I believe that the concept of core stability has the power to help many people suffering from pain, injury and dysfunction. But when taken out of context, I have seen the core stability phenomenon cause more harm than good.
 
In my practice as an Exercise Physiologist and Pilates Instructor, I use core stability theories and exercises every day.  Unfortunately, I see many clients that have injured themselves by “working on their core” with the wrong information or damaging instruction.  Improper core work can be as harmless as wasting your time, effort and money on a practice that is taking your body backwards rather than functionally progressing.  At its most harmful, back pain and injury, separated abdominals, pelvic floor/continence issues, and hernias are just a few of the ailments that can be made worse with an improper use of the core.
 
With this in mind, I thought it was time to do some serious core stability myth busting.  When we start to understand the true definition of core stability, we will be able to choose our activities, instructors, and daily habits more wisely.   
 
Here are 3 Core Stability myths that can wreak some serious havoc on your body.  Let go of these myths ASAP for a happier, healthier core.

MYTH 1: Grip your abs/suck in your stomach to protect or brace your spine.
 
Core stability mechanisms, in a normal, healthy body, should be automatic. Your Transversus Abodminis (TA), pelvic floor, diaphragm and multifidus (respectively as seen below) work together to dynamically support the spine. These are small, postural muscles that have the ability to turn on and off all day long to bring support to the body. 

Research has shown that if you suddenly move your arm, these muscles (specifically TA and pelvic floor) will contract BEFORE your arm muscles.  The body naturally anticipates movement, and provides the muscular support needed for that action.
 
Unfortunately, it has been shown that people with back pain and women with incontinence have lost this anticipatory mechanism, and the core muscles switch on AFTER the arm moves.  This research illustrates that in a dysfunctional core, timing of the core muscles becomes an issue.
 
This timing problem was commonly solved by telling people to grip their abdominal muscles before movement and constantly “brace” to create support around the spine.  Because if those little muscles aren't activating when they are supposed to, shouldn't we consciously activate them while we move?

No! Rather than restoring your body's natural, dynamic function, consciously bracing the abdominals: 

1. creates tension and compression in the spine (greater wear and tear, risk of disc injury),
2. stops us from restoring the proper motor programs.  Remember this is supposed to be an automatic process, and we need to enable our bodies to restore their natural ability.  Holding tension in the abdominal area (much like a brace) will only weaken the muscles and their ability to function in the way they were intended.

 
Chronically bracing or "sucking in" the abs can also increase intra-abdominal pressure to a dangerous amount.  Imagine a balloon that you squeeze around the middle, where will the contents of the balloon go?  The contents or your abdominal cylinder will eventually seek escape, the possible cause of pelvic prolapse, hernias and other pressure related conditions. 
 
So the moral of the story, avoid sucking your stomach in and gripping/bracing your abdominals.
 
WHAT TO DO INSTEAD:
Learn how to isolate the individual muscles of the core, restore proper activation patterns, and work on whole body alignment so your core works automatically.  Let your core work for you instead of you working your core.
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HOWEVER, this type of movement has no bearing on our definition of core stability, and  does very little to support the integrity of the spine and internal organs. 

It is commonly thought that back pain is due to weak muscles, and strengthening the muscles of the torso is the best solution.  Yes, there can be weakness and muscle atrophy associated with back pain, and yes, strength can play a part.
 
But if the big, global abdominal muscles are activated without the help of the true core stabilisers, you can get some serious problems. As stated previously, people in a pain situation often have dysfunctional timing of these core stabilisers.  Also remember that these "little guys" are the only muscles that provide individual support to each vertebrae.  If you are only activating the big muscles and the little guys aren’t in sync, you can get a shearing affect on the spine, where you slide one vertebrae forward on the others, creating wear and tear on discs and joints.
 
You can also get a big increase in intraabdomnial pressure, especially if you aren’t breathing properly during your crunches, taking us back to all those pressure related injuries mentioned above (prolapse, hernia, diastasis recti, etc).
 
WHAT TO DO INSTEAD:
Restore proper breathing and activation patterns to your true core stabilisers before you layer in the big global muscles.  Taking time to work on the “little guys” will save you many problems in the future.  If in doubt, remember that there are hundreds of whole-body ways to work your “core” without doing a single sit-up.
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In my experience, most people that think they have an anterior pelvic tilt/large lumbar curve/lordosis actually have more of a “sway back” caused by a forward thrust of the pelvis and a lift of the ribcage (see pic below left).  

