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Training for the deep muscles of the core

Connecting to the deep muscles of your core without having had a proper assessment can be very difficult and frustrating, so for those of you visiting this site that haven't had a session with one of our staff we suggest you do so first.

Transversus Abdominis

Location, Function & Dysfunction

Transversus Abdominis

Transversus abdominis is the deepest of the abdominal muscles and wraps around the abdomen between the lower ribs and top of the pelvis, functioning like a corset. This picture shows the anatomy of this muscle with the outer two abdominal layers (internal and external oblique) removed. When transversus abdominis contracts the waist narrows slightly and the lower abdomen flattens. The function of the transversus abdominis is to stabilize the low back and pelvis BEFORE movement of the arms and/or legs occurs. This function is critical if wear and tear of the joints in your low back/pelvis (degeneration) is to be prevented. When healthy, this muscle anticipates motion and therefore we can use "intention" or imagery to retrain its function. This is a vital part of core training since you cannot strengthen a muscle that your nervous system/brain isn't using. Training comes before strengthening.

Mid or low back pain, abdominal injury/surgery and/or excessive lengthening due to pregnancy can cause a delay or absence in the anticipatory contraction of transversus abdominis. If this muscle contraction delay/absence is not corrected, this dysfunction will remain even after your pain has subsided.

Rehabilitation Principles - Train before you Strengthen

Restoring the recruitment patterns (order in which different muscles contract) of the core is different than most exercise you will have been used to in the past. The first step is to learn to isolate the muscle, to train it to contract. Research has clearly shown that the better you are at isolating this muscle the faster it will integrate into functional tasks. The second step is to strengthen or teach it to co-contract with the other muscles of the core, the deep multifidus and the pelvic floor as you breathe. The final step is to co-contract the entire core (connect to the entire core) and use this connection in functional activities.

Recruitment Training for Transversus Abdominis (TrA)

You cannot strengthen a muscle your brain cannot activate. These exercises help you ‘find the muscle’ and activate it properly.

Lie on your back or side with your spine in a neutral posture, (gentle curve in your low back).

Try the following connect cues to produce a deep, isolated contraction of TrA.

  • Imagine a line that connects the inside of your two pelvic bones (front of hips). Think about connecting, or drawing the muscle, along this line as if closing two book covers.
  • Contract your pelvic floor by drawing the muscles from behind your pubic bone to your tail bone and the left and right sides of your pelvic floor together and then like a draw string bag, gently draw the entire pelvic floor up.
  • In sidelying - gently lift your lower belly up away from your pubic bone

Breathe in and on the breath out contract the transversus abdominis with the best connect cue (have your therapist help you determine which is your best connect cue).

No movement of your hips, pelvis or spine should occur as you gently connect to TrA. If you palpate your belly just inside the left and right hip bones, this deep contraction should feel like a light, deep tension under your fingertips, not a contraction that pushes your fingers out.

Hold the contraction for 3 - 5 seconds and then release and breathe throughout this exercise. Repeat the contraction and hold for 3 sets of 10 repetitions 3 - 4 times per day for 4 weeks.

It is not uncommon for other muscles to co-contract in an attempt to compensate for a dysfunctional core. It is critical that you take the time to focus on your technique and achieve a correct contraction BEFORE moving on to any loading through the arms or legs. Watch for the following substitution strategies:

  1. Posterior tilting of the pelvis
  2. Bulging of the abdomen
  3. Depression of the rib cage
  4. Breath holding
  5. Fingertips being pressed out by a strong muscular contraction (internal oblique)

Strength Training for Transversus Abdominis

training tra

Once you can activate TrA, practice recruiting it in many different positions such as sitting, standing, squatting, lifting etc. Once you can easily recruit TrA you can progress to the following exercises.

Each progression begins with a proper co-activation of all muscles of the deep system (TrA, multifidus and your pelvic floor) and this co-contraction should be held throughout the movement. Remember to MOVE WITH YOUR BREATH - Exert with exhalation, breathe in to rest or hold.

