Monday, February 6, 2017

Trauma and Recovery

Maureen Mason MS PT, WCS, CCI, PYT

Self check:
Are you suffering from trauma? Trauma can be experienced from verbal, physical, or sexual abuse. We often think of trauma from sudden experiences like falls, car accidents, fights, or other dramatic events. Infants may be traumatized by difficulties at childbirth. Women may experience trauma with childbirth and unexpected difficulties with bodily changes, and loss of function. Military service is recognized as inherently life and safety–stressing, so as to have the effects linger after exposure to conflict, as in “post traumatic stress disorder (PTSD). First responders such as police, paramedic and firefighters may experience trauma in the line of duty, which may entail life threatening situations, or exposure to social conflict and crime.

Trauma may slowly occur with exposure to suffering for an extended time, such as hospice workers, or parents caretaking disabled children, or being a caretaker for someone in chronic poor health. Medical professionals often suffer from “vicarious trauma” as they are exposed to patient populations that are challenging, and they may take on the concerns and suffering of clients. There is an institutional as well as financial challenge medical staff face whether to be a medical problem solver, providing a treatment, or intervention vs. simply “being” present with clients, and in some scenarios MD’s only have 7 minutes scheduled per patient. This may be associated with medial provider “burn out” or “compassion fatigue” and you may unfortunately have experienced a medical provider interaction where the professional seemed dis interested, uncaring, or even dismissive.

Emotional loss as in broken relationships, and losing a loved one in death, are also significant traumas to the heart and soul, and there are physical stress reactions to emotional trauma. In looking at all these sources of trauma, most people have some elements of trauma exposure, and bounce back, whereas others may develop poor health from the trauma.

Our primal body:
Our brains are programmed for survival, and safety seeking, so we have primal mechanisms that help us to react to dangers, to threats to our safety and well being. This is the sympathetic nervous system, our protector. In response to a stressor, either physical or mental, the heart rate speeds up, blood pressure rises, and we become on alert for danger and threats. But with sympathetic nervous over-activation from prolonged or intense trauma, we may be stuck in the primal reactions once danger has passed, in physiologic processes involving the entire system. Initially termed the “fight or flight response”, we now recognize we may “freeze” to protect ourselves. We may state, “I’m ok” while holding rigid and breathing shallowly. Also we may be stuck in excess activity to soothe the body such as compelling interest in fornication, and or feeding. Drug and alcohol addictions are frequently developed in individuals seeking self calming, soothing, and escape from the monster of chronic unresolved stress. Consider if you have signs of unresolved trauma in your life. Chronic anxiety, depression, anger, sleep difficulties, and other mood imbalances are increased in individuals that have experienced significant trauma. Chronic pain is often associated with a history of trauma, and unresolved pain is on ongoing health challenge.

There is a protective nature of the stress response, to get out away from danger, or to fight to survive, or hide so as to be unseen (freezing), yet when it is constantly turned on, it is not adaptive, it is interfering with health, homeostasis, self -care, connection, and enjoyment of life, of work and play. Cortisol levels gradually rise, sleep difficulties worsen, blood sugar may be elevated, and inflammation increases in the body in a chronic stress response. Several practices can help reboot and recharge the body towards a calm, more contented state, with improvement in health and well -being. Consider trauma self care as essential as plugging in a battery that is blinking amber, or red.

Trauma Recovery Toolkits:
Trauma recovery is a process that is multidisciplinary and it can have profound improvement in an individual’s sense of wellness, health, and well -being. Trauma recovery starts with an individual, and often-social groups, such as the military health system care system, recognizing the presence of unresolved trauma. Trauma recovery entails a plan, a daily practice, a guide, or coach, or therapist, and the encouragement towards hope and resiliency. The best results are produced with a caring practitioner, and social support system. Successful programs may include mindfulness/meditation, walking meditation, yoga, exercise and massage therapy, sound/color therapy, acupuncture, aromatherapy, hypnosis, individual/group-cognitive behavioral therapy, and nutritional approaches. At CTS we have therapists that can provide mind-body spirit care with Medical Yoga, Pilates, and training in breathing exercises, and direction to healing resources such as sleep hygiene, stress management and trauma resolution. Also locally in San Diego, veterans may participate in horseback riding, kayaking, and other activities such as pet care and training. With current overloads in our veterans health care system, some are offered only pharmaceutical approaches.