Here's the missing link: for ideal posture in standing, you must have your ASIS and pubic symphysis in a vertical plane relative to the vertical leg.  The picture below left is how I tend to habitually hold babies, and after a quick look you might suspect a decent lordosis (big lumbar curve).  If you only looked at the pelvic markers, my pelvis appears neutral...but in fact, relative to my legs, my pelvis is actually posteriorly tilted and my lumbar is flat, my glutes are tightened and tucking under, and there is increased pressure on my lumbar discs.  Telling me to tuck my tailbone to reduce this curve will only make the issue much worse.  

WHAT TO DO INSTEAD:
​
Try this simple exercise: Stand how you would normally stand without thinking.  See if you can feel where the weight is in your feet.  Now back your weight up into your heels and line your pelvis up over the back of the foot, and you will probably notice your pelvis start to untuck (use a mirror if possible and look for a vertical leg).  You will get to a point where you feel like your bones are stacked and the load is distributed efficiently rather then "hanging off your joints" to keep yourself vertical.  There's a lot more detail to standing posture, but have a play with this and aim for feeling "free and efficient".  Nothing tucking or gripping here, and lots of lovely little stabilisers humming along for support!

When in doubt, stick it out (by it I mean your bum).  Let’s reclaim awesome glutes, proper lumbar curve, and put our true core muscles in the alignment where they can best work automatically.

To conclude our myth busting session, let me clarify by saying that sit-ups, tightening abdominals and posteriorly tilting your pelvis are not evil movements unto themselves.  I’m a Pilates instructor for goodness sakes, and these actions have a valid place in a well-balanced workout for any normal, healthy body.  Unfortunately, I find that many of our bodies are struggling to meet the demands of the 21st century lifestyle, and we can make a big difference by tuning in to our true core before working on our 6-pack.
 
If you’ve recently got off the couch/office chair, or if you're recovering from pain, injury, or babies, nurture your body, allow it to heal, and focus on restoration and rehabilitation before pushing marathons and big gym workouts.  And when you do progress towards the more intense training or heavier sports, don’t forget that a little corrective exercise can go a long way.  
 
We need to return core stability to a concept that enables our body to become empowered, efficient and easy.  Take a few minutes everyday or every workout to reconnect with your breath and your more subtle muscles; here you will find your true core strength.

In Part 1 we looked at how the pelvic floor works and came to the conclusion that although kegels can be helpful, in most cases they are just not enough. In Part II I would like to explore the effect of lifestyle and “natural movement” on pelvic floor health, and suggest some tips to help you incorporate a strong pelvic floor as part of a healthy, functional whole-body.

Natural Movement and Lifestyle Factors

When we want to figure out if something is “Natural” for the human body (like a kegel for example), we have to take ourselves back to our “natural” environment.  Our bodies evolved to a time and place where we hunted/gathered our food, lived in a tribe, walked miles every day, squatted to toilet and rest, and lived without the modern conveniences that now rob of us of most of this “natural movement”. 

It is safe to say that our genetics have not changed much since this time, but our world certainly has.  Office work, driving cars, heeled shoes, and doing an hour of crazy exercise each day to make up for the lack of movement in the other 23 hours is what our bodies currently experience.  Vastly different to our ancestors.  What would their bodies be like if we could study them now? 

The closest we can get to observing our ancestors in action is to look at the few hunter-gatherer populations that still exist.  Some very cool researchers took a look at the pelvic health of around 400 women from the Xiangu tribe in Brazil[i].  These tribal women live as close to nature as you can get, living in huts made of grass and mud with their giant extended families, collecting their food, squatting to toilet, and surviving without any of the modern age’s “helpful” technologies.  The women of the Xingu tribe, with an average age of 33 and 4.3 children, average a 5% incontinence rate across the female population.  Compared to our 50% incontinence rate in the developed world. 

