Motherhood, Leaky Bladders, and Back Pain – Part 2


In last week’s blog post, “Motherhood, Leaky Bladders, and Back Pain – Part 1” I introduced the musculoskeletal structures of the pelvic diaphragm and their purpose. This week’s follow-up post will cover:

  • Correlation Between Chronic Back Pain and Stress Urinary Incontinence
  • Pelvic Diaphragm Facilitation and Multifidus Facilitation
  • Exercises to identify the Muscles of the Pelvic Diaphragm!!!
  • Exercises to Strengthen Muscles of the Pelvic Diaphragm

Correlation Between Chronic Back Pain and Stress Urinary Incontinence

Research has established the role that the pelvic diaphragm muscles play in continence.  Given that the pelvic diaphragm muscles facilitate sacroiliac joint stability, which in turn support lumbar vertebral column stability, one could hypothesize that there is a positive correlation between chronic back pain and stress urinary incontinence.  That is, the likelihood of having stress urinary incontinence is increased if one suffers from chronic back pain.

Bush et al., (2013), conducted a survey of 2,341 women who suffered from chronic back pain and found that 44% of these women also suffered from stress urinary incontinence (p.4).  Furthermore, Bush et al., (2013), references multiple studies with similar findings:

Finkelstein et al reported a strong association between “back problems” and UI in both men and women (find details from experts in New Jersey Neck & Back Institute, P.C.).  A cross-sectional study of women only by Smith et al found a relationship between continence disorders and back pain “in the past 12 months.”  In addition, Kim et al found women with greater UI severity also have a higher perceived severity of LBP and LBP perceived disability.  Lastly, Elliason et al surveyed women who were receiving physical therapy for LBP and reported 78% of these women also reported UI  (Bush, Pagorek, Kuperstein, Guo, Ballert, and Crofford, 2013, p.2).


Pelvic Diaphragm Facilitation and Multifidus Facilitation

Multifidus originates at the sacrum, the posterior superior iliac spine, the mammillary processes of the lumbar vertebrae, the transverse processes of the thoracic vertebrae, and the articular process of C04-C07.  It inserts to the spinous process two to four vertebrae superior from it’s origin.  According to Martini, Nath, Bartholomew (2012), it’s action is to extend the vertebral column and rotate towards the opposite side (p.341).

A study involving thirteen men and women who had chronic low back pain was conducted by Huang et al.  The goal of this study was to investigate the effects of an intervention that involved: 1) proprioceptive neuromuscular facilitation, 2) neuromuscular joint facilitation, and 3) neuromuscular joint facilitation combined with pelvic diaphragm muscle exercises.  According to Huang et al. (2013), neuromuscular joint facilitation combined with pelvic diaphragm exercises produced the greatest multifidus change (p.813).  Huang et al. (2013), speculates that while neuromuscular joint facilitation promoted isometric contractions of the multifidus, the pelvic floor exercises promoted increased intraabdominal pressure, thereby increasing lumbopelvic stability and enhancing the effectiveness of multifidus (p.813).

Case Study

Jellad, Bouzaouache, Salah, Migaou, & Sana (2009), conducted a case study in which they designed a rehabilitation program for a patient suffering from osteoarthritis of the sacroiliac joint.  The rehabilitation program involved strengthening the transversus abdominis, internal obliques, coccygeus, pubococcygeus, and iliococcygeus, as well as stretching psoas (p.511).  The program was found to have a positive effect on reducing the patient’s pain and functional impairments.

Exercises to identify the Muscles of the Pelvic Diaphragm!!!

Calais-Germain (2003) recommends the following two exercises for identifying muscles of the pelvic diaphragm:

  1.  Balloon Exercise
    1. While sitting, pretend you are blowing into a balloon.  Look to identify one of the three possible pelvic region responses:
      1. blowing caused the urge to urinate
      2. blowing caused the pelvic floor to be pushed down
      3. blowing caused the pelvic floor to draw up (p.104)

Calais-Germain (2003), notes that the urge to urinate is symptomatic or weak pelvic diaphragm, while the drawing up sensation is symptomatic of well-toned pelvic diaphragm (p.105).

  1. Face Cloth Exercise
    1. Fold a small face cloth into quarters.  Place the folded cloth between the two ischia, and between the coccyx and the pubis.
    2. Notice  pelvic sensations during normal breathing and while practicing the balloon exercise in this position.

