Everywhere you turn, it seems there is a commercial, headline, advertisement or article discussing some type of women’s health issue. In particular, many women face challenges with their Pelvic Core Neuromuscular System (PCNS). These problems affect women in all walks of life, including health professionals, teachers, executives, athletes and homemakers. Many do not even know that the pattern they’ve developed is not normal.
Chances are, if many of your clients are women, you’re training someone who has some level of PCNS dysfunction. She may even confide her problems to you. Whether her challenge is urinary incontinence, pelvic-organ prolapse or some other symptom, it is an issue that you as a fitness professional can address with the right education and tools. This article explores the PCNS from multiple angles—which is how you will need to approach a training program for a client facing challenges in this area.
Before learning how to train a client with PCNS dysfunction, it’s important to review the basic connections and foundations that contribute to the issue. The primary role of the PCNS is to integrate proximal stability, which allows for distal mobility (Kibler, Press & Sciascia 2006). The body is connected, bone to bone, muscle to muscle, system to system, by a web of vascular, neural and fascial tissue connections. All systems link through a common core to produce three-dimensional, functional, triplanar movements. The four walls of the core—the abdominals, paraspinals, respiratory diaphragm and pelvic floor—house the crossroads for top-down to bottom-up, three-dimensional, driven movements (Gray & Tiberio 2005).
The core must be activated through frontal, sagittal and transverse planes of motion to load eccentrically in order to concentrically produce functional movement. It sounds simple enough; however, for the core to perform this three-dimensional symphony, the pelvic floor must be able to translate proprioceptive feedback and feedforward from proximal segments of the body to distal segments (Kibler, Press & Sciascia 2006).
In order to sustain a proper degree of resting tone, pelvic-floor integration should occur before the load and unload sequence of function. This helps maintain a patent (unblocked) bowel and bladder, and supports the digestive, reproductive and excretory systems (Barber 2005).
When looking at the big picture of PCNS dysfunction, it is important to understand the anatomical differences between men and women, outside of the obvious. The male pelvis and its contents are biased toward physiologic denseness. The structures are more adjacent and approximated, which allows for faster proprio-
ceptive overflow and muscle recruitment (Ireland & Ott 2004). In addition, the density of the tissues alone may provide a greater support system with less delegation of responsibility on isolated muscles (e.g., muscles that contribute to continence). The result is communal, chain-reactive functional support.
The female pelvic ring and all of its anatomic structures are both advantaged and disadvantaged by fascial space and gapping. The female pelvis must be able to go through the triplanar functional marathon of housing and delivering a baby; however, the room available for expansion and retraction also provides a pathway for proprioceptive miscommunication, or a delay in muscle recruitment. When you understand the female functional anatomy of the PCNS, you will be better able to train your female clients in an environment that will facilitate three-dimensional pelvic-core engagement.
A key element to understand is the orientation of the pelvis in the upright functioning female. The bony pelvis is made up of the ilia, ischia, pubic rami, sacrum and coccyx. When the body is standing, the pelvis is oriented in an anterior tilt position (Barber 2005). The pubic symphysis provides skeletal support to the pelvic-floor muscles and pelvic viscera (bladder, uterus and rectum). The anterior tilt provides a stacking mechanism to the pelvic viscera and the bottom of the PCNS. Many women with PCNS dysfunction present with a posterior pelvic tilt and decreased lumbar lordosis, which compromise the stacking system. You would not want to emphasize a posterior tilt–type exercise with a client of this type. Rather, it might be more beneficial to teach her to take the pelvis through full excursion—exploring the range of anterior to posterior tilt—with an emphasis on returning to an anterior tilt position, hence providing mobility and stability or “mostability.”
The four components of the PCNS are the abdominals, paraspinals, respiratory diaphragm and pelvic floor. If we look more specifically at the pelvic-floor muscles (Figure 1), the striated skeletal muscles include the levator ani muscles, the coccygeus, the external anal sphincter, the deep perineal muscles and the superficial perineal muscles. The levator ani group is made up of several muscles, including the pubococcygeus, the puborectalis and the iliococcygeus.
A valuable connection to appreciate is the fascial connection of the pelvic-floor muscles (levator ani) to an important hip muscle (the obturator internus) via the arcuate tendon. The pelvic fascia is also an important component of support. The fascial attachments of the vaginal wall provide the most important preventive measure against collapse of the bladder or bulging of the rectum into the vagina. Fascial tissue will have added stress in the absence of adequate muscular supports (Calais-Germain 2003). The integrity of the fascial system can be influenced by genetics, hormones, chronic straining, obesity and smoking.
