Many women come to pelvic health physical therapy and mention their frustration with their lower belly “pooch”. Even in thinner women, no amount of core exercises seems to affect the appearance of their abdomen. The concerns over this so-called pooch can manifest beyond how it looks however. I am often working with women with pelvic floor related problems including incontinence and/or pelvic pain or low back pain. Others may have an excessive abdominal diastasis (a thinning of the connective tissue between the two sides of the abdominal muscles, most common after childbirth). One of the frequent findings in my assessment is that many of these women are chronically “gripping” with their upper abdominal muscles…specifically the external obliques. What I see is increased tone in that area with a bulging just below. There is little expansion of the lower rib cage with breathing as it is being held down by the obliques. In others, the gripping muscles are the internal obliques, and the rib cage is held wide and spread more open.
There are many reasons why this habit may develop. Culturally, we are often told to hold our tummies in and it may sometimes be an effort to appear thinner. Some people have developed the belief that this kind of holding is what they need to do to stabilize their core. Other times, the gripping may be in response to stress, fear or a protective response due to pain. (And though this post focuses on women, many men grip with their abdominals as well!) Whatever the reasons for the gripping habit, it does need to be addressed in order to improve pelvic floor or core function and to better optimize breathing.
Our inner core functions like a canister. Picture a balloon- at the top of the balloon is the respiratory diaphragm. The bottom of the balloon is the pelvic floor musculature. In the middle lies the multiple layers of abdominal muscles, with the inner most transverse abdominus being most integrally connected to the top and bottom of the canister. The pressure within the canister is perfectly balanced.
Now picture hands gripping at the top of the balloon, mimicking what is happening with the obliques. The pressure within the balloon must be displaced somewhere. Sometimes the pressure is directed down into the pelvic floor which may result in leaking, or symptoms of pelvic organ prolapse. The pelvic floor may respond by increasing its activity to match the pressure, which can be a factor in pelvic pain. Other times the pressure is directed outwards into the front abdomen (contributing further to either a diastasis or to a lower belly bulge). There are others with beautiful appearing six pack abs, however they do not know how to relax the gripping when needed, causing unneeded pressure and rigidity around the spine and limiting their mobility. .
In physical therapy I work with people to let go of this oblique gripping habit…and it is not easy! They must learn to breathe by allowing their rib cage to both expand and close three dimensionally while relaxing their upper obliques. These muscles do need to work during more strenuous or balance challenging activities, but certainly not so hard during quiet sitting or standing. Often, we need to address standing alignment habits to allow the obliques to let go. A bit of hands on manual therapy may be needed. Finally, they learn what it feels like to feel quiet stability of the innermost transverse abdominus and pelvic floor muscles- supporting themselves from the bottom up rather than gripping from top down. All of our core muscles are meant to move with us, lengthening, contracting and relaxing depending on the task at hand. Rather than chronically holding and gripping, we want our core to work reflexively along with the movements we make. With enough practice, these new strategies can become automatic and allow us to move with greater ease...and improve the appearance of that lower belly pooch!
Pelvic Health physical therapy is a specialized field within PT that involves additional training. We are able to help many men and women who are suffering from incontinence (leaking urine or feces) or various types of pelvic pain. I talk with women all the time who have no idea that the leaking they are experiencing during exercise, coughing, laughing and sneezing is not something they have to live with the rest of their lives nor is it "just part of aging or having children." Leaking urine is a common problem and not something to be ashamed of, however it is not to be considered "normal". A Women's Health/Pelvic Health physical therapist can help and these conditions can often be improved or eliminated!
Pelvic Health physical therapists learn all about the anatomy, assessment and treatment of the pelvic floor muscles and their involvement in incontinence, pelvic pain and orthopedic conditions. I will leave it for another post to explain more about the function of the pelvic floor and how these muscles team up with other important core muscles. Many people aren't aware of that there even are muscles "down there". In fact, the pelvic floor muscles encompass the entire area from pubic bone to tailbone and outer hip bone to outer hip bone and have an integral relationship with maintaining continence (keeping you leak free!), sexual function, supporting the pelvic organs, and contributing to dynamic stability and efficient movement of the trunk.
There are several types of incontinence. Stress incontinence involves leaking during activities that create a downward pressure into your pelvis, such as jumping, running laughing and coughing. Urge incontinence involves an involuntary loss of urine along with a sudden strong need to urinate. This can sometimes (but not always) go along with an overactive bladder during which a person has a sense of urgency and needs to urinate more than 8 times in 24 hours on a consistent basis. It is not uncommon to have "mixed incontinence" which involves both stress and urge incontinence. Though most women know about Kegel exercises, and may try using them to improve their incontinence, it is often not enough. Studies show that between 30-50% of women doing kegels are doing them incorrectly. In addition, kegels do not work in isolation and need to be trained with other muscles of the body. Many people also need to learn to let go of their pelvic floor musculature, lengthening and relaxing the muscles before they can adequately strengthen them. Conditions such as overactive bladder and urge incontinence can be made worse when women do excessive kegels without first learning to lengthen and relax the muscles. A pelvic health physical therapist is trained to assess these conditions and come up with an individualized treatment plan that may include a bladder retraining program, types of biofeedback, manual therapy, specific exercises that may be isolated to the pelvic floor + other muscles of the core, integrated breathing work, and more. Later in rehab, new musculoskeletal or breathing strategies may be combined with other movements and into your fitness routine or home activities.
Pelvic pain is another condition that pelvic health PTs are trained to assess and treat. There are many examples of pelvic pain. A few examples include: tailbone pain, dysmenorrhea (painful menstruation), vulvodynia, vaginismus and painful sex, interstitial cystitis/painful bladder syndrome, pelvic girdle pain, pelvic organ prolapse and piriformis or buttock pain. Pelvic Health PT is not just for women! Men also suffer with pelvic pain and are often diagnosed with "Chronic Nonbacterial Prostatitis", which usually doesn't involve the prostate at all but rather painful pelvic floor muscles. They may experience pain in the testicles, penis, buttocks, rectum, perineum or lower abdomen that is related to pelvic floor overactivity and tender points. Post prostate surgery, many men experience urinary incontinence and physical therapy is often part of the rehab process. In addition, we are starting to learn that low back pain and pelvic floor muscle overactivity, weakness and tenderness are often associated. Urinary incontinence and low back pain in women also often go hand in hand.
If any of these problems sound a little too familiar, don't hesitate to call and make an appointment with a pelvic health/pelvic floor physical therapist! You can look for a specialist through Herman & Wallace directory or the APTA Section on Women's Health, found through this link.
Stacy is a physical therapist specializing in pelvic health/pelvic floor physical therapy and chronic pain in Germantown and West Bend, WI. Schedule an appointment at Health in Balance PT