For some, these changes have been positive and for others, detrimental. But how does this related to an individual’s experience of pain? It all has to do with what these changes have done to each person’s nervous system. I think the best way to illustrate this is to introduce two very different people who both have chronic pain, let’s call one Jane and the other John.
Jane thrives off social connection outside of her home. She also loves her job, specifically because of those she works with. She doesn’t have a great relationship with her husband and her two teenager children want nothing to do with her at this point so she has found her happiness elsewhere. The happiest times with her family are always when they travel, especially outside of the country so she makes sure they go on a few trips a year. Jane has had neck pain for years. She believes it is likely because of a few horseback riding accidents in her childhood as well as a car accident in her late 20s. She manages it through massage and group exercise classes. She does yoga 3x a week and strength training 2x a week. She is extremely consistent with her exercise and looks forward to connecting with her instructors and her community, plus it helps her pain so that’s an added bonus.
John is as introverted as it gets. He loves quiet, he loves to be alone. His happy place is reading in his favorite chair with a good cup of coffee. He also has a very stressful job as an engineer. The amount of work he is required to do for his job is ridiculous. He often puts in 60-70 hour work weeks but if that were the only stressful part, he could manage. What makes him miserable with his job is the toxic work environment he is in. Everyone is out for themselves and there are some very wealthy and equally needy clients that are just impossible to please. Every weekend he tries to escape to the outdoors to breathe fresh air, move and be immersed in nature but often he is forced to work through the weekend just to get the required projects done. John has low back pain and it’s just gotten worse over the years. He thinks it started when he got this job with the commute increased time at his computer. He knows that movement helps and feels better when he can go on walks but he just doesn’t find the time to do it all that often. He has resorted to pain medication to help him get through his day and he feels it’s becoming less and less effective. He is afraid to go get an MRI because he doesn’t want back surgery. He just can’t deal with that right now.
Everything that brought Jane joy has been eliminated. She got laid off from her work because of COVID and is now spending all day, every day inside with her family where her husband works from home and her two teenagers are doing distant learning. In many respects, she feels like she has become the full time house nanny and professional nagger to people who never want to listen or do as they’re told. She feels stuck and with the travel restrictions, she literally is. For awhile Jane tried to do her exercise classes virtually but it made her realize that she didn’t do them for the exercise, it was all about the community that was there. It was her social time and without that piece, she has no motivation to do them. Here massage therapist has also been shut down and she needs the bodywork more than ever. Her neck is killing her. She is carrying the weight of the household and is extremely worried about getting COVID. She has asthma and an autoimmune condition that puts her at risk. Everyday she watches the news and it just keeps getting worse and worse. Jane is struggling and she doesn’t see any way out of it.
Meanwhile, John is living the dream. He no longer has to commute to work and there is less work for him. He doesn’t have to be surrounded by any of the toxic co-workers and he finds he can accomplish what he needs to far more efficiently. He is also able to go out for a walk or go read by the ocean at his leisure. He has even started to make home cooked meals with his extra time and is finding a lot of joy in experimenting with recipes. He’s lost 20 pounds without trying and is finally feeling what it is like to live exactly as he wants to. John’s pain is basically gone. He notices it comes back a bit after a long zoom meeting with his boss and co-workers but he found that if he goes for a quick walk after, it’s goes away. He is amazed!
There are many reasons that Jane’s pain increased while John’s decreased, the most obvious being that they each has a change in their physical movement/position/activity level but there are also some not so obvious reasons that their pain was effected by the way life changed with a pandemic.
For instance, Jane lost all of her social connections and her work which made her feel like she wasn’t contributing or participating as much in the world. She feels solely responsible for the household and the success of her teenagers with distant learning. She is also incredibly worried all the time. Worried about getting COVID, worried about her family and friends getting COVID and mourning everything that is being lost every day and every minute. This stress, worry, grief, anxiety and lack of joy are all contributing to the increase in her neck pain.
In John’s case, most of his stressors have been removed. He feels like he can enjoy each and every day now and do exactly what makes him happy. He is sleeping and eating better in addition to getting outside every single day. This absence of stress, freedom to find joy, ability to sleep more and exposure to the sun are all contributing to his decrease in low back pain.
