Beth (as we will call her) was an energetic nurse in her mid-thirties with two young boys to chase around. She was an elite runner in her early twenties, but these days walking a few blocks was a painful chore and picking up her kids was nearly impossible. Pregnancy had done a number on Beth…twice. She had endured the slow nine months of body changes. She had powered through the labours and deliveries and ended up with two lovely little boys to watch grow and thrive, but her body as a result decided to stop cooperating with her desired lifestyle. She went from competitive running, to running a few times a week with discomfort, to just chasing her kids around in pain, to simply walking being a painful task in a period of just a few years.
When Beth first walked into my office she had "tried physio, massage, chiro, core training, prolotherapy and IMS" for her back problems with mixed success. IMS (intramuscular stimulation) had provided her with the most relief, but she still sat in front of me with a dysfunctional body so she obviously needed something more or different to help her get her body back. Her goals were simple: walk without pain, play with her toddlers and generally live an active lifestyle. I had to push her to include running on that list because she had resigned herself to the idea that she would never run again at the age of 37.To look at her, Beth was a thin, lean looking runner with a big smile on her face and a positive attitude, even though her body had crapped out on her. She appeared to have all the pieces, so why was she still having so much trouble? Therapists had massaged her, needled her, stretched her, cracked her and strengthened her but she still couldn't even walk without significant discomfort in her back. The problem seemed to be that no one actually took the time to teach her how her body functions biomechanically. Loosening things and strengthen things were helpful, but she needed to understand some basic concepts of how to live in her body. The 'why' and the 'how she needed to do things' with her body became much more important than 'what' she needed to do. I explained the why and the how to her and she started to gain control of her body and her symptoms and running began to look possible again.
Beth's biggest challenge was that she was relatively hypermobile, or loose jointed, particularly in her hips. It becomes very challenging, especially for a hypermobile new mom, to figure out how to balance her upper body on her lower body; most people that haven't been through pregnancy have a hard time standing, sitting and walking properly, so I am always impressed when some women bounce back after having a baby and I am not surprised when many have trouble.
In order to effectively stack your skeleton up for functional movement, your ab muscles work together with your butt and the backs of your legs, while your back muscles pair together with your thighs. Life, sports, work and genetics result in common variations of these pairings and the resultant postural muscle imbalances can create pain over time. Pregnancy has to be the single biggest life event that will change a person's posture.
Beth's body slowly got heavier over nine months. Her pelvis, hips and feet got even looser due to hormonal changes. Her abdominals were slowly stretched out and her weight distribution changed as her belly got bigger. Her organs were slowly moved to new locations in her abdomen as the baby got bigger and hopefully they all shifted back into place after the labour, but nobody had considered that. After nine months of slow changes, Beth's labour created fast and dramatic body changes. She probably lost 25lbs in one day, her stretched out abs lost all their tension, her pelvic floor was damaged and now she had to carry and care for a rapidly growing human twenty four hours a day. To her credit, she got through that process twice, but a few years after the fact she needed a few key things to be loosened on her body and then literally be taught how to stand, sit, walk, breathe, bend and lift again. She could do all those things, but her way hurt. I taught her how her body was built to do them, and how her way, although easier, was causing the problem.
Beth had a small diastasis or separation/hernia in her upper abdominals, just below her rib cage; this drew therapists to help her train her abs. Beth had mild urinary incontinence; this drew therapists to teach her pelvic floor kegels. Beth had very flexible hips; this drew therapists to give her leg strengthening exercises. She had all the pieces addressed, but no one effectively taught her how to hold the pieces together in a coordinated manner.
Looking into her past, Beth was a gymnast before she was a runner and her posture showed it. She had chest up, shoulders back and down engrained into her. She held herself up from her mid back and when she moved or bent she kept that mid torso nice and braced. It wasn't surprising that the small hernia she had in the front of her torso was at the exact same level as where she holds all her tension in her back. When there was no room to move in her back, the tension and pressure of her abdomen had to go somewhere so it bulged forward and inhibited her abdominal wall; that tear was a warning sign of bad torso posture, but a red herring for her back pain.
The back dominant muscle imbalance that Beth had developed in her torso made it very difficult for her to balance her upper body on her lower body effectively. Overly bracing her mid back was tipping Beth's torso backward and levering her loosey-goosey hips and pelvis forward causing a lot of compression in her low back, SI joints and hip sockets. It was this pattern of movement that was ultimately responsible for most of her pain. The pattern stemmed from the combination of a learned behaviour in a childhood sport, her genetic hypermobility and the effects of pregnancy and motherhood. The learned behaviour is the only changeable thing in that list so that's what we went after.