The women in the study still saw average rates of minor prolapse when examined by researchers, but most were asymptomatic (they didn’t notice), and their pelvic floor muscles were found to be very strong compared to the female "norm" of western culture. Another interesting finding of the study was that 90% of these women had their babies at home in a squat position (but before you run and attempt this birth position please remember that these women squat ALL THE TIME).  
As the author puts it:

“Instinctively, through their lifestyle, indigenous women have been protected against POP (pelvic organ prolapse) during their daily activities. In contrast, we have a sedentary lifestyle and require physical therapy sessions for training our PFM (Pelvic floor muscles)”[i]

A separate study looking at incontinence in Chinese women found that place of birth (mainland China or Hong Kong China) was the biggest predictor for stress urinary incontinence, suggesting that the environment women were exposed to early in life can play a role in continence later on[ii].  Here is another author’s take on how modernization affected pelvic floor health in this study:

“The old diet based on fibers and grass plants has been replaced by a diet rich in carbohydrates; the preferred delivery position is no longer squatting but rather supine; and a sitting position has been adopted for urination and evacuation. Apparently these changes may have caused increased prevalence of prolapse and urinary incontinence”[i]

There are so many variables at play in these studies that make it impossible to come to any real conclusions.  They do, however, provide evidence that our lifestyle could be playing a role in the high incontinence rates in our population.  And the evidence fits with the logical thought process that if our bodies were living in their natural environments we wouldn’t need to keep doing our kegels to maintain pelvic floor function.

Now before you decide to sell everything and go live in a cave in the mountains, I believe there are some practical, whole-body solutions for pelvic floor health we can try first.  We need to look at what parts of our modern lifestyle are holding us back from the pelvic health we were designed to have, and what we can introduce into our lives to live closer to our natural state.  The closer we can align our bodies with what they really need to thrive, the better we can function as happy, healthy, whole-body people.

Whole-Body Pelvic Floor Treatment: the long term solution?

Please don’t give up your kegels just yet.   Especially if they were prescribed to you for continence help, back pain, etc, as the research shows they can help.  For your long term pelvic floor health, I would ADD IN these tips to help the pelvic floor function as part of a happy, healthy WHOLE you.

1.     Treat the body as a whole:

Your pelvic floor is only as functional as the rest of the body, and the rest of the body functions best with a healthy pelvic floor.  Everything from tight neck/shoulder muscles to tension in the bottom of the feet can effect the workings of the pelvic floor so we need to look at the WHOLE picture. Which leads to point #2…

2.     Alignment:

When your bones are in the right place in relation to each other and gravity (correct body alignment), the core muscles should function naturally as a unit creating dynamic stability throughout the body.  Our modern lifestyle and lack of natural movement is forcing us out of our natural alignment and robbing the core of the work it could be doing (automatically) all day.

Corrective exercise can help you get into better alignment, but more importantly you need to observe your daily habits and the postures you are spending large amounts of time in to discover what got you out of alignment in the first place.

For more information please head to the goddess of alignment and “Nutritious Movement”, Katy Bowman and Restorative Exercise.
(I would especially recommend Al Fo' the Pelvic Floor Snackbyte)

3.     See a trained professional if you need help:
Sometimes you just need an outside pair of eyes to look at the WHOLE YOU and help you retrain your funky motor patterns, put you back into alignment, and prescribe exercises that can help keep you in a place where you can be your strongest, most stable self.  I have a team of different health/wellness professionals that I use when I need an outside pair of eyes or hands to give me a fresh perspective.  We have quite a blind spot when it comes to our own bodies sometimes, so never be afraid to ask for help.

5.     Re-introduce some natural movement:  When I am outside with my son at the park we often play “What would the hunter-gatherers do?”  I know it sounds corny but we think it's super fun, and we spend our time gathering sticks and nuts, building, carrying, climbing, squatting and trying to get a decent amount of walking mileage in each day.  Squat to cook something on your kitchen floor, get rid of the furniture in one room of your house, create a work-station that allows you to get some movement into your day.

Have a play or check out MovNat for more fun ideas.

6.     WALK and Build a bum:  Walking is a fundamental human movement and a fantastic way to strengthen the pelvic floor (when done properly).  You need to be walking EVERY DAY (even if you are an athlete with an intense training regimen) as this is a movement that the human body was designed to do and needs to do a lot of to stay healthy.

The bum muscles are what hold the sacrum in place so that the pelvic floor gets an eccentric (lengthening) contraction with each step.  Without a bum that knows how to activate there is no stability to the sacrum, which can cause shortening of the pelvic floor or reduce the leverage the pelvic floor needs to function properly.

