Under Pressure

​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 people 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.

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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.

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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.

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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. . 

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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! 

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