I explained this all to Beth and showed her in the mirror what I was talking about and told her that I wanted to walk her through the process of release, re-educate, re-build. We would find the tight things that were causing her problems and loosen them for her, then teach her how to stand, sit and move differently; only when she could wrap her brain around how to physically perform her day to day tasks would we start extra strengthening exercises. She agreed, so we began the process with what she had already found to work: IMS (intramuscular stimulation).Even though her hips had a LOT of flexibility it was evident that the tension in her deep hip rotator muscles was part of her pain, so I needled her glutes, piriformis, tensor fascia lata, and their tug-of-war buddy the adductor longus, in her groin. Beth felt better immediately, but I knew that I had only loosened the tension created by her compensation pattern and that it would eventually come back if she was left to her own devices; so I taught her about how she was holding her trunk. We talked about gymnastics. I showed her, her side profile in the mirror, and helped her see what I was talking about and then sent her home with the project of thinking about her torso and to observe how other people hold themselves in funny ways.
- Everything your mother taught you about posture is WRONG
- How to stand
- How to sit
- 4 point neutral spine
She came back to see me feeling better with the suspicion that we were on to something. Although her back was still sore and her new posture seemed impossible to sustain for very long, she felt less pain and stronger when she paid attention to her trunk instead of the pain in her pelvis and back. Instead of trying to focus her on turning on her 'core muscles,' I showed her how if she puts her body in the right position, her core muscles will activate on their own..
a practice that is more sustainable long term and the way your body is supposed to work.
Once Beth got more comfortable with standing and sitting tasks, she needing to learn how to move and not forget everything she learned about staying still. Effective movement requires stabilization of some areas and dissociation of others. People with chronic pain tend to strongly brace particular areas and then move in the joints that are left over; a practice that helps prevent acute pain in the short term, but produces chronic issues over time.
The Re-Educate process I walked Beth through:
- Beth needed to learn how to support her trunk in a neutral position and then freely move in her hips. Exercise videos: 4 point neutral spine then 4 point rock backs
2. Beth needed to learn how to breathe into her ribcage and not brace her back.
Exercises videos: How to Sit then Breathing as an exercise then Rib Shimmy
3. Beth needed to discover how to use her feet to support her hips
Exercise videos: Foot tripod then Foot Flex then Ankle skewer then One leg stand
4. Beth needed to understand that her chest tightness and forward head posture were making her compensate and brace her torso backward. Explanatory videos: Why Necks Hurt then Why mid-backs hurt5. Beth needed to see that when she lifted her arms up in front of her, her whole torso leaned backward, but with awareness and practice, she learned to control it.
Exercise videos: Why Shoulders hurt then Reaching up 11 then Air bench press
I only treated Beth once with IMS and then started teaching her movement. Each week she came back with a new aha sensation about her body and a revelation that she needed to be more careful about how much she does in a day or week. She had a few set backs and flare ups that required some IMS, but she was learning to control her body, she knew when she needed a tune up and she would bounce back way faster after a flare up instead of going into a pain cycle of a few weeks. She started moving better and better so I started giving her harder and harder things to do.
- I taught her how to use her legs while stabilizing her torso. Exercise Video: Kneeling Squats
- I taught her how to use her hips, knees, ankles and feet while stabilizing her torso Exercise Videos : Squats & Thirsty birds
- I taught her how to move sideways Exercise Videos: Speed skater and half squat crab walk
Although she was moving better and feeling better, she kept complaining that the pain in her left SI joint just wouldn't go away. Initially with Beth, I got the sense that if I released anything on her, it would just keep coming back because of her movement habits, but now that she moved better and continued to get a specific pain, I felt it was my turn to work on her again. This time I assessed her visceral system in more detail, that is to say I manually assessed the fascial mobility of the organs in her abdomen and pelvis. What I found was a restriction in her sigmoid colon and some of the loops of her small intestine. The sigmoid colon sits just on the inside of the left SI joint and can be the cause of persistent left SI pain and even sciatica. I did some visceral manipulation with her to free the left side of her pelvis from the front and let her go with the confidence that she was moving better. The result was that she cancelled her follow up appointment because she was feeling so good and was now able to physically play with her kids.
Beth's path to improvement was not a linear one. She had had her flare ups, but we just continued to push the envelope of what she could do. We introduced jumping, pushing, pulling and twisting with a strong focus on form and function. She is now aware of her body with daily movements, she can walk and play with her kids with little to no pain and she is able to start a walk-run program to build her fitness. She comes in for semi-regular tune ups of IMS, exercise progression and occasional visceral work, but she is largely independent living the active lifestyle she couldn't previously manage.
Beth's story is an extremely common one for women to go through after pregnancy. As a physiotherapist, I can see the effects of pregnancy on women's movement and posture even decades later. I find that with a little help and direction most women can find their way out of the physical turmoil they can find themselves in after pregnancy. IMS, movement training and visceral work tend to be the three missing ingredients.
Related Articles & Videos
- Pregnancy, Pain & Posture: a video progression to restore movement
- Six Degrees of Movement: Life as a Workout
- What does it mean to be hypermobile?
Please feel free to leave questions or comments in the section below and I will try my best to get back to you.