According to Dr. Bart Billings, in his text “Invisible scars”, which focuses on military recovery post trauma, pharmaceutical interventions have increased 700% from 2005 to 2011, with a concomitant increase in suicide rates. Many medications for depression have a black box warning regarding suicide risks. In times before the Vietnam War, military service personnel had extended time on leave with their troops following active engagement, allowing for team caring and communication and mental and physical refreshment. Veterans stayed with their comrades and had rest and recuperation following exposure to conflict. Current practice is for many veterans to be sent home solo, with no decompression time, and then given a disability rating for PTS (D). Our veterans need encouragement for as much relational support as possible, as well as the establishment of a plan and adherence to a recovery toolkit.

Trauma Sensitive Yoga Therapy (TSY) has been developed by psychologists to help recover mind, body and spirit, for survivors of trauma. TSY, according to the author David Emerson, places the client in the driver’s seat to assume comfortable seated yoga postures. Participants are guided towards noticing breath, and sensations in a variety of modified yoga poses, and this allows a sense of control and empowerment for the client. TSY allows clients to get back into their body, in a non- judging, accepting, loving manner. And in the text Yoga Therapy, (Horovitz, Elgelid) the authors note that certain people have a positive engagement, and sense of release and recovery, from the vigorous, repetitive practice of Bikram Yoga. An idea presented in both of these yoga texts is that trauma “lives in the body” and the body has to participate in the recovery. The latter text is a comprehensive review of the history, philosophy, styles of yoga therapy, and practical applications. It may be useful for self-care for individuals, but a key is to get on a mat and engage the body, vs. just reading about stress management.

Here is a sample of daily practices for trauma recovery:
  • Journaling thought and feelings and goals.
  • Add one new healthy food item per week.
  • Attend individual or group therapy.
  • Take a yoga class that suits your style.
  • Make a place in your home or room a sanctuary, including an item from nature such as a shell, aromatherapy, and plan for sleep hygiene.
  • Listen to a 10 min mindfulness guide such as self-compassion.
  • Play with self guiding your breath on a breathing app.
  • Social: Walk with a friend, meet a friend for tea, call someone and video chat or facetime if possible.
  • Sample a meditation/mindfulness class.
  • Practice gratitude daily.
  • Nurture a mind body spirit connection with inspirational readings and time in nature.

Resources for trauma recovery:
  • A cool app developed by the military to help vets, valuable for all, nice visual guides as well, helps develop the skill of breath-awareness and control - breathe2relax

  • Proven strategies to help improve sleep -

  • Proven strategies to help reduce stress -

  • Profile of bereavement triggers, processes -

  • Risk factors for trauma, healing options -

  • Cultivate the healing power of gratitude -

  • Seven Principles for Cultivating Gratitude -

  • Audio Guides for Healing: UCSD Center for Mindfulness: Practice 6-40 minutes per day, in a seated or comfortable reclining pose. Use headphones/boundaries for family/prioritize this for self care. Choose a voice you like. The center offers 8 -week mindfulness based stress reduction classes. -

  • Specific "Body Scans" that may you may like -

  • Loving Kindness Meditation: Self care -

  • Yoga Therapy: Individualized for client needs: 11 Free Videos and links to audio guides for mediations: Focus, align breathe, be. I am certified in Medical Therapeutic Yoga through her institute -

References: Billings, Bart, Invisible Scars, How to Treat Combat Stress and PTSD Without Medication, Paradies/Inspire, Florida, 2016

Emerson, David, Trauma-Sensitive Yoga in Therapy, Bringing The body Into Treatment, Norton and Company, NY, London, 2015

Figley, C.R, Compassion Fatigue: Toward a New Understanding of the Cost of Caring. In BH Stamm (Ed) Secondary Traumatic Stress: Self care issues for clinicians, researchers, and educators, Baltimore, Sidran Press, 1995

Figley, C, Compassion Fatigue: Psychotherapists chronic lack of self-care: Journal of Clinical Psychology, 58, 2002, p 1435

Garner, Ginger, Medical Therapeutic Yoga, Biopsychosocial Rehabilitation and Wellness Care, Handspring Publishing 2016

Horovitz, Ellen, Elgelid, Staffan, Yoga Therapy, Theory and Practice, Routledge, NY, NY 2015

O'Dowd TC, Five years of heartsink patients in general practice. BMJ. 1988; 297(6647): 528-30 (ISSN: 0959-8138)

Kate Sheppard, PhD, RN, FNP, PMHNP-BC, FAANP, Compassion Fatigue: Are You at Risk? Am Nurs Today. 2016; 11(1)

Skolvt, Thomas, Trotter Mathison, Michelle, The Resilient practitioner, Routledge, NY 2016

Thursday, March 10, 2016

Pelvic Pain; PMS or beyond with the blues?

