“Bulletproof” Your Core and Pelvic Floor – CrossFit Furnace, Perth, WA, Australia – November 14, 2015

CF Furnace Sat 2015.11.14How to “Bulletproof” Your Core and Pelvic Floor – 09:30am – 2:30pm (seminar is from 10am-2.30pm)


CrossFit Furnace
4/25 Mosey st,
Landsdale WA 6065
Tel: 0407 080 618

Presenter: Antony Lo

Book Seminar Here:
Appointments – Book now!

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How to Activate Your Pelvic Floor With Breath Holding For Lifting / CrossFit / Everyday Life!

IMG_8511This blog post is for EVERYONE – Men and Women!!! It will improve your performance and improve your symptoms.

Everyone knows you should activate your pelvic floor…but why?

You do your Kegels but you still leak urine…why?

You saw a Pelvic Floor Physiotherapist…but you still want to keep squatting 220lbs (100kg)…did they teach you how?

In this post, I will be using Maria Hogan as an example. Maria is one of the “old guard” of CrossFit in Australia. She is an ex-rower who competed at a high level. She had a 150kg (330lbs) deadlift, 112kg (246.5lbs) back squat, 83kg (182.5lbs) power clean and 64kg (141lbs) snatch…at 3 months post partum! She is married to 3-time CrossFit Games athlete Chris Hogan and runs CrossFit 121 with Chris in Melbourne, Australia.

All of these are fair questions. I hope to briefly explain how to combine the good work that Pelvic Floor therapists have done over the years and combine it with the knowledge I have gained in the Musculoskeletal and Sports Physiotherapy field I have worked in.

For more information on the Pelvic Floor, I have written this one for CrossFitters and as a general explanation.

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Ep 2 of The Physio Detective Podcast – Lori Forner (Continence and Womens Health Physio) and Antony Lo discuss the pelvic floor

The thoughtful physio...Lori Forner

The thoughtful physio…Lori Forner

Last weekend, I had the opportunity to present the “Bulletproof” Your Girls seminar to athletes and coaches at CrossFit Cuties. Many thanks to Sim Irvine, the owner of CrossFit Cuties for hosting us. During the presentation, I introduced the holistic philosophy that Lori and I both utilize, Lori then presented on the pelvic floor, its functions, stress urinary incontinence, pelvic organ prolapse and pelvic pain from an overactive pelvic floor. During the presentation, there was about 30mins of questions, which was fantastic…Lori is very professional, approachable and made things easy to understand. After her presentation, I presented the practical side of things – how the core works together, how to do “core” contractions properly and then how to transfer those things to skipping, box jumps, running, and lifting. We even had one lady do a PB (personal best) on her power clean using our techniques! Of course, things have to end and we could have easily spent another 2 hours going over exercises so we may make it a 6hr seminar next time!

In this podcast, Lori shares her experiences having treated CrossFit athletes in the past as well as hearing my presentation. Read more of this post

Are your pelvic floor exercises making you weaker?

Purpose – to challenge your thinking and beliefs…and those of your therapist!
Method – questions and answers, haven’t had a chance to look at the research
Summary – my beliefs were challenged…I hope yours are!

***i will add pictures and formatting to this post when I get home 🙂 ***

Do your kegals!
Switch on your core by using your pelvic floor!
Do more pelvic floor to increase your core stability!
A strong pelvic floor will help your back pain!

We have heard it all before…but do you (and your therapist) understand what the implications are?

These are my musings about the hysteria about pelvic floor exercises and how it affects your back pain and performance. I have not read about this mentioned anywhere in the past so if you find resources, please let me know. The closest I have found is Taryn Hallam from WHTA in Sydney…brilliant woman.

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Open email to Women’s health PTs about Crossfit and peeing

This blog post is an open email to all physiotherapists interested in helping women who leak during exercise, especially skipping and box jumps.

I wrote this email to some women’s health PTs but all patients and health professionals are free to respond.

Please comment below if you have suggestions or want to be included in the discussions as it will give me your email address privately.

Please share this to those you know who help those who have stress incontinence.

Thank you!

Ok, I had some interesting patients in LA which led to some interesting findings. Some background first.

From the survey I did on CrossFit and peeing (which has issues: acknowledged) 73% of those who answered as leakers cited skipping as an issue. About 50% cited box jumps then running I think in 33% (from memory – it is nearly 5am here). Dead lifts was the worst weight lifting one and came in at 13% and anecdotally, it is when they go close to 1RM ie HEAVY. In the ‘other’ column, they reported some pull-ups, rings dips, trampoline and star jumps/jumping jacks as non listed exercises. Not many had signs of prolapse.

So my thinking is:
1. Crossfitters who leak are probably ok in normal ADLs and don’t prolapse – have to check the stats. This is obviously a subgroup of the incontinence population

2. Vertical Visceral Load (VVL) – have I just made up a new term? – seems to be the major contributing factor by far. Heavy dead lifts is to do with massively high IAP. Out of interest, 1994 study that included hoping estimated 9kg visceral load with vertical visceral displacement between 5-8cm. Have to read whole study for population stats etc. interesting though… 8cm I believe is the amount a b-cup moves during running unsupported? ? Berlei study – wearing their bra cuts it to 4cm from memory? But anyway, that amount of displacement seems to fit.