These not so obvious factors for each individual all have to do with the nervous system. Chronic pain is a nervous system problem. It is the point at which pain does not correlate with tissue damage and it becomes more about the faulty alarm system of the brain. So anything that turns this alarm system up, or heightens the nervous system, will increase pain while anything that calms the nervous system and quiets the alarm will decrease pain. And this is how the pandemic can have extremely different effects on individuals with chronic pain.
If you are more like Jane, think about all of the things that you have lost. Think about what you are missing and brainstorm how you can achieve a similar outcome but with a different means. Social connection was really big for Jane so perhaps she can find that same joy by doing a socially distant walk with her friends or a zoom happy hour. Then think about the things that stress you out even further. Can you eliminate any of them? Sure, Jane can’t remove her teenage children but maybe she can stop watching the news or at least limit it so she isn’t adding to her stress.
If you resonate more with John, good for you 🙂 but also, this pandemic isn’t going to last forever. Think about how your life has changed for the better because of COVID. How can you keep what you have gained once the world starts to return to a more normal state. You have felt what it feels like to live, don’t give that up.
Do you want to learn more about pain science? Check out my pain science blog series part 1 here.
Do you want to be out of pain? It’s time to address your nervous system. Check out my Conquering Chronic Pain program here.
The first step toward change is recognizing that there is a problem and I believe we are there when it comes to peripartum care in the United States. Research is showing that as a first world country, the US is falling short, especially when it comes to postpartum care for mothers (article).
I have experienced this first hand even with the best insurance, the most amazing OB and my own medical background. I can only imagine how poor the level of care is for mothers that are not as privileged as I am. A big step in the right direction happened in May of 2018 when the ACOG (American College of Obstetricians and Gynecologists) released new recommendations for peripartum care (article). It finally includes a visit for mom within 3 weeks of baby’s arrival versus the standard 6 weeks. IT’S ABOUT TIME! It also states that “postpartum care should become an ongoing process” and include a “comprehensive postpartum visit with a full assessment of physical, social, and psychological well-being, including the following domains: mood and emotional well-being; infant care and feeding; sexuality, contraception, and birth spacing; sleep and fatigue; physical recovery from birth; chronic disease management; and health maintenance.” Pelvic physical therapy even got a shout out!
Now the real question to ask is whether moms are actually receiving this recommended peripartum care. In a study surveying the office visits of postpartum women from 2008 to 2016, less than 50% of most recommended services were performed during a comprehensive visit and this was consistent across all insurance types (article).
I think there are many reasons for this shortcoming. First off, a comprehensive visit requires time: something most doctors do not have in our current medical system. I believe it is unreasonable to expect an OBGYN, midwife or family doctor to cover all of these areas in the 20 min they are allotted per patient. They are doing the best they can within the model that they work which means screening for life threatening conditions and moving on to their next patient.
Another reason is that mothers don’t know they deserve and need more than what they are currently receiving. I know many that are itching to get back to things so when they are given the “all clear” at 6 weeks, they are stoked! What they don’t know is that this is a disservice to their body in the long run. Many have symptoms they are experiencing but don’t know something can be done to help them, aren’t comfortable talking about it or aren’t asked in the first place. Too often, women accept that they will pee themselves when they sneeze or have pain with penetration because these common symptoms are a “consequence” of having kids. Women just don’t know that it doesn’t have to be this way.
Motherhood is also a place of selflessness. The needs of the child are prioritized and mom is often left with no time, space or energy to take care of herself. There is so much emphasis on the baby’s health and well-being, mom doesn’t realize that her health should actually come first so she can be there for her child fully. I wish more moms believed and lived by the saying “happy mom, happy baby”. Instead, most mothers sacrifice their own needs for the needs of their child. I believe its up to perinatal professionals to make sure moms know that their well being matters too. In fact, it matters first and foremost.
So here is my contribution: some education regarding what peripartum care should look like. I recognize there are many barriers to this actually happening including but not limited to socioeconomic disparities and racial inequality but I figure the first step is naming what it should be. Once more people know the destination, we can start to figure out how to get there. If you aren’t a mom or expecting to be a one in the future, please tell your friends and family. And any stranger that might listen.