The pelvic-floor muscles are interlayered and interconnected. They must be worked in synergy—not in an isolated fashion—for optimal biomechanical function. Should you tell your client to hold in her abdominals or pelvic-floor muscles when training? In some cases, yes; however, you can create an environment for training the PCNS to react subconsciously and automatically through integrated movements. Understanding the functional anatomy (as well as the dysfunction) will help you design programs to stimulate the PCNS to function as it needs to in everyday life. >>
The pelvic-floor muscles and the diaphragm work in a three-dimensional fashion symmetrically and asymmetrically, depending on the functional task performed. A well-functioning pelvic floor assists in lumbopelvic stability (Markwell 2001). The abdominals, hip muscles and paraspinals provide integrated support through corseting. The most important component in facilitating functional success is creating an environment in which function occurs subconsciously (Gray 2005). All structures must work in an orchestrated fashion. The brain thinks in terms of whole motions, not individual muscles, according to IDEA presenter Chuck Wolf, MS, who specializes in applied biomechanics and is the director of Human Motion Associates in Orlando, Florida.
PCNS dysfunction often begins with weakness in the pelvic-floor muscles, which most commonly starts during pregnancy. Special attention should therefore be paid to this important group of muscles (Moen et al. 2007). The three most common types of dysfunction are urinary incontinence, pelvic-organ prolapse and anal incontinence (Center for Population Research 1999). Pelvic-floor pain is also prevalent and may include various types of pain that can influence urinary, defecatory and sexual function. One in seven American women suffer with chronic pelvic pain (Mathias et al. 1996).
There are various types of urinary incontinence. They include stress incontinence (involuntary loss of urine with an increase in intra-abdominal pressure); urge incontinence (the urge to void with small production of urine); and frequency incontinence (urinating more than eight times in a 24-hour period). Pregnancy increases the incidence of urinary incontinence. Normal bladder patterns include voiding every 2–4 hours during the day and 0–1 times at night (Chiarelli 2002). Another dysfunction, pelvic-organ prolapse, is frequently associated with a feeling of rectal fullness, pelvic heaviness or a bearing-down sensation, especially when standing (Messelink et al. 2005). Other states of prolapse include cystocele (prolapse of the bladder), uterine prolapse (prolapse of the uterus) or rectocele (prolapse of the rectum) (Calais-Germain 2003).
In addition to PCNS dysfunction, orthopedic issues may exist. Low-back pain, sacroiliac joint dysfunction, sciatica, thoracic pain, knee pain, ACL deficiencies and ankle sprains can all be influenced by deficits in the PCNS. Many women do not recognize that the issues they have are abnormal and that treatment is available. You can help them become aware of their dysfunction with appropriate questions (see the sidebar “Recognizing Pelvic-Floor Dysfunction”) and a PCNS assessment (while staying within your scope of practice). Knowing what type of healthcare professionals are available for PCNS issues is also important (see the sidebar “Know Your Healthcare Professionals”).
With an understanding of pelvic-floor anatomy, function and dysfunction, it is safe to apply the concepts to training. It is impossible to train a client and condition the body to function through three-dimensional space without applying proprioceptive “feeding” throughout the pelvic core. Take respiration and the concept of exhalation during exertion, for example. Have you had clients who hold their breath while performing an exercise? Quiet respiration needs to be subconscious and rhythmic in
nature, but the demand of conscious breathing changes with
exertion of force against resistance.
The respiratory diaphragm is three-dimensional and expands in the frontal, sagittal and transverse planes. It activates “ecconcentrically,” which results in the entire group working together as an integrated unit, based on the attachments to the spine and rib cage and the response to gravity and ground reaction force (Christie & Colosi 2006). The diaphragm is fascially connected to the core and loads the anterior and posterior walls, elevating and depressing “the roof” from the top down and the pelvic floor from the bottom up (Christie & Colosi 2006). Three-dimensional core training will automatically stimulate this subconscious activation to allow for proper oxygenation, organ motility, thoracic- and lumbar-spine mobilization and neuromuscular loading and unloading.
At the base of the core, the pelvic-floor muscles also need to be activated subconsciously and automatically in order to establish mobile stability throughout our entire system. Again, these muscles activate ecconcentrically, both lengthening (loading) and contracting (unloading) throughout the musculature and at its insertion points simultaneously, based on functional demand. See the sidebar “Breath and Core Support” for an exercise to try with clients.
Another region of the body that must be assessed for triplanar mostability is the pelvic-hip complex. Hip rotation activities facilitate subconscious activation of the pelvic-floor muscles. Each hip (femoral head, acetabulum, sacroiliac joint and pubic symphysis) must move as symmetrically as possible, through all three planes of motion. Functional, triplanar excursion proprioceptively feeds the pelvic floor on a subconscious level as the lower extremities internally and externally rotate. Gravity and ground reaction forces create dynamic loading and unloading at the hip and in the pelvic core as the body traverses the environment, loading from the top down (e.g., upper-extremity reaching), as well as from the bottom up (e.g., walking). See the sidebar “Pelvic-Hip Complex Pivot Shift Matrix” for a quick test to use with clients to assess the flexibility, mobility and stability of the entire pelvic-hip complex.