Lying on your back with your knees and hips flexed:

training tra
  1. Slowly let your right knee move to the right, keep your low back and pelvis level. Return to the center and repeat with the left.
  2. Lift the right foot off the floor keeping the knee bent. Don’t hold your breath and don’t bulge your lower abdomen. Return the foot to the floor and repeat with the left foot.
  3. Lift the right foot off the floor and then straighten the leg only as far as you can control your core with a proper strategy. Slowly bend the knee and return the foot to the floor. Repeat with the left leg.
  4. Lift the right foot off the floor and then the left foot off the floor. Alternate leg extensions, exert with exhalation, breathe in to rest or hold.

In side lying:

  1. Maintaining your connection to TrA, keep your ankles together and lift your top knee (only as high as you can control without breath holding), focus on turning your inner thigh outwards. Return your knee.
  2. Maintaining your connection to TrA, keep your ankles together, lift your top knee and then lift your ankle. Return your ankle and then your knee.

With all these exercises maintain the leg lift for 10 seconds, build to 3 sets of 10 repetitions before moving on.

Incorporate TrA Activation into other Activities

The final step is to remember to use this muscle (TrA) during regular activities. Each time you get out of the chair, lift, bend or reach, the deep muscle system should be working with and for you. The goal is to help the brain remember to use the deep system (dMF, TrA and your pelvic floor) and the more you use it, the less you will be likely to lose it.

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Multifidus

Location, Function & Dysfunction

Multifidus

Multifidus is a deep muscle located along the back of the spine very close to the midline. The deep fibers are short and span single vertebral segments. This muscle functions together with transversus abdominis & pelvic floor muscles to stabilize the low back and pelvis BEFORE movement of the arms and/or legs occurs. "Intention" or imagery is also used to retrain its function. Low back pain causes a delay or absence in the anticipatory contraction of multifidus. If this muscle contraction delay/absence is not corrected, this dysfunction will remain even after an individual's pain has subsided increasing the incidence of re-injury. This is a vital part of core training since you cannot strengthen muscle that your nervous system isn't using. Like transversus abdominis, training comes before strengthening.

Recruitment Training for the Deep Fibers of Lumbosacral Multifidus (dMF)

training multifidus

You cannot strengthen a muscle your brain cannot activate. These exercises help you ‘find the muscle’ and activate it properly.

Lie on your back or side with your spine in a neutral posture, (gentle curve in your low back).

Try the following connect cues to produce a deep contraction of multifidus isolated from the long back extensors.

  • For the part of multifidus that supports the SIJ - imagine a line that connects your left and right SIJ and think about connecting, or drawing together, along this line.
  • Imagine a line connecting your groin (or back of your pubic bone) to the part of multifidus in your low back you are trying to train (wake up). Connect along this line and then gently think about suspending (lifting) the lumbar vertebra 1 mm above the one below.

Breathe in and on the breath out contract the deep multifidus with the best connect cue (have your therapist help you determine which is your best connect cue).

No movement of your hips, pelvis or spine should occur as you gently activate the dMF. If you compare how heavy your leg is to lift with and without this dMF contraction you should find that it is lighter with the proper contraction.

Hold the contraction for 3- 5 seconds and then release and breathe throughout this exercise. Repeat the contraction and hold for 3 sets of 10 repetitions 3 – 4 times per day for 4 weeks.

It is not uncommon for other muscles to co-contract in an attempt to compensate for a dysfunctional core. It is critical that you take the time to focus on your technique and achieve a correct multifidus contraction BEFORE moving on to any loading through the arms or legs. Watch for the following substitution strategies:

  1. Anterior tilting or rotation of the pelvis
  2. Flexion of the hip joint
  3. Gripping with the big buttock muscles

Strength Training for Lumbosacral Multifidus

Once you can activate the dMF, practice recruiting it in many different positions such as sitting, standing, squatting, lifting etc. Once you can easily recruit dMF you can progress to the following exercises. Each progression begins with a proper co- activation of all muscles of the deep system (deep abdominals, multifidus and your pelvic floor) and this co-contraction should be held throughout the movement. Remember to MOVE WITH YOUR BREATH - Exert with exhalation, breathe in to rest or hold.

training multifidus

In side lying

  1. Maintaining your connection to TrA, keep your ankles together and lift your top knee (only as high as you can control without breath holding), focus on turning your inner thigh outwards. Return your knee.
  2. Maintaining your connection to TrA, keep your ankles together, lift your top knee and then lift your ankle. Return your ankle and then your knee.