Guest blogger Elizabeth DeLozier SPT from SDSU
March 2016

Pelvic Pain can be due to many causes, with Physical Therapy at CTS treating myofascial, postural, biomechanical, and post injury (trauma, surgery) related pelvic pain. Often times we notice a cyclical nature of pain flares over the course of treatment, and some of our clients have a strong hormonal influence over the pain, related to PMS, or a more intense cyclical pain cycle PMDD.
We did some research this month to assist our clients who are presenting with cyclical pain flares that can be improved with Physical Therapy, Lifestyle and Nutritional interventions. Discuss the items listed below with your health care provider. Let us know if you suffer with PMS or PMDD and what you have found to be helpful.


What is PMS?
PMS, or pre-menstrual syndrome, is a broad term referring to physical, emotional, and psychological changes which affect women 1-2 weeks before their menstrual cycle and ease when they begin their period. Approximately 30-80% of women of reproductive age experience PMS. Symptoms include abdominal bloating, headaches, increased or decreased appetite, muscle aches or joint pain, fatigue, depression, and irritability.

What is PMDD?
PMDD, or pre-menstrual dysmorphic disorder, is a more severe form of PMS that affects approximately 3-8% of reproductive-age women. PMDD is characterized by significant mood disturbances and irritability which impair occupational and social interactions. The major risk factors of PMDD include a history of mood or anxiety disorders, familial menstrual or pre-menstrual disorder, and age in the 20’s or 30’s.

What causes PMS and PMDD?
Although researchers are unsure of exactly what causes PMS and PMDD, many women suffering from these disorders may have underlying anxiety or depression. Some researchers believe that the hormonal changes that trigger the menstrual cycle may worsen the symptoms of mood disorders. A recent study found that many women who exhibit signs of PMDD have low serotonin levels. Serotonin is a neurotransmitter involved in controlling mood, attention level, pain, and sleep. Women who believe they may have a mood disorder should talk to their doctor about treatment options.

Diagnosing PMDD
The best way to confirm a diagnosis of PMDD is charting daily symptoms. Women suffering from PMDD will experience a symptom-free phase between menses and ovulation. Well-validated studies on using symptom charting for the diagnosis of PMDD can be found below.

Non-pharmacologic treatments for PMS and PMDD can include:
  • Lifestyle changes and nutritional supplements:
  • Decrease nicotine, tobacco, and alcohol use in the 2 weeks prior to menstruation
  • Decrease sugar, caffeine, and sodium intake in the 2 weeks prior to menstruation
  • Ensure adequate rest: at lease 6-8 hours a night
  • Regular aerobic exercise has been shown to be beneficial for women suffering from PMS or PMDD.
A large, multicenter study found that 1200 mg of calcium per day significantly decreased emotional and physical symptoms of PMS and PMDD.

Studies have found that vitamin B6 in doses of 50-100 mg/day are beneficial for women suffering from PMS and PMDD

Herbal supplements:
There is some evidence that 200 mg of magnesium and 400 IU of Vitamin E per day can decrease symptoms.

A recent double-blind, placebo-controlled study found that 1 tablet of chasteberry extract, also known as agnus castus fruit, significantly decreased PMS and PMDD symptoms of irritability, headache, anger, and breast fullness.

Gingko Biloba has been found to decrease fluid retention and breast fullness associated with PMS and PMDD.

More info about PMS and PMDD can be found at:

Thursday, February 18, 2016

The Happy Heart, The Healthy Heart

Maureen Mason, MSPT, WCS, CCI, PYT-C

February is heart health month, and I am writing this in honor of a dear friend who confided in me she discovered during a recent medical procedure that she has significant heart disease. She is now intent on, and practicing, heart health in mind, body and spirit. She may use medication and /or surgery, as needed, yet in her post op lifestyle she is on a health quest incorporating mindfulness, walking, and healthy eating daily. I want her to live long and prosper!