Peripartum care should start with a preconception visit. It provides a space to ask questions, voice concerns, talk about fears, understand what to expect and get some basic tests to confirm your body is fit to grow a baby. This is also where difficult but ever so common occurrences like miscarriage and infertility should be discussed. By knowing about all of these things BEFORE they happen, women can be better equipped to deal with it when it is happening.
Once pregnant, the education should shift toward what to expect during pregnancy. It’s actually quite simple, expect anything and everything. But knowing this before the skin rash, insomnia, discharge, dizziness, shortness of breath etc. comes on would again be helpful. Pregnancy can be scary and it’s important for expecting mothers to know what constitutes a reason to call the nurse or head to urgent care. All of this should be covered in prenatal visits to a nurse, midwife or OB but sometimes it won’t be volunteered information. So ask questions mamas! No question is dumb. In fact you are likely wondering the exact same thing as that pregnant person sitting next to you in the waiting room. This is why I absolutely love prenatal yoga, prenatal fitness classes and group prenatal care. It’s so important to know and feel that you are not alone throughout all of this. If you are in Santa Cruz, check out Luma and Fit4Mom. We are so fortunate to have such amazing programs in our backyard. Go take advantage of it!
I have to refer to doctors, midwives and doulas for most prenatal education but when it comes to the musculoskeletal system, a pelvic physical therapist is the expert to consult. One day I hope pelvic PT will be part of routine prenatal and postnatal care but until then, it’s important you seek it out on your own. You don’t need to wait until you have pain or incontinence to see a pelvic physical therapist. Even before you’re showing, you can learn about how to engage your core, how to contract and relax your pelvic floor and how to stand properly so that when the belly is big and the system is challenged, you are better equipped to manage it and prevent pain, incontinence and prolapse. Sound like a good plan? I think so! During the later stages of pregnancy modification of exercises, sleeping positioning and preparation for delivery can be addressed. Doing so can minimize tearing, hemorrhoids, prolapse and diastasic recti. What an opportunity that is so often missed!
Ok so you have the baby. Chances are good labor and delivery aren’t going to go as planned but its a good lesson in letting go of control and expectations. All attention is turned toward baby and let me tell you, the baby always wins. But what about you? Your body has just performed a miracle! It grew a baby and now that baby is out either through a small hole or through a cut in your abdomen. In my opinion, neither are great options. If prenatal care didn’t fall short, postpartum care definitely will and this is why I am spending the time to write all of this and get it out there for anyone who wants it. Very little time goes into preparing a mama for what to expect physically after delivery. Again, I have to leave most of this up to doctors but ask the questions! If something isn’t working or feeling right, if you’re depressed and nothing brings you joy, or if you’re just wondering if something is normal, go see your doctor and ask questions! You are just as important as that baby you just made. In fact you are more important because a healthy and happy mom is going to nurture a healthy and happy baby.
What I can tell you is this, everything is going to hurt at first and pooping is going to be very painful and scary so take your stool softeners! Rest is the most important thing at first which is hard because you have a baby to keep alive and likely feel like you don’t know what you are doing when it comes to parenting. But rest. Please rest. As tissues heal and hormones level a little, a new version of your physical self will emerge. The most important thing I can tell you is this, you DO NOT have to live with pelvic pain or incontinence or anything else for that matter! Fancy diapers that look like panties or avoidance of sex does not have to be the answer! Go see a pelvic physical therapist. A pelvic PT can help guide you through low or mid back pain from lifting and nursing a baby, return to exercise safely so you can avoid injury, scar tissue release so you have less pain, so your c-section mark is less visible, so you can heal your diastasis recti, find you abdominals again, and train the pelvic floor so panty liners are no longer needed. The rebuilding process is just that, a process. And it doesn’t happen naturally, especially if you are having a kid any later than age 18. It’s hard work but if done properly, you can have a body that functions better than it did before having children. Trust me. You just need the proper guidance and support.
It’s also never too late to get the care you might have missed. Sure the “fourth trimester” is a very important time but technically, every mama is postpartum for the rest of their life. It’s never too late to work on scar tissue or strengthen the pelvic floor. We can wallow in what should have happened or what peripartum care should have looked like but instead, its best to look ahead. Spread the knowledge and know that postpartum care today was better than yesterday and will be even better tomorrow.
