neutral spine adherent and that my biggest mentor and my go-to spine researcher (McGill) would completely disagree with me :). But that’s why he likes me.

        All the best,

        Greg

        1. Julie Wiebe says:

          Hey Greg,

          Just a few comments on the Capson study. Regarding the thoracic issue: while I agree that any change in lumbar position will impact the thorax and vice versa, this is not how we typically analyze or discuss postural alignment. The Capson group discussed/cited studies on pelvic and sacral contributions to lordosis, modified the posture by bending knees, and put 3-D analytic sensors on all the LE joints, but none on the thorax. So it does not seem they gave the attention to the possible contribution of the thorax and thoracic cage they gave to the LQ. Whereas the Sapsford studies were in sitting, so the thorax and thoracic cage were one of the primary areas that could be altered to impact the lordosis and pelvis. As a side note, a sitting vs standing study was noted by Capson as a source of the differences in the outcomes and something worthy of note.

          So in the face of conflicting study results, not uncommon in the world of research, what is the weary clinician to do? We sift through the differences and seemingly contradictory information by matching it with our clinical perspective and experience, and then move forward with well-informed patient care. From the results of these studies we can gather that alignment impacts the activation, and participation of the pelvic floor. This in and of itself is an important and critical takeaway from both studies for any practitioner that has not considered the value this has in their patient’s course. My preference for neutral to include that piece of the puzzle for my patients is multifaceted, and has nothing to do with a “fear of flexion”.

          First, in my experience, posterior pelvic tilt/hypolordosis tends to create an overuse of the posterior pelvic floor. Many women, particularly those learning to use the PFMs consciously for the first time, are more familliar with the posterior floor and tend to squeeze/grip their anus (everyone gets stopping a fart) and/or their glutes. This activation pattern adds pressure on hips, impacts pelvic joints, adds to constipation, and is ultimately ineffective in eliminating urinary incontinence. This is reinforced, in my experience, in a posterior tilt/hypolorditic position. This does not create the functional, fluid and balanced pelvic floor activation we hope to create for our patients in an integrative model.

          Second, my focus is on an integrative model of pelvic floor activation. In neutral, which I define as rib cage stacked over pelvis, the diaphragm and pelvic floor have the opportunity to optimize their interaction. This is a piece of the puzzle for re-educating the neuromotor/brain strategy for their contribution not only to their physiologic priorities, but their postural control and movement support duties as well. This D/PF optimized relationship is also critical to teaching the PF to relax and lengthen along with inhale, vs just to squeeze. This is important for hypertonic, painful pelvic floors, and re-educating the normal concentric/eccentric capacity of the this muscle group. In neutral that pelvic floor descent on inhale is perceptible and exaggerated, and it is diminished in a posterior tilt. In addition, building pelvic floor activation integratively as a neuromotor/brain strategy vs just as a strengthening model is how I eventually translate this to positions and activities out of neutral. This interaction between the Diaphragm and PF is why thoracic cage positioning is an important variable for me to look at in alignment studies.

          Third, while I am pro-neutral, I am not a fan of the McGill model of achieving it or maintaining it in terms of global bracing of the trunk. Despite that I think he would like me too if he met me. This, to me, is a stiff and un-functional neutral. Perhaps since you have a McGill-esque background this explains why you consider any advocacy for neutral as a “fear of flexion” or “kinesiophobic”. I have an alternative view, I think of neutral as a dynamic balance of systems: physiologic, neuromotor, sensory, pressures and postural control. It is not a stiff, superficially braced entity, but fluid, balanced, functional and fearless! For example, I want my runners in neutral because this encourages reciprocal rotation between torso and pelvis, leading to increased hip extension to finish the stride. Rotation also prevents them from gripping their abs, so they can breathe and access that Diaphragm/Pelvic Floor interaction. You can’t grip your abs or brace if you are rotating. Hardly a fear based or fear communicating clinical decision or approach.

          And look, I managed to get the whole conversation to come full circle again to NO overused or gripped abs!

          Bottom line, if Stu McGill can’t convince you of the merits of neutral then I doubt I ever will. So I think its time we shake and simply agree to disagree.

          All the best. Julie

  7. Laura Gifford says:

    Hi Julie!!
    I love the conversation the two of you are having! Thank you! I just want to add my perspective….
    I am in no way shape or form a researcher and not only appreciate but depend on the work the two of you do to better service my patients.