Sages throughout the ages offer strategies and methods for peace, enlightenment, and wisdom. Certain habits and practices help mind, body and spirit to thrive. Here are a few habits that can improve your health,and can specifically help your heart health.

Exercise regularly, 12 x per month or more.
Regular exercise may include the practice of yoga, either solo, or in a class that is safe and sound. A study published in research gate identified significant reductions in anxiety, depression, worry, and reduced salivary cortisol in women practicing Iyengar yoga for 3 months, compared to controls. Walking is also a wonderful form of exercise.Recent research is noting health benefits of yoga as similar to that of traditional cardiac training.

Maintain a good weight, BMI range 18.5 to 29.9
Calories count: Eat a diverse, Mediterranean diet. Eating a lot of vegetables, nuts, and good fats and proteins helps fill you up and nourish your body.

Practice meditation*: clear your mind
"Being", sitting or reclining, breathing, and cycling a mantra or prayer can calm and control the wandering mind. Use free guides, friends, or links in prior yoga posts here to develop a meditation practice. Research is showing improved mental and physical health in individuals who meditate regularly.

Alcohol: moderation
Women may benefit from one drink per day, men, 2 drinks. But alcohol use can cause impaired health by adding extra calories, upsetting blood sugar, irritating the throat, stomach lining, pancreas and liver, so if used, only in moderation.

Engage the positive with Spirituality, or Religious affiliation.
Reading uplifting literature or prose regularly, or having spiritual or religious devotions can enhance your life, and your health. Individuals that have spiritual or religious devotions as part of their life rate higher on compassion, forgiveness, and on heart health standards.

Comprehensive Therapy Services has resources to help improve your health, including free handouts on Mind Body health strategies, Meditation*, “Medicine Mind” mindfulness training, Doterra essential oils, pilates and other fitness classes, acupuncture and massage. Ask your therapist for resources to improve your heart health and self care. One on one private training is available for health and wellness in professional yoga therapy.

Ginger Garner is a a preventative health care leader with free mediation* podcasts and a gentle yoga DVD you can practice.She founded the Institute for Professional Yoga Therapy. The PYT-C after my name denotes my Professional Yoga Therapy affiliation and training, which has helped me practice self care and expand my integrative health care offerings to clients. She created PYT to offer medically based, safe, sound yoga programs. Here is her link:

Research based articles on heart health:
Rapid stress reduction and anxiolysis among distressed women as a consequence of a three-month intensive yoga program.
"Women suffering from mental distress participating in a 3-month Iyengar yoga class show significant improvements on measures of stress and psychological outcomes. Further investigation of yoga with respect to prevention and treatment of stress-related disease and of underlying mechanism is warranted."

Measurement of the effect of Isha Yoga on cardiac autonomic nervous system using short-term heart rate variability
During both supine rest and deep breathing, Isha Yoga practitioners showed well-balanced activity of vagal efferents, overall increased HRV, and sympathovagal balance, compared to non-Yoga practitioners. Hence, it may be postulated that Isha Yoga practitioners: have better exercise tolerance, their cardiac response to adverse conditions like day-to-day stress is improved following Isha Yoga practices the probability of them experiencing hypertension and other premature cardiac events like ischemia or infarction is decreased after the practice of Isha Yoga. However more studies should be conducted to explore these areas further.

Mediterranean Diet and Incidence of and Mortality From Coronary Heart Disease and Stroke in Women
Cardiovascular disease mortality was significantly lower among women in the top quintile of the Alternate Mediterranean Diet Score (RR, 0.61; 95% CI, 0.49 to 0.76; P for trend less than 0.0001).

Thursday, January 28, 2016

Eat More! Optimal Nutrition for Health

Eat More! Eat Less! Optimize Your Nutrition for Health
Maureen Mason, MS PT, WCS, CCI, PYT-C   January 2016

   Choosing specific foods can reduce inflammation and pain, so here are medical guidelines recommended by the experts. Check with your health care professional for any questions or concerns. Add one new item per week to your current routine. 