Lying on your back with your knees and hips flexed:

  1. Slowly let your right knee move to the right, keep your low back and pelvis level. Return to the center and repeat with the left.
  2. Lift the right foot off the floor keeping the knee bent. Don’t hold your breath and don’t bulge your lower abdomen. Return the foot to the floor and repeat with the left foot. There should be no clicking in your low back.
  3. Lift the right foot off the floor and then straighten the leg only as far as you can control your core with a proper strategy. Slowly bend the knee and return the foot to the floor. Repeat with the left leg.
  4. Lift the right foot off the floor and then the left foot off the floor. Alternate leg extensions, exert with exhalation, breathe in to rest or hold.

With all these exercises maintain the leg lift for 10 seconds, build to 3 sets of 10 repetitions before moving on

Incorporate dMF Activation into other Activities

The final step is to remember to use this muscle (dMF) during regular activities. Each time you get out of the chair, lift, bend or reach, the deep muscle system should be working with and for you. The goal is to help the brain remember to use the deep system (dMF, TrA and your pelvic floor) and the more you use it, the less you will be likely to lose it.

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Pelvic Floor Muscles

Pelvic Floor Location, Function & Dysfunction

Pelvic Floor Muscles

The pelvic floor (PFM) is a hammock of muscles that connect the pubis bone at the front to the tailbone (coccyx) and "sitz" bones (ischial tuberosities) at the back. The pelvic floor supports the bladder as well as the reproductive organs and connects the inferior aspect of the innominates (hip bones) and the sacrum. The urethra, vagina and rectum pass through these muscles and are affected by their function. The tension in these muscles must be balanced in the front (beneath the pubis) and the back (at the sacrum). They must also work in cooperation with the multifidus (a deep back muscle) and transversus abdominis for your lumbar spine, sacroiliac joints, bladder and uterus to be stabilized properly.

Changes in recruitment of the PFM's can occur as a result of pain, poor movement patterns, trauma, surgery or childbirth. This altered recruitment often results in over activation of some muscles and under activation of others - the patterns are highly variable. Your pelvic floor therapist will assess and determine which muscles need more activation and which ones need less. This imbalance will not spontaneously recover as pain in the region subsides and can lead to low back, pelvis and/or hip pain or urinary incontinence.

Pelvic Floor Muscles

Recruitment Training for the Pelvic Floor (PFM)

Unfortunately, 65% of people that think that they know how to contract their PFM’s are doing it incorrectly. The first step is to learn to produce a proper contraction of these muscles.

Lie on your back, or side, or sit with the spine in a neutral posture. Firmly palpate your abdomen 1-2 inches inside of your hip bones. Try the following cues to connect to (contract) your pelvic floor:

  • Females - Think of your vagina as a clock, pubis is 12, tailbone is 6, left lateral wall is 3, right lateral wall is 9. Visualize drawing the 12 to the 6, the 6 to the 12 and finally gather the 3 and 9 toward the middle of the clock and gently lift.
  • Females - Nod your clitoris down toward the vaginal opening, curl your tailbone toward your clitoris, now gently imagine sucking a jellybean up off of the floor toward your head.
  • Females - Visualize ‘squeezing’/close off the urethra (as if to stop urine flow), hold this while you ‘squeeze’/close the anus (as if to stop flatulence) and gently lift.
  • Males - visualize gently drawing your testicles up and forward into your abdomen. (aka ‘bring the boys home’).
  • Males or Females - Think about a guy wire or line from the anus up to the back of your pubic bone and connect along this line.