Let’s first define what endocrine means. Endocrine is the body’s system of hormones (chemical messengers that are both produced and used throughout the whole body). An endocrine disruptor (also known as endocrine disrupting compound, EDC, or hormone disruptor), is anything that gets in the way of proper messaging throughout the body. The unfortunate fact is that we are exposed to such disruptors everyday through our environment and the products we use.
Biphenols (ex. BPA), phthalates and parabens are the most commonly known and researched hormone disruptors but most research looks at less than 5% of known endocrine disrupting compounds.
EDCs can interrupt the messaging system in several ways. Some mimic hormones and bind to receptors causing too much of a hormone to be produced or released. Others actually block the activation of a hormone or cause too little of one to be produced or circulated in the blood. The more these compounds are being researched, the more we are learning about how they can effect expression of DNA and the metabolism (removal) of hormones resulting in disease passed on to subsequent generations.
The description of what an EDC is should explain most of it but in case you still aren’t convinced, I’ll break it down a bit further. Hormones literally run and regulate every system in our body. This includes sex hormones (estrogen, progesterone, testosterone etc.) as well as the thyroid hormones, insulin which regulates blood sugar and our stress response (cortisol, epinephrine, norepinephrine). We may think about these different hormone loops as separate when in reality, they are extremely tied together. Cortisol effects insulin effects thyroid which effects estrogen and thats just ONE connection. So you can get an idea of how disruption in ANY of these messaging loops will have a cascade effect throughout the whole body.
This is how EDCs have been shown to be the cause of disease and dysfunction in literally every system of our body. The diseases and conditions most heavily researched include heart disease, cancer (especially breast, prostate and testicular), infertility (male and female), immune and autoimmune conditions, ADD/ADHD and lower IQ, autism, birth defects, obesity and type 2 diabetes. And just a reminder, this is looking at 5% of known EDCs.
The other alarming fact is that the effects of these synthetic chemicals are not dose dependent. Research shows that for some, a low dose exposure can be more harmful than a high dose. Research is also demonstrating that although most of these chemicals are often eliminated from the body within a few days, they can leave lasting effects which can be passed on from generation to generation through the effect they have on gene production and expression.
In 2012 the World Health Organization and United Nations Environment Program published a report calling the endocrine disrupting chemicals a “major and emerging global public health threat” and yet most of these chemicals still aren’t regulated. I don’t mean to instill any sort of fear into you but I do think its important that we all know what the ingredients are in the products we use and how they effect us so we can make educated decisions in purchasing and using them.
I’ll start with the heavy hitters…
BISPHENOLS: used to line food and beverage cans as well as in thermal paper receipts. Bisphenol A (BPA) is most commonly known but replacements including BPP, BPF, BPS, BPZ and BPAP are just as harmful, if not worse.
PHTHALATES: used to make plastics softs especially in food packaging. Also used in lotions, deodorants and cosmetics to enhance scents.
PARABENS: preservatives used in cosmetics to prevent growth of bacteria and mold.
Flame retardants (organohalogens especially polybrominated biphenyl ethers or PBDES): found in plastics used for furniture (sofas, chairs and mattresses), electronics, wire insulation, carpets and foam used in car seats.
Perchlorate, thiocyanate and nitrate: found in food packaging such as plastic wrap, baggies and to-go containers.
Perfluoroalkyl substances (PFASs): used in teflon or any non-stick surface. GenX, a chemical developed to replace teflon, has also been shown to have similar harmful effects.
Pesticides (organophosphates): used to prevent, destroy, repel or mitigate any pest on crops.
I know this information can be overwhelming and it’s tempting to ignore all of it instead of going down the rabbit hole. I lived in that space for quite sometime until my daughter’s skin and gut issues forced me to do otherwise. But I’m here to tell you that small changes can have a dramatic effect on your overall toxic burden. Here are some tips for where to start:
And here is a list of steps to take. By doing any of these swaps, you are significantly decreasing your exposure to EDCs so always remind yourself, something is always better than nothing.