Exercises to Strengthen Muscles of the Pelvic Diaphragm

Calais-Germain (2003) recommends the following exercises for strengthening muscles of the pelvic diaphragm:

  1. In a sitting, or supine-crook position, visualize your two ischia and your pubic symphysis.  From here mentally visualize two inches above the ischias and pubic symphysis.  Now, draw theses two areas of visualization upward and inward.
  2. Contract your anal sphincter.  Notice how it constricts and draws up.  Now, try to contract your anal sphincter without constricting it, but just drawing it up.
  3. After performing the above exercises, relax completely and feel the weight of pelvic organs dilate.

The research suggesting that pelvic diaphragm muscles enhance lumbopelvic stability is convincing.  Pel, Spoor, Pool-Goudzwaard, Hoek Van Duke, and Snijders (2008) showed a decrease in sacroiliac joint shear force by 20% with a 400% increase of transversus abdominis and pelvic diaphragm muscles (p.415).   Additionally, Bush et al. showed that nearly one-half of women who suffer from chronic low-back pain also suffer from urinary incontinence (p.4).  Huang et al (2013), suggests that the compressive forces that the pelvic diaphragm muscles can exert between the coxal bones and the scarum enhance lumbar vertebral and trunk stability (p.813).  Lastly, Jellad, Bouzaouache, Salah, Migaou, & Sana (2009) successfully applied a rehabilitation protocol for a women suffering from sacroiliac joint pain that involved pelvic diaphragm exercises (p.511).

That’s it ladies (and gents) not only will strengthening your pelvic floor muscle recover urinary incontinence it will also enhance lower back strength. Get to it, find those pelvic floor muscles and when you can, incorporate pelvic floor contractions into whatever exercises you are working on, whether that be supine ab exercises, standing arm exercises, leg exercises like squats, or whatever. Now, onward, upward, and inward!


Bush, H. M., Pagorek, S., Guo, J., Ballert, K. N., & Crofford, L. J.  (2013).  The Association of Chronic Back Pain and Stress Urinary Incontinence: A Cross-Sectional Study.  Journal of women’s health physical therapy, 37(1), p.11-18.  doi: 10.1097/JWH.0b013e31828c1ab3

Calais-Germain, B.  (2003).  The Female Pelvis: Anatomy & Exercises.  Seattle, Wa.: Eastland Press Inc.

Floyd, R.T.  (2012).   Manual of Structural Kinesiology.  New York, NY: McGraw Hill.

Huang , Q., Li, D., Yokotsuka, N., Zhang, Y., Ubukata, H., Huo, M., & Maruyama, H.  (March 1 2013).  The Intervention Effects of Different Treatment for Chronic Low Back Pain as Assessed by the Cross-sectional Area of the Multifidus Muscle.  Journal of Physical Therapy Science, 25(7), p.811-813.  doi: 10.1589/jpts.25.811

Jellad, A.,  Bouzaouache, H., Ben Salah, Z., & Sana, S. (July 2009).  Osteoarthritis of the sacroiliac joint complicating resection of the pubic symphysis. Interest of a rehabilitation programme.  Annals of Physical and Rehabilitation Medicine, 52(6), p.510-517.  doi: 10.1016/j.rehab.2009.03.002

Martini, F. H., Nath J. L., & Bartholomew, E. F.  (2012).  Introduction to Anatomy and Physiology.  San Francisco, CA: Pearson Education Inc.

Nestor, K.  (n.d.).  Sacroiliac Joint.  Physiopedia.  Retrieved from: http://www.physio-pedia.com/Sacroiliac_joint.

Pel, J. J. M., Spoor, C. W., Pool-Goudzwaard, A. L., Hoek Van Dijike, G. A., & Snijders, C. J.  (18 January 2008).  Biomechanical Analysis of Reducing Sacroiliac Joint Shear Load by Optimization of Pelvic Muscle and Ligament Forces.  Annals of Biomedical Engineering, 36(3), p. 415-424.  doi: 10.1007/s10439-007-9385-8

Visible Body Software.  (2014).  [All images].

Too little movement or too much food?


Take a Booster Break!


booster breakHow do you spend your work breaks?  Do you find yourself munching on M&Ms, smoking a cigarette, or even working more?  A qualitative analysis conducted at the University of Texas investigated the effectiveness of structured work-break activities designed to enhance physical and psychological health.