Build a bum in functional ways like walking, squatting, lunging etc.  To start your squat progressions I will send you again to the wonderful Katy Bowman:

http://www.katysays.com/you-dont-know-squat/
http://www.katysays.com/you-still-dont-know-squat/

Why do none of us have bottoms that works well? We sit on them way too much! Leading to the next two points…

7.     If you have to sit:
Sitting on your tailbone (pelvis in a posterior tilt, picture a) can put your pelvic floor in a shortened position and reduce the activation of pelvic floor if done all of the time.  Find your ischial tuberosities and learn how to sit on them, use a wedge or cushion to get rid of the bucket seat slope in the car, and invest in a proper chair that helps you stay in a “neutral” (c) pelvis position if you are going to be seated in a chair at work.
Find more details and ideas in my "sitting" article here.

8.  Explore other positions: I have nothing against rest and relaxation, honest, I’m actually really good at it.  I do however recommend varying your rest positions to place different loads on the body and ensure you are not "casting" your body in a single position. As Westerners we tend to get stuck in “sitting”, “standing” or “lying”.  Gordon Hewes in 1955 came up with this collection of other positions from studying cultures around the globe[iii].  Have a play!

9.     Mindfulness and Meditation:  A study in 2013 showed that depression and anxiety were correlated with increased pelvic floor dysfunction in a group of postnatal women[iv].  If this is the route cause of your pelvic floor dysfunction it may need to be treated first.  Mindfulness Based Cognitive Therapy can be an effective way to manage depression and anxiety, and directed meditation can help people that hold tension in their pelvic floors to learn how to relax it.  And of course, please see a professional for the best kind of help.

““To visualize how the pelvic floor responds to stress, one need only look at the movement of a dog’s tail: when the dog is happy, the tail wags loosely from side to side; when the dog is stressed, the tail is tightly under its legs. It is the pelvic floor muscles that control the tail. In fact, the pelvic floor muscles are still attached to the rudimentary tail [in man], the coccyx, which is pulled forward when contracted, thereby compressing its penetrating organs. Therefore, man’s pelvic muscles, as the dog’s, may be the ultimate representation of the mind/body connection, for they are constantly responding to fluctuations in feeling.” – Jerome Weiss, MD[v]

10. The right food choices: 
You need to make the right food choices for your body, as something as simple as a food intolerance can create bloating and gut inflammation which will affect the muscles of the core.  Chronic constipation caused by dietary issues will also affect the pelvic floor. 

I am not an expert in this area but I know that sorting out digestive issues has made such a difference for so many of my clients, so please seek help with a nutrition expert if you are struggling in this department.

As you can see, when I said the WHOLE YOU I really did mean the entire picture of your mental and physical health can affect the pelvic floor.   As a culture, as researchers, as health care providers, as people with pelvic floors, let’s start asking the right questions.  We need to think more about why our pelvic floors got so weak/tight/overused/underused in the first place and start to come up with some long term solutions to this very common dysfunction.

These tips should get you started on the road to long-term pelvic floor health.  Please get in touch with any questions and let me know how you’re traveling!

Stacey xx

p.s.  My 30 Day Postnatal Workshop “Restore your Core and Pelvic Floor” will be launching in January.  Please sign up for my newsletter here or “like” my Facebook page to get updates on the big launch!


References
[i] de Araujo M.P., Takano C.C., Girão M.J., Sartori M.G. (2009). Pelvic floor disorders among indigenous women living in Xingu Indian Park, Brazil. Int Urogynecol J Pelvic Floor Dysfunct, 20(9), 1079-84.

[ii]  Brieger G. M., Mongelli M., Hin L.Y., Chung T.K.H. (1997). The epidemiology of urinary dysfunction in Chinese women.  International Urogynecology Journal, 8(4), 191-195

[iii] Hewes, G. (1955). World Distribution of Postural Habits. American Anthropologist, 57(2): 231-244.

[iv] Khan Z.A., Whittal C., Mansol S., Osborne L.A., Reed P., Emery S. (2013) Effect of depression and anxiety on the success of pelvic floor muscle training for pelvic floor dysfunction. J Obstet Gynaecol 33(7):710-4

[v] From Chronic Pelvic Pain and Myofascial Trigger Points. The Pain Clinic, December 2000, Vol.2. No. 6:13-18