Maintain your lateral costal breath throughout this exercise. When contracting your PFM you should feel a deep tension in your abdomen (under your fingers). You should NOT feel your buttocks tighten, legs rotate out or movement of your spine or pelvis. If you feel bulging of the abdomen, butt gripping or spinal movement then you are not properly contracting just your pelvic floor muscles. A correct contraction should result in a very gentle tension deep in the abdomen (often very hard to feel initially).

When you isolate your pelvic floor muscles you should feel a deep tension in your abdomen (under your fingers), you should NOT feel your buttocks tighten, legs rotate out or movement of your spine or pelvis. If you feel a muscle pushing your fingers out of your abdomen, butt gripping or spinal movement then you are not being successful in connecting to your pelvic floor muscles or you are overcontracting for this part of the program. A correct contraction should result in a very gentle tension deep in the abdomen (often very hard to feel initially).

Ultrasound Imaging

perineal view pelvic floor

If you are having trouble connecting to your pelvic floor muscles consider the following options. Ultrasound Imaging will allow you to watch the impact the pelvic floor muscles have on the bladder as you attempt to produce an isolated contraction. The absolute best view is a perineal view (translabial but not intravaginal). This will allow you and your therapist to explore various strategies and find one that works for you. Using the ultrasound to show you what you are doing when you contract (biofeedback) will solidify your understanding of a proper contraction. It may help you shortcut any frustration you are feeling to "get that connection" happening. Your bladder needs to be moderately full (1 cup / 500 ml) during the assessment so don't 'pee' before your appointment.

The Educator

In addition to rehabilitative ultrasound imaging, the Educator can be used at home. Retraining the core muscles takes mental focus and practice. If you are interested in having greater knowledge of performance (i.e. did I do it right, or did I do it wrong) when you are practicing at home then you should ask your therapist about the Educator which is a useful tool to use to assist the retraining the anterior pelvic floor.

Co-ordinating a PF Contraction with Transversus Abdominis and the Deep Fibers of Multifidus

The next step is to learn to co-contract the PFM’s in conjunction with transversus abdominis and the deep lumbosacral multifidus. These will be added as progressions once you can successfully maintain an isolated PFM contraction. As you practice connecting to your pelvic floor muscles combine your cues to ensure that TrA and dMF are co-contracting (your physiotherapist will confirm both your cues and your performance of this task).

Endurance/Strength Training with a focus on the Pelvic Floor

Hold Em’s

  • Breathe in (widen your lower rib cage) then breathe out using your PF cue. Engage and hold the contraction for 3-5 seconds, while breathing normally.
  • Repeat 10x. Perform these in supine, hands and knees, sitting and standing. Speed Em’s
  • Breathe in (widen your lower rib cage) then breathe out using your PF cue. Perform a quick contraction/lift then immediately let go and relax.
  • Repeat 10x (work towards 15-20-30 reps). Perform these in supine, hands and knees, sitting and standing.

Hold Em’s with Functional Movement

  • Heel Slides – Lie on your back with your hips and knees bent.Perform a ‘hold em’ then slowly slide one leg straight while maintaining your PF contraction and breath. Slide the leg back to its original position. Repeat with the opposite leg. Repeat 5x/side.
  • Wipers - in the same position as above, perform a ‘hold em’. Keep your low back and pelvis level and slowly move one bent knee out to the side. Maintain your PF contraction and exhale to bring your leg back to neutral. Repeat this with the opposite leg. Repeat 5x/side.
  • Leg lifts – in the same position as above, perform a ‘hold em’. Slowly bring one knee toward your chest. Maintain your PF contraction and on the exhale return the leg to the floor and repeat this with your opposite leg. Repeat 5x/side.

The final step is to be able to co-contract all of the deep muscles during functional activities, which include nose blowing, coughing, sneezing, walking, jumping and lifting. Retraining the deep muscle system requires repetitive use and the more you use it, the less you will be likely to lose it.

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Diane Lee & Associates
#102 - 15303 31 Avenue
South Surrey, BC V3Z 6X2

Phone: 604 538 8338
Fax: 604 538 3277
Email: info@dianelee.ca