Eat more for specific anti –inflammatory* effects:
Nuts such as Walnuts, Almonds, Flaxseed
Avocados   Mushrooms
Salmon, Sardines, Herring
Green Tea, Tart cherry juice, Red wine, 5 oz., and Soy
Spices Turmeric, Ginger, Cinnamon

Eat more for overall health: fresh fruits and vegetables, seeds and nuts and beans, low glycemic foods, “whole food” with no chemical additives, lean poultry, fish, and omega 3 enriched eggs. Balance good fat and protein and carbs to equalize blood sugar response after eating.

Eat Less
Processed food, fried food, meat, and dairy. Seafood such as shrimp and lobster can be pro-inflammatory. Gluten is in any wheat product and also used as an additive in many products, consider limiting if your provider advises. Dairy is associated with indigestion and IBS and many health care providers advise limiting to reduce indigestion. Alcohol and soda are big calorie items and associated with negative health indices. Overall portion size of items from this list can be reduced with benefit, such as having ½ of a donut vs. 3 donuts.

Notice how your stomach and digestive system react for hours after you eat. Notice energy levels, mental focus and clarity, and ease of sleep and waking.

*Anti-inflammatory effects occur on a cellular level with an optimal nutritional intake. Protein molecules called cytokines that are produced with injury act as part of the immune system. Cytokines circulate and sensitize nerves to pain and increase pain sensations. Omega 3 healthy fats and other items listed in the anti inflammatory list help dampen the cytokines and reduce pain signal production. Effects of food are cumulative, so choosing a regular grazing habit from the best items can help you feel better in the long term.

Nutrition Websites and Resources to help optimize eating habits
1.     1..Dr Ski Chilton advises we reduce our overall calorie consumption 20% -30% if overweight or obese; here is a link to his advised anti-inflammatory nutrition program, with a free information guide on healthy eating and suggested good fats:

2. Here is a tremendous link Dr Michael Lara, a holistic psychiatrist, with his outline of slides explaining the inflammatory process and the role of nutrition, supplements, and exercise in health and disease:

3. Do you have “brain fog” after eating, or feel tired? Perhaps you are eating meals that have too high of a glycemic index. Check out this link for excellent detail as to why you may be on a glycemic roller coaster: Foods that are high on the glycemic index include: white bread, cereal, rice, white flour, potatoes, beer, fruit drinks, and processed foods.

4. Are you on the paleo trend? What’s the buzz? If you are a high level athlete you may need more protein to support your training, and some MD's are leaning towards plaeo, Here is a link to the Mayo clinics explanation and medical advice on the topic:

5. Do you really understand what the Mediterranean diet is? Here is the Mayo clinics profile and medical advice:

6. Fact: Physical therapists treating pelvic pain, bowel and bladder problems, sexual medicine, and any musculoskeletal pain problem are directing clients towards self care and healing with optimal nutrition. Here are links to women’s resources for optimizing nutrition in relation to health concerns:

Additional: Fluid and Fiber Management

Optimal fluid intake can be considered an intake of ½ of the body weight in ounces of water per day. A 150# individual may need 75 ounces of water per day.  Food and other fluid intake, temperature, age, and activity level all influence hydration need. Increased temperature and increased activity level both will increase the need for hydration. Signs of dehydration include fatigue, fainting, low blood pressure, falls, constipation, and dry, itchy, wrinkled skin.

Optimal fiber intake is 20-30 grams per day, ideally from consuming excellent nutrition with fiber rich foods.  Fiber supplements are extensive, but the easiest fibers to consume include prunes, plenty of fruits and vegetables, beans, nuts and seeds. Constipating, binding foods include toast, bananas, and applesauce.

Discuss these topics with your health care provider, and enjoy your food, with gratitude,
In health,

Thursday, October 22, 2015

Medical Yoga for Centering, Energizing.

Medical Yoga for Centering, and Energizing              

Maureen Mason, MSPT, WCS, CCI, PYT-C
Celebrate PT month with yoga! October 22
Warrior Series

  What is your mood as you approach exercise?  With a yoga repertoire, you can choose and adapt your own home program to meet your needs. Start an energizing session with mountain pose. Stand tall, and notice all the textures around your feet, from heels to toes, and the inner and outer pressures on the soles.

Taking a few slow breaths here and sensing feet, ankles, knees, hips and pelvis-can help your nervous system to steady and “ground” into appreciation for any aspect of your life. You can practice outdoors, or indoors, and a yoga mat on top of a padded rug is soft and easy.