A note here about Kegel exercises—conscious pelvic-floor contractions. These exercises are an important component of PCNS function; however, subconscious activation of the PCNS is even more important for the complete pelvic-core integration needed for activities of daily living (see the sidebar “Training in 3D” for exercises that promote this activation).
Understanding functional anatomy will help you to create more variety within your training programs and to obtain, measurable results more quickly. First, understand that triplanar hip rotation activities will facilitate subconscious activation of the pelvic-core muscles. Adding upper-extremity reaches in all three planes of motion and diagonal patterns will integrate abdominal and paraspinal components of the core, further enhancing its synergistic activation. The abdominals need to be loaded in all three planes of motion, beginning with eccentric lengthening or loading, before triplanar unloading (e.g., trunk extension with rotation before moving into trunk flexion with rotation).
Remember to assess the abdominals for diastasis recti, separation of the rectus abdominis muscles at the linea alba. The paraspinals also need to be loaded in all three planes of motion (e.g., trunk flexion and rotation before moving into trunk extension with rotation). Muscles must lengthen first to load, and then shorten to explode into functional movement.
Here is a sequence that will take you and your client through the developmental progression:
- Begin in “hook-lying” position (supine with knees bent): roll knees inward and outward.
- From hook-lying position: roll knees side to side, alternating knees together with knees apart.
- From bridge position: roll knees inward and outward.
- From sitting: roll knees inward and outward.
- From standing: roll knees inward and outward.
Fitness professionals and healthcare practitioners can seek common ground in the effort to improve clients’ overall quality of life. One in three women will develop some type of PCNS dysfunction in their lifetime (Chiarelli 2002). Injury epidemics—
as seen, for example, in the high number of female athletes with anterior cruciate ligament (ACL) tears—may be preventable by influencing PCNS function in three planes of motion (Sokolove 2008). Connecting all parts that make up the whole individual
is key to avoiding patterns of dysfunction that can later become impairments or, in worst-case scenarios, disabilities. By asking the right questions and fully understanding functional female anatomy and biomechanics, you can enhance your clients’ quality of life.
The sample exercise below produces subconscious activation of the PCNS. This is very different from the conscious pelvic-floor contraction known as the Kegel (Kibler, Press & Sciascia 2006). Ninety-nine percent of everyday function is subconscious. The PCNS must be trained to turn on automatically so that it supports the core and allows for optimal biomechanical health.
Cue client to exhale upon exertion. For additional strengthening, add a Pelvicore™ Pro exercise tool, a small round “sponge” ball or a Pilates ring. For additional exercises, read “The Inner Pelvic Core” by Christina Christie, PT, in the November–December 2008 issue of IDEA Fitness Journal. Perform all exercises in sets of 10 repetitions.
Mini Squat With Cross-Punch
- Stand with feet neutral (shoulder width apart, feet facing forward).
- Perform mini squat and roll knees inward.
- Cross-punch in the air (alternate arms) at various levels (up, down, to the side, to the back, diagonally, etc.).
- Perform with toes turned inward and with toes turned outward.
- Repeat whole series with knees rolled outward.
In addition to the Pelvicore, there are other tools available to help you successfully train and stimulate the PCNS. Here is a partial list of products, with contact information:
- Bodyblade®, www.bodyblade.com
- The CoreStick™, www.thecorestick.com
- Tri-Stretch®, www.tristretch.com
- TruStretch, www.grayinstitute.com
Mobility in three planes of motion is an effective way to allow for more resilience throughout the Pelvic Core Neuromuscular System (PCNS) and to wake up the neurological system propriopceptively. Traditionally, stretching has taken place in one plane of motion. By integrating triplanar stretching, you effectively stretch muscles from different angles.
For example, take any traditional stretch and add gentle motion in the sagittal, frontal and transverse planes. To stimulate the PCNS from a traditional runner’s calf stretch against the wall, turn the back foot inward approximately 45 degrees and drive the hips front to back (sagittal plane), side to side (frontal plane) and then clockwise and counterclockwise (transverse plane). Perform each motion for 30–60 seconds. This will allow for mobility throughout the lower girdle, including the PCNS.
When training a client with PCNS challenges, one important task is to teach her how to breathe using the respiratory diaphragm for core support against low resistance. Sounds arbitrary considering that we must breathe to live, but as we know, clients do not always know how to inhale and exhale appropriately upon exertion.