There are a few companies that I stand behind and I will continue to look for more. At this point I have personal experience with these products and can say that they actually work! I am hopeful that one day many of these EDCs will be regulated so we can all purchase anything on the shelf without being worried about harmful ingredients but until then, we need to be our own health advocates. By purchasing only human safe products, our dollars can help contribute to the movement toward permanent change.
Beautycounter: a certified B corporation that has banned the use of 1,800 ingredients from their products, has a large presence in the movement to change legislation and produces some of the most effective products I have ever used.
Primally Pure: completely natural skin care.
Branch Basics: plant and mineral based, fragrance free, biodegradable cleaning products.
There is a common misconception that the pelvic floor is only relevant for women who have had kids. I’m here to tell you this is bonkers. Sure, having a child tends to lend to more obvious pelvic floor dysfunction, but there are many signs of impairment that aren’t recognized as coming from the pelvic floor. Also, why has it been deemed acceptable to completely neglect a part of the body until a baby is shoved out of it or cancer shows up in the prostate? We wouldn’t ignore a person’s right leg until it needed amputation right? And yes, males have pelvic floors too! There is definitely more talk about the pelvic floor within the perinatal population which is progress, but male pelvic health continues to be taboo leaving most men to suffer quietly not knowing there is any other option. I can’t bring up quiet suffering without also acknowledging the fact that those who don’t identify with the genitalia they were born with and those who have experienced physical and/or emotional abuse or trauma are even more likely to be silent. This can come from not knowing there is something that can be done, feeling uncomfortable or too ashamed to bring it up and/or not trusting that a medical professional will listen and actually hear them which is unfortunately a valid concern. Each one of these barriers to pelvic floor health can, should and will be a blog post of their own but my main purpose here is to just convince you that it’s time you introduced yourself to your pelvic floor if you haven’t already.
The pelvic floor is a group of muscles that are responsible for poop and pee control, all sexual functions, lymphatic drainage, support of the organs that lie above it and stability of the spine, hips and pelvis. Do I need to say more? All of these functions are absolutely essential to our ability to be functional and happy people in the world.
Even further, the pelvic floor is our emotional holding place and our energetic center. Did I lose you with that one? I never thought these words would be a part of my western-based practice either but when you specialize in the pelvic floor they have to be. Again, I’ll save most of my words and RESEARCH to back it up for another blog but for now, just think about how the root chakra has been a part of many ancient practices that still hold true and effective in today’s modern world.
The most obvious signs of dysfunction include: peeing yourself, pooping yourself, erectile dysfunction, pain with penetration, feeling like your organs are falling out of your vagina and/or butthole, and inability to sit because of tailbone pain.
The not so obvious signs include: peeing too frequently, always feeling like you have to pee, having to rush to the bathroom, difficulty initiating voiding, non-continuous urine stream, post-pee dribble, not feeling like you empty poop or pee all the way, waking up at night to pee, feeling like you have a urinary tract infection when you don’t, interstitial cystitis, overactive bladder, not being able to hold a fart in, not being able to discern whether its a fart or poop that is waiting to come out, having to bear down to get poop or pee out, pooping taking longer than 10 min, not pooping everyday, clinically diagnosed constipation, constipation-diarrhea yo-yo, irritable bowel syndrome, hemorrhoids, premature orgasm, inability to orgasm, decreased natural lubrication, decreased libido, enlarged prostate, fibroids, cysts, endometriosis, the feeling of pressure or heaviness, peeing/pooping/farting a little when you laugh/cough/sneeze/run/jump, poop getting stuck in a pocket, having to splint to poop (if you have to do this you will know what I mean), pain with pooping or peeing, painful menstrual cycles, perineal, testicular, scrotal, sacroiliac and pubic pain. Whew! Anyone else winded from that?
And the signs that you wouldn’t guess had anything to do with the pelvic floor include: abdominal pain, hernias, diastasis recti (abdominal separation), hypersensitive nervous system, PTSD, piriformis syndrome, sciatica, groin pain, hip pain, low back pain and get this…even knee, neck and shoulder pain! How can this be? It’s because the pelvic floor is the bottom of our core which stabilizes the spine. Without spinal stability, nothing works right. You can read more about this in my previous blog post, “Spinal Stability”.