The study involved 35 subjects across 5 worksites and was conducted over a period of 6 months to one year.   While Booster Breaks may involve physical activity, meditation, and rhythmic breathing, this study focused on using physical activity oriented breaks to reduce sedentary behavior.  Subjects were required to participate in one 15-minute physical activity booster break per work day.  Researchers found three themes among the subjects response:

  • Reduced stress and increased workplace enjoyment.

  • Increased health awareness and facilitate positive behavior changes outside of the workplace.

  • Enhanced interpersonal relationships with coworkers.

Subjects noted two barriers to participation in the interventions:

  • Desire for greater variety in intervention’s activities.

  • Lack of permission, encouragement, and support from managers and supervisors.

To support workplace health promotion, Bodytonic Pilates is now offering 30-minute private sessions!  We hope your bosses support you in creating a healthier, happier, and more efficient workplace.   See our rates page for more pricing details.  For a limited time we will be offering a booster break promotion:

3 30-minute private lessons for $99!



Taylor W. C., King K. E.,  Shegog R., Paxton R. J., Evans-Hudnall G. L., Rempel D. M., Chen V., Yancey A. K. (2013).  Booster Breaks in the workplace: participants’ perspectives on health-promoting work breaks.  Oxford University Press Health Education Research, 28(3), 414-425.   doi:  10.1093/her/cyt001


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PNW Hikes


summerlandI’ll admit it, when it comes to outdoor exercise I’m a fair-weather friend.  I consider myself, of course with the proper skin protection, much more of a sun bird than a snow bunny.  Yesterday was the most gorgeous spring day I can remember in Seattle with temperatures reaching the mid-80s.  All this sunshine has me really excited for an amazing Pacific Northwest Spring and Summer full of beautiful and temperate, outdoor exercise.  In my enthusiasm, I created a pinterest board of hikes within a 3 hours drive from Seattle and with a minimum roundtrip distance of 5 miles.  All of these hikes feature waterfalls, rivers, lakes, and/or wildflowers.  I guess I’m a sun and water bird!

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The Limitations of “No Pain, No Gain”


23physed-tmagArticleA New York Times article published on April 23rd, 2014 references a study conducted at the University of Utah in Salt Lake City that investigates the the relationship between neuromuscular activity and perceived as opposed to actual fatigue.  During the study mice were injected with equal amounts of lactate, adenosine triphosphate (ATP), and other chemicals.  The scientist found that the neuromuscular response demonstrated in the mice varied depending on how much lactate, ATP, and other chemicals were injected.  Next, the scientist injected the abductor pollis brevis muscle (thumb) of ten humans.  The scientists produced three different dosages of these chemicals to simulate the amounts that would be found in the muscle during moderate exercise, strenuous exercise, and finally muscular exhaustion.  Following the moderate exercise dosage, subjects reported feelings of fatigue, puffiness, and tiredness in their thumbs.  The strenuous dosage was associated with increased fatigue and the onset of slight pains and aches, and the muscular exhaustion dosage was associated with considerable soreness.  The findings as interpreted by NYT reporter, Gretchen Reynolds (2014), suggests that “Each subsequent increase in the levels of lactate and other substances amplifies the sense of fatigue, Dr. Light said, until the substances become so concentrated that they apparently activate a different set of neurons, related to feelings of pain”.  Furthermore the article suggest that working through some levels of fatigue and achiness is associated with improved physical performance, though working through symptoms of pain can cause muscle damage.  Hence the adage “no pain, no gain” is not the wisest strategy to use in improving athletic performance.

I appreciate and agree with Reynolds conclusion that “no pain, no gain” is an antiquated training approach.  She references the original article (which unfortunately was not available in it’s full version on pubmed) and sought out to personally interview a researcher associated with the study, which lends to the article’s credibility.  Though one issue takes away from her credibly; she states that ATP is released during muscular activity, whereas according to sliding filament theory, it is actually hydrolyzed during muscular activity.  In other words, Reynolds suggestion that ATP is released or produced during muscular activity is incorrect, rather ATP is consumed and broken down during muscular activity.