Getting your feet NAKED is important, our feet get numbed from our footwear and the level surfaces we often walk upon. You can thank your feet for getting you around all your life. 

A yoga colleague Dina Chalom, PT,  cued me to not quickly blast out of this mountain pose into the warrior series, but to really make this a focal point to a start of a session. Sense yourself with stability, being alive, energizing with rhythmic inhalation, exhalation. Grounded feet. Diaphragm breaths are utilized, and the transverse abdominus is engaged to stabilize the trunk, as well as a slight engagement of the shoulder blades, meeting each other, while in front holding the shoulders open. The hand position of prayer pose reminds me to engage both front and back shoulder muscles.
 Mountain pose:feet may be slightly apart as well.
Thank your muscles and bones for holding you steadily in position.

Ginger Garner, of Professional Yoga Therapy, advises hands held together
in mountain and balancing as you step back into Warrior I. Pulling this off 
smoothly requires dynamic stability, holding steady in one part while moving
 Warrior I is a great pose to open up the hips, and focus on stability at the feet and up to the trunk stacked above. Breathing and holding the spine neutral and pain-free, I no longer throw my leg back far and wobble-I lift the leg back into place, pressing down into the back and front foot with equal pressure, and hold and breathe, and allow the small muscles around my joints to work with the larger sling-muscles. This is a therapeutic exercise concept of generating biomechanical stability and co-contraction of muscles around joints.

In  Warrior I, above, I am checking that both hips are in the same plane, not tipped down on one side, and also that the entire pelvis is aligned towards the front. This allows me to really stretch my quad and hip flexor, vs rotating my spine and pelvis back. After I warm up with this series and few other Asanas, I am able to open up the pose more…but this is it for me in an early am photo shoot. Add Arms up for more of a workout with Warrior I.
Thank your digestion for energizing you. Look forward to your next meal.

Warrior II is a great pose to further open up the hips. You can step back into the pose from mountain, and allow your pelvis and body to turn to the side. Check if your hips are level, and your body is stacked comfortably above your pelvis. Look down to your forward knee, as it moves into a lunge it should optimally align in line over the foot, not be diving in towards the ground. I align by consciously activating the deep hip muscles that turn the femur bone outward. 

Warrior II with arms lifted, shoulder blades can lightly meet each other, then palms can turn down to the floor.While here, sense the back ribs lifting a little as you inhale, while at the same time hold the navel in for stability. Keep shoulders soft and easy.
I like to look out over my forward facing fingertips and consider what I want to focus on for the day, to accomplish.Or if this is a sunset workout for me,  I consider a positive emotion to focus upon. When outdoors, I let the natural beauty of the environs refresh me in my own little yoga bubble.
Here, you can thank your lungs for oxygenating all your tissues 

Move into the poses from the prior post for more power, Chair, Plank, Side Plank, and Hip Bridge. 

These Asana poses may be used prior to meditation practice, or to simply be a self care and refreshment time in your day. In yoga philosophy, the poses are part of a lifestyle for wellness; see the 8 limbs of yoga reference. 

After I perform these postures (Asanas) my body feels lighter and my hips move more fluidly as I walk. A great feeling, older, stronger! Look at the link below on yoga for healthy aging. 

 Next up: Warrior III, and the Hip and Yoga

Medical Therapeutic Yoga Definition: Medical Therapeutic Yoga is the practice of yoga in medicine, rehabilitation, and wellness settings by a licensed health care professional who is completing or has graduated from the Professional Yoga Therapy Studies program and has been credentialed as a Professional Yoga Therapist-Candidate or Professional Yoga Therapist.
I share this link for the option for you to read more about how one may “ground” or feel connected to the earth, and your feet, during yoga exercise. However specifics on foot and knee alignment as given here may not pertain to you, in other words you may need to have feet slightly turned in or out depending on your ankles, knees, hips and pelvic structure. Look at all the medical benefits of regular yoga exercise

Tuesday, October 20, 2015

The Core, week 4: Pelvic Floor Muscles

The Core, week 4: Pelvic Floor Muscles

“Because you know I’m all about that bass, ‘bout that bass, no treble” 
(Meghan Trainor's fantastic lyrics from “All about that Bass”)

Abdominal core stabilization is not complete without activating the muscles at your base--a group of muscles located at the bottom of your core. You may know them as “Kegel” muscles. They are your pelvic floor muscles (PFM). They play a role not only in core stability, but also in urinary  function, fecal function, and sexual health.