SOOOOOO MUCH! As I mentioned right off the back, the pelvic floor is a series of muscles. As with all muscles of the body, their strength can be improved leading to more functional capacity and decreased symptoms. Sometimes this has to start with learning how to relax the pelvic floor (again, needs to be another blog…I have created quite the list for myself), sometimes it has to begin with posture and breath, and other times its pressure management, loading the system and introducing impact. It never ever ever ever, is just kegels. I will save that soap box for another day.
When the dysfunction is beyond what can be fixed through muscle strength, there are many surgeries to fix any ligamentous or tissue damage. This is the equivalent of when leg strengthening isn’t enough to return to soccer without an intact ACL. The surgery replaces the ACL but then rehabilitation after the surgery is a must. Same goes with any pelvic floor surgery (having a kid counts as such). The post-op rehabilitation is absolutely imperative to gaining proper function afterwards. Scar tissue doesn’t magically disappear and muscle strength doesn’t miraculously pop back.
I encourage everyone to start using the words poop, pee, vagina, penis and sex in their day to day conversations. I think part of the problem here is that we aren’t comfortable saying or hearing, let alone discussing these things with anyone, especially doctors.
If you are experiencing any of the above signs or symptoms, don’t sit and wait for your doctor to bring up the topic. While it should be part of their routine screen, it’s often forgotten or breezed over. If your doctor asks you the questions, feel comfortable answering them honestly. It does nothing for you to lie and say no just because it’s an uncomfortable conversation. It doesn’t have to be!
When you do bring it up or answer honestly, don’t be surprised if your doctor goes straight to prescribing a medication or giving you a urologist or gynecologist referral. This is when you need to be your own advocate and ask for a pelvic physical therapy referral first. Pelvic physical therapy is a relatively new thing in America so it still isn’t the go to for most doctors. Heck, we are still trying to get some doctors to refer to physical therapy for back pain. It will definitely be some time before doctors routinely refer to PT for incontinence. So ask for it yourself. You wouldn’t sign up for a back surgery before trying to strengthen your core first nor would you choose to be addicted to narcotics for pain before trying to improve your musculoskeletal impairments. Same goes for the pelvic floor. Address the muscles first before signing up for bladder surgery or viagra.
I gotcha covered. Shoot me an email here. Let’s work through it.
Most of us want to be healthy or know we should be. But what is health and how is it measured? When do we know that we have achieved it and how can we achieve something that we haven’t yet defined? We can’t. My aim is to briefly outline what I would consider the pillars of health. I am going to keep it simple here. In future posts, I will dive into each one of these pillars and their components with research to back it all up but I want to start with an overview of the big picture, of what it means to be healthy and what our bodies need in order to function at an optimal level for as long as we are on this earth.
Happiness: another vague term just like “health”. I always hate it when people define something with yet another word that needs a definition, but here I am doing it. I use the word “happiness” because there is a lot that goes into our mental well-being and it’s the best we have when it comes to summing it all up. Our mental state is foundational to our health. Feelings and thoughts drive our actions and results. Negative emotions are also absorbed in the physical body and manifest disease. For these reasons, I would argue that nothing matters more to our health than our level of happiness. It over-rides everything else we do or don’t do for our body.
So what is happiness? It’s the state of being happy, obviously. Ha! Sorry, couldn’t resist that one. In all seriousness, I believe there are many components to achieving the state of happiness. In my opinion, this includes proper stress management, permission to feel with a high level of emotional intelligence, positive self talk, unconditional self love, the feeling of purpose, deep social connection and support. Easy peasy right? Absolutely not. I don’t think we put enough time and effort into improving these areas. Nor do I think people realize how essential they are to our physical health. I could write a novel on each of these components and I eventually will but for now I am going to leave it at this: you can’t be physically healthy unless you are happy. Period.
Food: a simple but not so simple thing. Everyone knows you are what you eat but there isn’t a lot of agreement on what that should be. Sure, we can all agree sugar intake should be limited but what about natural sweeteners? what about artificial ones? how much sugar is too much? and are carbs considered a sugar? The same confusion exists when considering meat, dairy, alcohol and carbohydrates. I have even witnessed debate around which vegetables and fruits are quote-on-quote “good or bad” for you.
