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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
• Multifidus
• Pelvic Floor

Transversus Abdominis

Location, Function & Dysfunction

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.

Step 1: Isolation of Transversus Abdominis

• Lie on your back or side with your spine in a neutral posture, (gentle curve anterior in your lumbar spine).
• If you and your therapist have found an image that works for you to connect to your pelvic floor and TrA then focus on this image.
• If you are not sure what image to use consider one of the following:
  • Think about gently closing the muscles around your rectum and then connect the rectum to the back of the pubic symphysis.
  • Think about the muscles around your urethra / vagina or the muscles that draw your testicles up and then gently and slowly lift the urethra, vagina or testicles up and forward into your abdomen.
  • Imagine a line connecting the inside of your two hip bones. Think about connecting along this line.
• Breathe in and on the breath out contract the transversus abdominis with your image. No actual movement of the hip, pelvis or spine should occur.
• The isolated contraction of transversus abdominis will feel like a light, deep tension under your fingertips, not a contraction that pushes the fingers out.
• Hold the contraction without becoming rigid, and continue to breathe.

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)

Step 2: Strengthen the co-activated Core

Once you can isolate the transversus abdominis, practice this isolation in many different positions - i.e. sitting, standing, bending over etc. Once you can turn the muscle on easily you can progress to the following exercises. Each progression below begins with a good core contraction (which includes transversus abdominis) and this connection should be held throughout the movement.

Remember to MOVE WITH YOUR BREATH - 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 reps before moving on.

In side lying

1. While maintaining your connection to core (lifting the pelvic floor gently), keep your ankles together and lift your top knee (only as high as you can control without breath holding), by focusing on turning your inner thigh outwards. Return your knee.
2. While maintaining your connection, keep your ankles together, lift your top knee (as in #2), and then lift your ankle. Return your ankle and then your knee.
3. While maintaining your connection, keep your ankles together, lift your top knee, then your ankle, then extend your leg, then flex your leg, return your ankle and finally your knee.

Lying on your back with your knees and hips flexed:

1. Slowly let your right knee move to the right, keeping your low back and pelvis level. Return to the center and repeat with the left.
2. Slide the right foot along the floor, straightening the knee. Slide the foot back towards the hip, and repeat with the left. Be sure that the floor supports the weight of the leg and that the foot does not lift off of the floor. Try putting a plastic bag around your foot to help it slide easily.
3. 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.
4. 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.
5. Lift the right foot off the floor and then the left foot off the floor. Alternate leg extensions making sure a proper strategy for core stabilization is used. Exert with exhalation, breathe in to rest or hold.

Step 3: Incorporate into Other Activities

The final step is to remember to use the core during regular life activities. Each time you get out of the chair, lift, bend or reach, this local stabilizing system should be working at a low level. The goal is to teach the body to resume its normal stabilization strategy of connecting to the core BEFORE movement begins.

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Multifidus

Location, Function & Dysfunction

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.

Step 1: Isolation of Multifidus - Train Before you Strengthen

• Lie on your side with your spine in a neutral posture, (gentle curve anterior in your lumbar spine).
• Palpate the multifidus you are trying to isolate, (find the spine bone and then fall off into the gutter just sideways from the bone). If you have a multifidus deficit it will feel like a hole or soft spot compared to the opposite side.
• Imagine a guy wire running from the inner part of your thigh, up into your groin, through your pelvis, to the finger palpating the multifidus.
• Breathe in and on the breath out contract the multifidus with your image or connect the leg firmly along the guy wire (think about drawing the thigh into the pelvis). Think about suspending, or lifting, the vertebra slightly off the one below (like lifting the lid of a tea pot). No actual movement of the hip, pelvis or spine should occur.
• The contraction of the multifidus should feel like a slow, firm, 'swelling' under your fingers much like air filling up a balloon. You should not feel a rapid contraction.
• Hold the contraction without becoming rigid, and continue to breathe.

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

Step 2: Strengthen the co-activated Core

Once you can isolate the multifidus, practice this isolation in many different positions - i.e. sitting, standing, bending over etc. Once you can turn the muscle on easily you can progress to the following exercises. Each progression below begins with a good core contraction (which includes transversus abdominis and your pelvic floor) and this connection should be held throughout the movement.