Your client may feel that holding her breath provides stability by locking down the core. Actually, it does not provide functional mostability (mobility and stability); what’s more, it doesn’t feel very good. Breathing through pursed lips provides greater stability, while slowly letting the system adjust through rhythmic, three-dimensional decompression and unloading. The following simple exercise shows how to integrate core stability into breathing.
- Have your client stand with feet shoulder width apart with hands at shoulder height, elbows flexed to sides (you mirror her).
- Instruct the client that she will take a deep breath in, and on the count of three you will give her hands a gentle push as she holds her breath.
- Compare stability.
- Do the same sequence—only this time instruct your client to exhale forcefully as you gently push her hands (compare with task 2).
- Repeat the sequence, but now instruct your client to exhale through pursed lips (like blowing through a pinhole) as you provide gentle, increasing resistance to your push.
- Compare stability.
Urogynecologist: specializes in the care of women with pelvic-floor dysfunction. This professional has completed medical school and a 4-year residency in obstetrics and gynecology. A urogynecologist has additional training and experience in the evaluation and treatment of conditions that affect the female pelvic organs and the muscles and connective tissue that support the organs.
Gynecologist: a physician who has completed specialized education and training in the health of the female reproductive system, including diagnosis and treatment of disorders and diseases.
Obstetrician: a physician who has completed education and training in the management of pregnancy, labor and puerperium (the time period directly following childbirth).
Obstetrician/Gynecologist: a physician who provides medical and surgical care to women and has particular expertise in pregnancy, childbirth and disorders of the reproductive system. This field includes preventive care, prenatal care, detection of sexually transmitted diseases, Pap test screening and family planning.
Physical Therapist: licensed professionals who work with people who have impairments, disabilities or limitations in their overall physical function. Physical therapists examine, evaluate and develop treatment plans on an individual basis. They use manual therapy, functional exercise and other modalities to restore function, improve mobility and decrease pain with the goal of re-establishing a patient’s prior level of function.
Women’s Health Physical Therapist: a physical therapist who has specialized skills and education in the care of the female patient. Areas of focus include pregnancy and pelvic-floor dysfunction.
Fellow of Applied Functional Science: a physical therapist, personal trainer, medical doctor or fitness professional who has specialized training in applied functional science through the understanding of functional principles, strategies and techniques appropriate for use with patients and clients of all types and for all purposes, including prevention, rehabilitation and performance enhancement. This professional will also be certified in functional manual reaction.
The following test (remember, tests become exercises and exercises are tests) assesses and exercises the functional flexibility, mobility and stability of the entire pelvic-hip complex. This is a “Pivot Shift Matrix,” in which we load from the bottom up.
- Have your client demonstrate her ability to perform single-limb balance (SLB) on both lower extremities.
- Start with the more successful side (in this case we will describe standing on the right leg, moving the left leg through space).
- Sagittal Plane: In right SLB, instruct the client to swing the left leg, intentionally and with control, pivoting forward and back at the hips. Let her use the upper trunk to counterbalance. If this is difficult, allow her to toe-touch down in front, then in back.
- Frontal Plane: In right SLB, instruct the client to toe-touch as far to the left as possible and then return to midline. After a brief pause, instruct her to reach the left leg to the right, across the body. Again, let her tilt the torso to counterbalance the full loading and unloading of the hip.
- Transverse Plane: In right SLB, have the client rotate at the right hip, turning the body as a whole to the right and then turning across the body to the left. Again, if balance is deficient, instruct the client to toe-touch at the threshold of each rotation.
This exercise assesses glutes, hamstrings and calf muscles in the sagittal plane; hip abductors and adductors in the frontal plane; and hip internal and external rotators in the transverse plane. It also submaximally and subconsciously stimulates the pelvic core from the ground up. Synergistically you have allowed the abdominals to contribute by decelerating, loading and unloading the upper torso to counterbalance the excursion of the hips.
While it is clearly not within the scope of practice for fitness professionals to diagnose pelvic-floor dysfunction, there are questions you can ask that will help in the allied health professional referral process. The answers will also help with program design.
- How often do you urinate during the day? (Every 2–4 hours, or 6–8 times per day is considered normal.)
- Do you get up at night to go to the bathroom? If yes, how many times? (Zero times to once per night is considered normal.)
- Do you ever have accidental leakage of urine during activities such as coughing, sneezing, laughing, running, exercising or lifting?
- Do you ever have accidental leakage of urine associated with a sudden strong urge to urinate, or do you have trouble reaching the toilet in time?
- Do you do a lot of “just in case” toileting?
- Do you have trouble controlling gas?
- Have you ever lost bowel control?
- If you are sexually active, do you have pain during or after intercourse?
- Do you have pain before, during or after urination or bowel movements?
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