Again, I could spend my whole life writing about food and I will write more in future posts but for now, I just want to highlight what I consider to be the most important principles to follow when it comes to what you eat. I think Michael Pollan sums it up nicely when he says “eat food, not too much, mostly plants”.
Exercise: finally one that is easy to define but not necessarily easy to consistently do. When it comes to what type, how much and how often, I would say that variety and consistency are key. It’s important to have both a strength and endurance component to your exercise as well as a form of recovery like stretching, yoga, hot tubs or bodywork. From there, it depends on what your goals are and what you enjoy doing. I think exercise is most effective when it is functional aka it looks a lot like what you want to accomplish in your day to day. But nothing is effective when it’s not consistent so it’s important that you choose forms of exercise that are enjoyable so you are motivated to do it and keep doing it.
Sleep: something so simple and yet so difficult. There are two components to sleep: quality and quantity. In order to attain the restful sleep that our body needs, you have to have both. There are many reasons that sleep can be disrupted (which I will write about in the future) but sleep also tends to be something we don’t prioritize. Often we feel there is too much to do and no time to sleep. Or we develop habits that we think are necessary to get everything done that interrupt our ability to get deep sleep like loading up on caffeine or working on the computer late into the night. The reality is that we would be far more effective in our day and feel better if our priority was sleep. Try sleeping 8 hours every night for one week. You will be amazed at how much of a game-changer sleep is.
The environment: the often forgotten and oh so covert component to health. I’m still wrapping my head around all of the things in our environment that we can’t see or aren’t aware of that have a profound impact on our physical health. Infections and parasites are the most obvious ones but then there are heavy metals, pesticides and plastics that we can’t see but are in our water, on our food and in most of the products that we use. It’s a scary rabbit hole to go down which is why I avoided for as long as I could but there are small changes you can make that go a long way like removing plastics from your kitchen, replacing your make-up and skin care products with ones that don’t contain metals or hormone disruptors and using cleaning supplies that are made from natural products instead of chemicals. Once again, there is a lot to talk about here and I will write more in future posts but for now, just start looking at what you use in your house and on your body. Items or products that you use everyday are worth replacing even if you only just opened the bottle. Your body will thank you.
I have none for this one but as I address each pillar in future posts, I will be sure to provide the evidence for everything I say or I will make it clear that it is my opinion 🙂
Are you interested in a specific pillar? Let me know which one you want me to dive deeper into by emailing me here.
The intricacies of spinal stability can get complicated but the big picture is pretty simple. It can be summed up in a few sentences: a stable spine is required for strength and proper function of our limbs or whole body for that matter. The spine is stabilized by two mechanisms: intra-abdominal pressure (IAP) and muscle activity. Contraction of the diaphragm produces intra-abdominal pressure. Muscles including the transversus abdominis, pelvic floor and multifidus control that pressure and are responsible for spinal stability in the absence of it. Breath coordinates the system.
Just kidding. Jenny write a short blog? Never.
Let’s break this down further. Stability is “the precise control of excessive joint motion while allowing for the generation of necessary torques for desired multi-joint movement” (C. Frank 2013). In normal talk, it is a lack of movement at one joint allowing for enough force production to create movement at another joint. Spinal stability aka stiffness, enables limb motion and strength. It can be likened to a tree trunk and its branches. A large, stiff and stable tree trunk can support branches that can sustain a heavy load whereas a Gumby-like, thin tree trunk would give way to the weight of even the smallest branch.
This comparison of the spine to a tree trunk should give insight into why spinal stability is absolutely essential to the function and strength of all joints and limbs. If the spine isn’t stable, the body struggles to find stability elsewhere leading to compensation and overuse of small muscles trying to do a really big job that shouldn’t be their responsibility. It also lends to excessive movement in the spine which can cause degenerative disc disease, arthritis, fractures, spondylolesthesis, stenosis, nerve compression and the list goes on. This would be the equivalent of a flimsy trunk breaking under the load of a heavy branch.
So how do we achieve spinal stability? There are two components: intra-abdominal pressure and muscle activity. Both have been proven to be effective in stabilizing the lumbar spine and the preferred mechanism has been shown to be task, movement and posture dependent.