Remember to MOVE WITH YOUR BREATH - Exert with exhalation, breathe in to rest or hold.

With all these exercises maintain the leg lift for 3-5 seconds, build to 10 reps before moving on.

In side lying

1. While maintaining your connection to multifidus, keep your ankles together and lift your top knee (only as high as you can control multifidus), by focusing on turning your inner thigh outwards. Return your knee.
2. While maintaining your connection to multifidus, keep your ankles together, lift your top knee (as in #2), and then lift your ankle. Return your ankle and then your knee.
3. While maintaining your connection to multifidus, keep your ankles together, lift your top knee, then your ankle, then extend your leg, then flex your leg, return your ankle and finally your knee.

Step 3: Incorporate into Other Activities

The final step is to remember to use the core during regular life activities. Each time you get out of the chair, lift, bend or reach, this local stabilizing system should be working at a low level. The goal is to teach the body to resume its normal stabilization strategy of connecting to the core BEFORE movement begins.

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Pelvic Floor Muscles

Pelvic Floor Location, Function & Dysfunction

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 overactivation of the deep posterior muscles (ischiococcygeus (small square) and piriformis muscles just above the small square) and underactivation of the anterior pelvic floor sling (pubococcygeus). 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. The solution; relax or turn off the posterior pelvic muscles and fire up or increase your connection to the entire pelvic floor sling.

Retraining the Pelvic Floor

Retraining the stabilizing muscles of the core, which includes the PFM's, is different than most exercise you have done in the past. The first step is to learn to produce an isolated contraction of these muscles. Unfortunately, 65% of people that think that they know how to contract their PFM's are doing it incorrectly. The second step is to learn to co-contract the PFM's in conjunction with the other muscles of the core. The final step; co-contract the entire core (connect simultaneously to the PFM's, transversus abdominis & multifidus) in coordination with the larger superficial muscle during functional activities, which include nose blowing, coughing, sneezing, walking, jumping and lifting.

Step 1: Isolation of the Pelvic Floor 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.
• If you and your therapist have found an image that works for you to connect/contract your pelvic floor muscles then focus on it.
• If you are not sure what image to use try one of the following:
  • Think about the muscles around your urethra / vagina or the muscles that draw your testicles up and then gently and slowly lifting the urethra, vagina or testicles up and forward into your abdomen.
  • Think about the muscles around your anus and think about closing them (same motion you do after completing a bowel movement).
  • Think about a guy wire or line from the anus up to the back of your pubic bone and connect along this line.
• If the connection is successful you will feel a response in the deep abdominal wall and the contraction should feel symmetrical.

When performing core exercises follow these guidelines; slowly generate force in the target muscle, contract the muscle at about one quarter the force of your maximal ability, continue to breathe, and strive to breathe by expanding the lower rib cage rather than the upper rib cage or abdomen. It is not uncommon for other muscles to want 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 pelvic floor contraction BEFORE moving on to any loading through the arms or legs.

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

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.

Step 2: Learning to Co-contract the Pelvic Floor with Transversus Abdominis and Relax the Deep Posterior Pelvic Muscles

Once you can maintain a 10 second contraction of the pelvic floor you need to learn to co-contract the floor with your deep abdominal muscle, transversus abdominis, while relaxing the deep posterior pelvic muscles (ischiococcygeus and piriformis). Begin by sitting on a firm chair. Find your neutral spine position - you should feel your body weight directly over your 'sitz' bones. Squeeze the muscles in your buttock and turn your hips out (butt grip) and feel the muscles in the deep posterior pelvis contract and draw your 'sitz' bones together. Now complete relax these muscles and maintain the relaxation as you gently and slowly contract the pelvic floor muscles (squeeze the muscles around the vagina, urethra and anus as you did in step #1). Repeat this a few times and then palpate the transversus abdominis just inside your anterior hip bones. As you contract your anterior pelvic floor you should feel a light, deep tensioning in the lower abdomen. Keep your buttocks relaxed, maintain your neutral spine position and repeat this gentle contraction a few times while focusing on relaxed breathing.

Things to avoid:

1. Gripping with the deep buttock muscles
2. Breath holding
3. Contracting the upper abdominals or lifting the rib cage

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