If you don’t want any “trouble” (such as leaking urine, prolapse, or ineffective core activation) then it's time to learn to use your “base”.

How do they (PFM) make my core stronger?

A strong core gives your spine stability when you move or lift something. The core muscles work together to add pressure inside of your abdomen so your spine is stable. If the rest of your core (diaphragm, abs, and back muscles) are all contracting and adding pressure, but you have no “floor” to resist that pressure, then you get a leak of pressure. This leak at best means you don’t build enough pressure to stabilize your spine. For some, it means you leak urine.

How do I strengthen them?
This is the question we are asked at CTS all the time. The answer seems backwards. Most women I see are not weak because they haven’t done enough Kegels, but because they are Kegeling too much, making their muscles short and tight. Or they are long and weak because they bare down often-straining to poo or pee. Or they have scarring from childbirth that keeps the muscles short. And for both men and women I see pelvic floor muscles that are confused or de-activated after a surgery. So here are my best generalized tips on how to strengthen your pelvic floor muscles.

So where are these muscles anyway!?! This is a front view of a model of a female pelvis with bones and muscles showing. The white represents the bones of the pelvis. The brown is the pelvic floor muscles (PFM). They span from the pubic bone to tailbone. 
Here is a sideview.

1.Relax. Do a diaphragmatic breath that you learned last week. Can you feel your pelvic floor muscles stretch when you inhale? If so, you are doing a good job relaxing.
-Are you someone who holds stress in your pelvic floor? Many people do!  Throughout the day, think about tension levels in your pelvic floor and do a diaphragmatic breath to relax if you feel tension.
-Relax when you defecate and urinate! No straining!!

2. Try a basic Kegel, it works for many people. For women it feels like a closure and lift of the vaginal opening. For men it feels like a slight lift of the scrotum. This is the same contraction you do to stop the flow of urine.
                -How long you hold depends on how strong you are. Start with just 2 seconds and build up to 10 seconds. More importantly, rest completely for 20 seconds.   So, if you are new to Kegels, then hold for 2 sec, rest for 20 sec. Only do 10 reps. Three times a day. These are teeny tiny muscles you are strengthening, so they will fatigue quickly and you won’t be doing good if you try to do all 30 in one set.
                -Don’t hold your breath while contracting. No need to use full force effort to contract, a gentle contraction is all you need. Also, keep your hips, buttocks, and legs still. If you do the contraction right, no one should be able to see that you are contracting :)

Do I contract all of my abdominal core muscles together, or is there a better order?
There is a better order! Stay tuned until next week to learn how to activate the final two muscles of your abdominal core and most importantly, how to coordinate them. For now, get really good at both contracting and relaxing your pelvic floor muscles in isolation so you can use them when needed, and give them the break they deserve when not needed.

Week 1: Let’s get acquainted, Core.
Week 2: Alignment - build the scaffolding to support your weak spots while they heal and repair
Week 3: Diaphragm and what Queen Elsa got right
Week 4: Pelvic floor muscles
Week 5: Transverse abdominis and multifidus muscles
Week 6: Shoulder girdle and hip
Week 7: Functional core exercises
Week 8: Round robin demonstration of CTS Physical Therapists’ favorite core exercises.

Happy Moving!

Crystal Hazelton, PT, MPT, OCS

This article is not medical advice. If you have pain or concerns, consult your physical therapist or physician.

The Core: Week 3. Diaphragmatic breathing and Letting Go

The Core: Week 3. Diaphragmatic breathing and what Queen Elsa got right

Take a really nice deep breath…ahhhh

Not only does a deep belly breath slow your heart rate and calm your nervous system, it is also a key component of your core. Why is the diaphragm important? It is one of 4 sides of a canister. When all 4 sides of the canister contract, pressure builds up and stabilizes the spine. If you only do crunches, you build up only one of the 4 sides.

 If you tried several core “exercises” and still are not getting results, first check your alignment, then check your diaphragm function. Correcting faulty diaphragm function has improved problems ranging from back pain to leaking urine while running.