Let’s turn the spotlight on intra-abdominal pressure. I’m about to rattle off a whole bunch of contradictory research that will likely confuse most people so I’ll start with a few statements that are largely agreed upon. First, intra-abdominal pressure stabilizes the spine. Period. It’s a known fact. Next, contraction of the diaphragm which occurs on an inhale, increases intra-abdominal pressure. Another known fact. And lastly, contraction of the abdominals control and contribute to intra-abdominal pressure. Thats about where the clarity ends.
The mechanism by which intra-abdominal pressure stabilizes the spine is not clearly understood. The theory most supported in literature is that the increase in intra-abdominal pressure is accompanied by a co-contraction of the abdominals which provides spinal stiffness and stability. This implies that tension of the abdominals in a lengthened state (eccentric contraction) is essential to the mechanism. Within this body of research, some studies show that all abdominals are involved while the majority say it is mainly, if not solely, the transversus abdominis. Like I said, there isn’t a lot of agreement in the details.
Most research indicates that intra-abdominal pressure is the preferred strategy for activities that place a large extension moment on the spine such as lifting and jumping because the spine is able to stabilize without additional activation of the erector spinae. Intra-abdominal pressure may also be preferred with heavy loads but there is no consensus as to whether it unloads the spine or increases intra-discal pressure. Some theorize that the intra-abdominal pressure unloads the spine by directly pressing upwards on the rib cage via the diaphragm as well as indirectly by generating an extensor moment on the lumbar spine that decreases back extensor muscle activity. Others have shown that there is an increase in intra-discal pressure during a Valsalva maneuver with no reduction in erector spinae activity making the unloading effect of intra-abdominal pressure controversial.
At the end of the day, I think it’s safe to conclude that the unloading and stabilizing effect of intra-abdominal pressure and the muscles responsible for generating it are posture and task specific. But really big picture, we know intra-abdominal pressure stabilizes the spine and we know the diaphragm and the transversus abdominis are involved in producing it. I hope I didn’t lose too many of you with all of that.
Let’s move on to muscle activity and it’s role in stabilizing the spine. On an exhale, the diaphragm relaxes, reducing intra-abdominal pressure. A shortening contraction of the core muscles replaces the absence of intra-abdominal pressure with tension that increases spinal stiffness and creates stability of the spine. However, there isn’t a lot of agreement regarding which muscles do this.
Most studies refer to the transversus abdominis, multifidis and pelvic floor as the core musculature. Some say that transversus abdominis is solely responsible but other studies show that all muscles of the trunk increase spinal stiffness and can be involved. Research supporting the later demonstrates that muscle activation is position, task and movement specific making the most important stabilizer transient to the task. Regardless of which muscles are doing the work, coordination and proportional tension of the muscles are required to provide effective spinal stability.
Both intra-abdominal pressure and muscle activity have been shown to increase stiffness of the spine in isolation but in function, they always go together. I believe this fact, combined with everything being task, posture and movement specific, explains why the details of spinal stability cannot be agreed upon within research.
So how do I apply all of this to my patient care? No matter where the pain is, I always assess spinal stability. If impaired, it is prioritized in addition to addressing impairments directly at or surrounding the location of pain. This includes posture and breathing patterns since spinal stability is directly tied to both. When it comes to my progression of spinal stabilization exercises, I start with static postures in spinal neutral to re-coordinate the system through breath and conscious muscle recruitment. At first postures are gravity eliminated (aka lying down) and gradually progressed to positions against gravity (aka sitting, kneeling and standing). Once coordinated and able to stabilize against gravity, I progress to loading the system with weight and/or limb movement on a stable spine. This is when we are training the muscles of the core to work while both lengthening and shortening, keeping tension throughout the whole breath cycle. From there I progress patients into loaded multi-joint movements while maintaining neutral spine. The last step is training out of spinal neutral because let’s face it, life doesn’t happen in neutral so it’s important that we are strong in all positions of the spine. And then voila! You have achieved spinal stability! Sounds easy peasy right? Definitely not. Which is probably why I have a job. But it is totally doable. It just takes a lot of work and an understanding of your why which I have hopefully helped with a little bit today.