3. Pull-ups and ring dips is high intrathoracic pressure so it got me thinking about that too.

Of the patients I saw in LA, only one had given birth or been pg – 40’s, 2 kids, nvd, episiotomy for forceps, no leakage on ADLs (incl cough, sneeze and laugh) but will lose/squirt urine on really heavy dead lifts to the point of going thru underwear and tights/shorts to form a puddle type of squirt. Skipping singles is ok for her but doubles result in drip loss type of incontinence. Apart from minor aches and pains, nil other sig findings.

The other girls were in a group and were drippers on double unders. No pregnancies or births. No issues with cough, sneeze, laugh, just double unders.

The common factor in this small group of 4 was rigid thoraces during double unders, and poor technique. Different for each person. One was a “stamper”. I have video of her skipping and deadlifting. Her deadlift at 40kg (light) is quite good.

All of them tended to hold their breath somewhat and had trouble going more than 3 double unders (du) in a row (novice at double unders).

So I did breathing coordination and high singles with them and it helped sig with one girl getting 12 in a row without leaking and setting a PB for consecutive DU.

Just want to acknowledge Julie Wiebe here. I have always taught the beginning of pf squeeze on exhale but hadn’t linked “relax” on breathing in before. Have taught low level pelvic floor hold throughout breathing cycles etc etc. Julie’s discussions with me about the relaxation cycle was a key factor in influencing my thinking here…and it was the key for these girls.

So I got them to time their “zip” cue that I taught them (gentle back to front with lift) with relative relaxation on breathing in and squeeze on breathing out. It helped! I also taught then to relax their thorax and not “grip” so hard during their DU but to allow their thorax to be more responsive during skipping.

The theory was to time their contractions with breathing, decrease excessive intrathoracic pressure and allow a more global, adaptable response to VVL, IAP, ITT and the weight of the body on the MSK system. They understood the cues really quickly which I tested using isometric arm contractions.

So the next stage in my mind is to see if I can classify responders to my program (they did NOT do my program, just one aspect of it) and have some baseline measures taken. Eleanor Bognar Lee is a local WH PT I am hoping to be working with who can do the internal examinations.

I will be offering free assessment and progression through the program for up to 20 women who leak during DU.

I need your help in determining what YOU would want to know about these women from an internal point of view as well as a history and usual examination point of view. Eleanor is an experienced WH PT but I would like your input as well so I can ensure we capture the information others want, not just what we want to collect.

If this goes well, it might be worth studying properly.

So, your thoughts, opinions and suggestions on subjective and objective / examination information are most welcome.

Thank you all for reading. I don’t mind if you pass on this email to others so long as it is in its entirety and you cc me so they and I can introduce ourselves 🙂

CrossFit, Your Pelvic Floor and Peeing During Workouts

Pelvic Floor Superior ViewThis post is inspired by the video that CrossFit HQ put out, presumably with good intentions, due to an “event” during the deadlift-box jump event at the Central East Regionals [see video below]. Pelvic floor dysfunction is real and I would never make anyone feel bad if it happens…but it is not “OK” or normal to pee during workouts – it is a sign of Pelvic Floor Dysfunction.

This article hopes to cover the following:

  1. What is Pelvic Floor Dysfunction
  2. What is “normal” and what is not
  3. Things that do NOT help
  4. Things that you can do that will help

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The Pelvic Floor – a draughty window or something more…???

Pelvic Floor Physiotherapist

Julie Wiebe

This post was inspired by Tweets from Julie Wiebe (www.juliewiebept.com).

To quote Julie from Twitter…the question was “What specific conditions do you think need specialist WH Physio care?”