Aside from the details relating to sliding filament theory, I like and appreciate this article.  I believe the attitude “no pain, no gain” has cummulative negative effects on the physical activity levels of communities.  The belief that exercise should be painful not only discourages people from participating in physical activity, it also creates more injuries and prevents people from exercise.  It’s important for people to have healthy and realistic expectations for themselves with regard to athletic performance and understand that experiencing some fatigue and mild to moderate discomfort can improve athletic performance, but acute pain is more frequently associate with damage and injury and will likely impede, if not recede athletic performance and health.

Reynolds, G.  (2014).  The Limit’s of No Pain, No Gain.  The New York Times.  Retieved from: http://well.blogs.nytimes.com/2014/04/23/with-exercise-the-limits-of-no-pain-no-gain/?partner=rss&emc=rss


Exercise and Your Pleasure Center


09well_physed-tmagArticleYesterday, the New York Times published an article titled “Are you programmed to Enjoy Exercise?”  The article reports on a study conducted by the University of Missouri-Columbia and published by the Journal of Physiology that investigates the genetic and environmental influences that impact the subjects behavior surrounding exercise.  In this study, the subjects were rats who were bred and divided into two subgroups; one group consisted of rats who spent hours on running wheels and the second group consisted of rats that spent zero to little time on running wheels.  The NYT article implies that active rats were hypothesized to produce active offspring and inactive rats were hypothesized to produce inactive offspring.  It was discovered that a portion of the brain called the nucleus accumbens was more developed in the rats who liked to run as opposed to the rats who did not like to run.  The nucleus accumbens is the portion of the brain, sometimes referred to as the “pleasure center” and is associated with motivation, pleasure, and addiction.  Two other noteworthy facts were discovered: 1) regardless of running behavior, the rats who were bred to run had a more developed nucleus accumbens than those rats who were bred for malaise and 2) when the non-running rats were encouraged to exercise on the running wheels, they started to develop more mature neurons in their nucleus accumbens.  In essence, both genetic and environmental factors influenced the rats behavior with regard to physical activity, and specifically the environmental factors may have a long-term influence over genetic factors.

Examples of Rehab-Pilates in action!


Check out this great video produced by the Pilates Method Alliance featuring their new intiative “Heros in Motion”, which is aimed at the rehabilitation of people with conditions that include, but are not limited to polytrauma, vestibular disorders, prosthetic limb(s) and traumatic brain injury.


New Mat & Make-up Classes Start Next Week!


April Mat Classes Begin Next Week

Reserve your spot today!

MaxMix                                                  Tuesdays, 11:30am
Instructor: Nadia                                    April 1, 8, 15, 22, 29
Cost: Full Monthly Series – $90 ($18/class)           Drop in – $20/class
This mixed level mat class is open to all students, from beginner to advanced experience levels.  The focus of the class will be on strengthening your upper and lower abdominals, pelvic floor, shoulder and hip girdles, and or course your back!


MaxMix New Day!                                          Thursdays, 6:00pm
Instructor: Keta                                             April 3,10, 17, 24
Cost: Full Monthly Series – $72 ($18/class)           Drop in – $20/class
This mixed level mat class is open to all students, from beginner to advanced experience levels.  The focus of the class will be on strengthening your upper and lower abdominals, pelvic floor, shoulder and hip girdles, and or course your back!


Pilates/Ballet Fusion                                        Fridays, 12:00pm

Instructor: Jessica                                           April 4, 11, 18, 25
Cost: Full Monthly Series – $72 ($18/class)           Drop in – $20/class
This 50 minute mat class blends pilates mats exercises with standing ballet-based conditioning exercises. Build a strong core, develop elongated and toned limbs, and learn to have an elevated carriage of the upper torso. You’ll leave this class feeling light and graceful!

unlimited monthly passes are also available!

Duet & Trio Students

New make-up classes are up!  If you need to sign up for a make up class check out the available classes!
Are you planning to miss any of your regularly scheduled lessons in the next one or two months?
If so, please email Nadia with the dates you are planning to miss.

The association between exercise and academic success


Top Ten States for Healthy Eating & Exercise


Apparently the Northwest is a great place to be if you are looking to live a healthy lifestyle!  An article published by the Huffington Post reports Oregon as ranking among the top ten states for both healthy eating and exercise, Idaho among the top ten for exercise, and Washington among the top ten for healthy eating.  Bodytonic is proud to a be a small business contributing to the health and wellness of our community, though we did find it surprising we weren’t ranked among the top ten for exercise.  Are you meeting your exercise goals?

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