CEF Seminars

March 2012 Evening News….Yet another Silver Fern has made an early comeback just weeks after giving birth.  Many viewers probably think this is heroic.  I wonder if her coach knows the high risks to her pelvic floor and the association between urinary incontinence and sports like netball….

This Olympic lifter's pelvic floor gives way during the 2000 Sydney Olympics

As health and fitness professionals we know the importance of regular, weight-bearing exercise.  It not only helps one feel good, but it actually reduces the risk of developing or dying from many of the leading causes of death and illness.  However, lesser known is that every exercise affects the pelvic floor; and certain exercises can actually harm these muscles, contributing to, or causing pelvic floor dysfunctions such as incontinence and prolapse.

Those most at risk of developing pelvic floor problems include pregnant and post-natal women, those undergoing gynaecological surgery and peri-menopausal women.  Two of the most common dysfunctions include urinary leakage and pelvic organ prolapse.  Both of these conditions can be extremely distressing, often causing women to withdraw from exercise all together.   

One in three New Zealand women will develop incontinence and one in two will develop prolapse following childbirth.  It is estimated that there are in total 1.1 million (25%) of people in New Zealand aged 15 years or over, who have either urinary or faecal incontinence, or both. Studies show increased rates of depression associated with incontinence and we know that most suffer in silence, avoiding professional help. Incontinence is surprisingly common, but it should never be considered normal or dismissed as “a woman’s lot”.

Gym based exercise is on the increase and virtuous women everywhere, thrash themselves at boot camp, boxing and pilates, endeavouring to lose the extra kilos synonymous with pregnancy and menopause.  Many are then devastated when they learn that their exercise programme has actually caused or worsened their symptoms.   Unsurprisingly many feel anger towards their trainer or health care providers for not explaining the risks appropriately.

Others simply withdraw from exercise and suffer in silence, too embarrassed to get help, hopeful that their secret problem will go away with time.  Unfortunately this is rarely the case.

But, it is not just women at risk.  Men already suffering from prostate problems, those lifting heavy weights and many elite athletes are also at an increased risk of pelvic floor dysfunction.  In addition, constipation, chronic coughing, and low-back pain all increase the likelihood of developing pelvic floor dysfunction.

So which exercises can be harmful to a weak pelvic floor?  Generally those that are higher impact, running, jumping, bounding and lifting heavy weights.  Certain abdominal exercises and anything involving breath holding isn’t great either.  And it’s not just certain individual exercises to watch for - Depending on the pelvic floor in question, it may be endurance that is a problem, with symptoms developing after a specific period of time.

The good news however, is that with the right help many pelvic floor dysfunctions can be treated and in many cases cured.  Pelvic floor muscle training is extremely effective (up to 84% cure rate), and is best done under the care of a specially trained physiotherapist or continence practitioner.  Effective treatment is usually holistic, looking at life-style, exercise, diet in association with specific pelvic floor therapies.

But what is the role of the personal trainer or health practitioner? Primum non nocere is Latin for "First, do no harm” and it is our duty of care to consider the risks and benefits of any intervention we suggest for our clients.  If certain exercises have the ability to cause harm to many of our clients’, surely we should be screening to determine who may be at risk?  Considering the huge number of women I have treated whose prolapse or urinary leakage started when doing group exercise, I believe appropriate pre-exercise screening should be mandatory.  The New Zealand Continence Association (NZCA) is also aware of this dilemma “We don’t want women to stop exercising” says Jan Zander, CEO of the NZCA.  Instead we want to encourage people to seek guidance from professionals – to ensure their exercise programme is suitable.

In the upcoming course Exercise and the Pelvic Floor workshop we’ll do just that. After analysing the functions of the pelvic floor, we’ll cover how to recognise symptoms of dysfunction and practice using a screening tool to help determine those most at risk.  Once you are confident doing that we’ll discover which exercises can do the most harm and then how to make appropriate modifications.  By the end of the workshop you should have a good understanding of how certain exercises can affect the pelvic floor and what you can do to keep your clients exercising safely. 

Scapula positioning is vital for shoulder function and clients are often advised by the well-meaning therapists to “pull the shoulders back and down” for good posture. This has a number of problems attached. Firstly the action of bracing the shoulders back and down limits the mobility of the scapulae and therefore glenohumeral joint functionally. The scapula and glenohumeral joints should be stabilised using minimal effort, not bracing, while allowing movement at the same time.  Secondly the muscles used for the "back and down" positioning are rhomboids (back) and latissimus dorsi (down), neither of which are key stabiliser muscles for the scapula.  These muscles will downwardly rotate and depress the scapulae respectively.  This can restrict scapula movement and cause impingement at end range flexion/abduction.

The original reason for the "back and down" instruction was in response to the recognition of the trapezius muscle being a key low threshold stabiliser muscle for the scapula. Lower trapezius in particular was considered most important as contraction of lower trapezius helped clients not to shrug the shoulders, a recognised movement fault around the shoulder girdle. Lower trapezius fibres topographically look as though they should be activated by following the fibre direction which is, strictly speaking, upwards and laterally from the spine, or downwards and medially practically speaking. However a key stability role of trapezius as a whole (not just the lower fibres) is to assist in upward rotation of the scapula during arm elevating movements in function. This is done as a force couple with serratus anterior (see diagram). So while back and down may elicit some contraction in the lower fibres of trapezius it does not activate much of the rest of trapezius nor the vitally important and often missed serratus anterior.

Specific motor control retraining for serratus anterior and trapezius together restores scapula control for optimum shoulder function. Specific motor control retraining for serratus anterior is not achieved by strength training alone such as push ups.  Serratus anterior needs to be activated in isolation from pectoralis minor initially before strengthening otherwise pectoralis minor will continue to pull the scapula down into a pseudo winging position from the front. This is important to understand so that impingement injuries can be avoided under the acromion. These are all tips and strategies that will be covered in the shoulder workshop, as well as rotator cuff retraining strategies.