    I have been implementing your (Julie) work in practice for almost 2 years with fantastic results! No I have not measured the mm of change in flexion of the sacrum or the emg firing of the PFM,s or the posterior translation of the rib cage etc etc, but, what I have seen is a huge reduction in incontinence, and in recurring pain in my patients. I do a lot of work with pregnant and postpartum women ( that being any woman who has ever had a baby) and the postural changes are remarkable! After teaching them a few cues about stacking their rib cage and pelvis and integrating the diaphragm and PFMs things start to change. One of the most significant changes I see is the change in glute recruitment ( no I did not measure this ). You can visually see these women get their bums back!! And this is not a static “hold you spine like this forever ” kind of change. I have found that once we teach this and get the proper recruitment going, the patient no longer has to think about it. The postural change is there! This is how they stand now and how they breathe, when relaxed and not conscious. They naturally come back to this new posture. It’s quite amazing to see. And most importantly the patients are feeling and looking better and are empowered by this knowledge that they can make this significant change by themselves!
    I am so thankful that research is being done. But ultimately, it comes down to how your patients look, feel, and perform. And all I know is that since integrating your work Julie our patients are doing amazing!!
    Thank you for all that you do!!

    1. Julie Wiebe says:

      It is so great to hear from you Laura. I really appreciate you sharing your experience and your patients response to implementing these ideas. Witnessing the system feed on itself through that interplay between the IAP pressure system, the neuromuscular system, and alignment IS fun to watch. I, too, am still amazed each time a patient transforms before my eyes. I am thankful for all the emerging evidence, but I do think there is something to be said for the repeatability of results in the hands of different practitioners. I get it, that is no RCT, but there has to be some merit in repeat results. We can wait for RCT before we act or, paraphrasing a colleague, we can continue to act with the best evidence based tools that we have and seek new answers or learn to refer when that doesn’t work.

      Thanks again Laura, and keep up the good work! Julie

  8. Now let’s talk about swimming. It is one of the best cardio choices for women experiencing pelvic floor dysfunction. Actually, it is one of the best cardio choices for anyone. It is an exercise that works both upper and lower body muscles and it promotes extension as you stretch your body out in the water. As you work to balance your body in the water and work your swimming strokes, it works the many stabilizing muscles, including your transversus abdominus (TA) and multifidi that are so important to pelvic floor recovery. So swimming gets a big thumbs-up from me. For those of you who just don’t like to put your face in the water, you are still not off the hook! You can get in the water holding a kick board with your arms and your head above water, allowing you to still work your lower body in an extended position.

    1. Julie Wiebe says:

      Thanks for weighing in. I like swimming too. My big piece of advice on swimming is to consider using a snorkel so that you can continue to breathe vs breath holding which can create a lot of pressure on the pelvic structures. Maintaining that stabilizing intra-abdominal pressure rhythm between the diaphragm and pelvic floor while swimming is important. OR I simply encourage a focus on bubble blowing between breaths, again this helps to engage the pelvic floor vs stress it thru breath holding. I like kick board training,too. I try to use the board to address rib cage position relative to the pelvis to optimize that diaphragm/pelvic floor position and interaction. Upper body position on the board can feed into a high chest and upper chest breathing pattern or it can be used to diminish it. Lots to consider!
      Thanks for your comments. Take care! Julie”

  9. Unfortunately, most of the resources you’ll find in books, magazines and the internet simply recommend that you limit your choice of exercises to pelvic tilts (literally just standing there and tilting your pelvic muscle back and forth) or Kegel exercises . News flash: these really don’t get rid of a lordotic curve or prevent low back pain.

    1. Julie Wiebe says:

      Agree, we need new tools and more info to help women beyond Kegels and pelvic tilts. Thanks! Julie

  10. Alba Mcmahon says:

    This can be expanded even more when you use the quick lifts, such as the one-hand swing. When compared to the plank, a heavy, one-hand swing can expose the opposing side of the body to as much as 180% of maximum voluntary muscle contraction. At the same time the body is being forced to learn how to stabilize the spine quickly time and time again. Looking at the forces generated in the swing you can see how something as light as a 24kg bell can quickly become all the core training you’ll ever need.

    1. Julie Wiebe says:

      Thanks for your thoughts. Julie

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