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).

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.

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.