How does it work? 
The diaphragm is a muscle and fibrous tissue that separates the thoracic cavity (heart and lungs) from the abdominal cavity. It is an upside down muscle that is shaped like a dome located at the bottom of your ribs. When it contracts, it moves down towards your abdomen and becomes flat.

The diaphragm is at rest on the left. This is what it looks like when you exhale. Your abdomen will feel hollow. The diaphragm is contracted on the right. This is what it looks like when you inhale, feel your lower ribs open like an umbrella, feel your abdomen rise, and feel your pelvic floor drop.  The red arrows show where pressure is moving.

This downward motion of the diaphragm increases pressure inside of the abdomen. But you still need activation of the other core muscles to maintain pressure for spinal stability. And preferably the diaphragm and pelvic floor muscles need to activate first.

How to breathe with your diaphragm, the basics:
1.     Lie down and relax. Place one hand on your chest and one hand on your stomach just under your ribs.
2.     Inhale through your nose slowly and feel your abdomen rise and the lower part of your ribs slightly expand like an umbrella. Now repeat this and feel the rise all the way to your lower abdomen and even down into your pelvic floor muscles. You should feel them stretch or expand slightly just like your stomach does. (more on the pelvic floor next week)
3.     Exhale slowly and observe the return of your stomach and pelvic floor like a balloon that has deflated
Use the hand on your chest to make sure you aren't breathing with the top of your ribs. You should have twice as much abdominal movement as upper chest movement. 
*Always check alignment first. Are your ribs lifted up, causing chest breath? Are they facing down,  causing an exclusive belly breath?
*When you get good at this, progress to sitting or standing
*Take about 5 min a day for practice with breath work. Get really good at this so that in a few weeks when it’s time to tie this all together you have a diaphragm that is ready to pull it’s weight!

-You’ll learn how to coordinate the diaphragm with the rest of the core muscles in a future post. For now, just learn how to do a diaphragmatic breath
-No need to hyperventilate, breathe slowly, and take some regular breaths in between the deep ones.
-Postpartum ladies may need some extra time or assistance getting their diaphragm back into shape thanks to a wiggly little human squishing the diaphragm for many months of the pregnancy. This squishing often also causes the ribcage to expand resulting in an overstretched and therefore weak diaphragm.
-Please stop sucking in your stomach all day! Go ahead and pull it in for that summer vacation photo, but like Queen Elsa said, “Let it GO,” the rest of the time! Where do your guts go when you suck in? They can go up into the diaphragm stopping it from dropping and therefore making it unable to help out with correct pressures. Or, they can go down into your pelvic floor contributing to pelvic organ prolapse for women and hernias for men. This constant pressure on your guts can also add to GI dysfunction such as irritable bowel syndrome, constipation, bladder pain, and bladder urgency. So, give your abdomen a break. Relax your belly more than you contract it. And when it is time to correctly activate your core, make sure all parts of the abdominal core are simultaneously contracted.
---And while we are on topic, sucking in makes your muscles tight and short. Remember last week when I said a short and tight muscle is a weak muscle? So, walking around “activating your core” all day long can actually make it weaker.
A quote from Katy Bowman, one of my favorite biomechanical authors, in her recent book, Move Your DNA:
            “Rather than stretching or adding exercises to address our chronic stress, we will focus on releasing areas of the body most prone to hypertonicity.”

Your homework this week:
Spend time learning how to breathe with your diaphragm.
Use your core when you need it.
Relax your core when you don’t need it. 

Still have no clue how to do a diaphragmatic breath? Never fear, your anatomy loving PTs are here! We can assess your breathing and all the muscular, bony, and neural structures that can possibly affect that breathing. Then, most importantly show you exercises and movement patterns that can help your “core” function as a useful unit.

Happy Moving!

Crystal Hazelton, PT, MPT, OCS

This article is not medical advice. If you have pain or concerns, consult your physical therapist or physician.

Week 1: Let’s get acquainted, Core.
Week 2: Alignment - build the scaffolding to support your weak spots while they heal and repair
Week 3: Diaphragm and what Queen Elsa got right
Week 4: Pelvic floor muscles
Week 5: Transverse abdominis and multifidus muscles
Week 6: Shoulder girdle and hip
Week 7: Functional core exercises
Week 8: Round robin demonstration of CTS Physical Therapists’ favorite core exercises.