I think the answer [to] that can’t be a formula and I think if we can change how we address MSK & pelvic floor and treat them together from the get go then women wouldn’t end up [with] the really awful stuff that internal [physios] have to sort thru. When I give courses I equate it to a drafty window that eventually turns into a huge reno project [because] the true issue wasn’t addressed early. Let’s normalize the pelvic floor, integrate it early in MSK and see if we can avoid the major reno projects internal therapists are seeing. Your thoughts?
My Thoughts:
I have been thinking about this for a little while.
Firstly, Julie is absolutely correct. Sometimes we see the problem (a draughty window) and we try to fix it. Doctors will say “oh, you can’t hold your bladder? Go see a WH physio” and then it becomes a “pelvic floor” problem, the patient doesn’t improve and doesn’t go back to the physio, gets referred for and has surgery (the big renovation) and a little while later the same problem is back… This is not a good result!
Julie’s suggestion to “normalize the pelvic floor” is correct as well. The problem has been that this can be hard to do. The pelvic floor could be the victim or it could be the primary problem. Let’s go through some brief examples but first a quick revision of the philosophy I use…
You may remember from other posts that I like to look at problems in a holistic manner. That means looking at:
1. The person’s story, what has meaning to them, their virtual body representation, their goals of treatment and their emotions.
2. Articular System – bones, ligaments, cartilage, etc
3. Myofascial System – muscles, fascia, tendons, associated soft tissues
4. Neural System – Brain, spinal cord, nerves, coordination
5. Visceral System – internal organs and their associated soft tissues
6. Strategies for Performance and Function – how the patient does what they do
The Pelvic Floor as the Primary Problem.
 If the pelvic floor is the Primary (main) problem, it means that it is responsible for initiating the cascade of reactions that are ending up causing the symptoms. Some examples of this are:
1. A physical tear of one of the pelvic floor muscles or their attachment to the bones
2. Local nerve damage causing dysfunctional pelvic floor contraction
3. A truly weak pelvic floor
I know this is a limited list but I am struggling to find other problems. e.g. coordination issue is actually a neural issue to do with the brain, a fractured pelvis is not a pelvic floor problem as the primary. In any case, if I find a Primary Problem Pelvic Floor, I refer to a Women’s Health (WH) Physio. I am happy to take  suggestions here for other conditions that require WH Physio…
The Pelvic Floor as a Secondary Problem
Now this part of the post is much easier! This is where a primary problem somewhere in the body impacts the pelvic floor in some way. Until you fix the primary problem, it will continue to affect the pelvic floor. Often, misdiagnosis of the pelvic floor as the Primary Problem results in frustration for the patient, therapist and doctor. If this happens, refer to a suitably qualified Musculoskeletal (MSK) Physio!!!
For me and my practice, the most common Primary problems come from around the pelvic region generating intra-abdominal pressure and so put pressure on the pelvic floor. Some examples:
1. Thorax and Lumbar dysfunctions – non-optimal biomechanics causing excessive activity of diaphragm, obliques or rectus abdominis with erector spinae tone. This can cause all sorts of secondary problems, one of which is a pelvic floor that appears to be weak but is really just tired of putting up with all this pressure from above! Or you can have asymmetrical pulling on the pelvic floor causing dysfunction.
2. Pelvic and hip dysfunctions – similar to above but sometimes dysfunctions can cause biomechanical disadvantages for the pelvic floor, compensations from other muscles bearing down to try stabilise a dysfunctional segment, altered neural input, etc etc
How do I manage these 2 different presentations?
Firstly, you have to diagnose correctly whether your patient’s pelvic floor symptoms are truly a pelvic floor problem (primary problem) or whether the pelvic floor is affected by other problems (secondary problem).
Next, you then have to decide if you have the skills to deal with the primary problem. I know my strengths and weaknesses. I will give a patient a small amount of time to develop her endurance and strength if I feel that is the primary. If I feel that she has a myofascial or neural problem or associated visceral problems (bladder or uterine prolapse), then off to the WH physio she goes.
If a patient has a primary problem elsewhere, I have 1-3 sessions to prove to the patient and to myself that I am on track. Otherwise I refer them on. If it truly is a Primary problem elsewhere, you should see evidence of change within the session and between sessions.
Management involves treatment of the relevant components of their problem (articular, myofascial, neural, visceral, strategy, person in centre of puzzle). This should then allow proper coordination of the pelvic floor to occur. Once that does normalize, I develop strength and endurance and ensure that this develops during their meaningful functional tasks.
I must repeat, this should happen relatively soon. If it doesn’t, you haven’t got the primary problem. Having said that, it can take time for muscles to develop etc but you should see steady, consistent improvements. If you have improvements that go back down to near your baseline measures, you don’t have the primary problem.
Check your ego at the door!
I believe that this is a lesson that most physios can learn. I know I have had to. Not knowing how to do something well does not mean that you are an ineffective physiotherapist. How you deal with a patient who doesn’t respond as expected is a measure of how good a physio you really are!
In Australia, we have 3-4 tiers of physios – Your regular physio with a bachelors (or now graduate entry masters), a Titled Physiotherapist who has a clinical masters or equivalent, specialists in training (me) who have the title of Associate of the College of Physiotherapists (but are still just titled physiotherapists) and Specialists.
Ideally, physiotherapists would refer difficult patients to Titled Physiotherapists for an opinion and a plan and Titled Physiotherapists would refer to Specialists (or specialists in training) for those that they can’t work out. It is like a General Practitioner doctor referring to Specialists – in Australian Physiotherapy, we have the Titled Physiotherapists in between.
When I refer someone, I send a letter explaining what I have found, what I would like assessed and for them to do what they think is necessary, just let me know what is going on.
When I get someone, I do the same back…so long as I know that is what they want! Sometimes I get nothing from the referring physio! They seem to want me to just take over…so I do…but no one learns!
Your patient knows you are a good physio and will actually appreciate your efforts to find someone who can help them. They will not appreciate you if you write them off as difficult or hold onto them as your patient for too long.
1. Accurate diagnosis is so important to finding out if the Pelvic Floor is the Primary Problem or a Secondary Problem.
2. Once you have identified the Primary Problem, you should address it holistically and see improvements within 1-3 sessions.
3. If you don’t see consistent improvements, refer to someone else to check your work. This is actually being a good physio!!!
4. Check your ego at the door. You are there to help your client. Find other physios you can liase with to help you – no one is the complete package!
Please leave your thoughts below. A tough but interesting post to write!

How I work with pelvic floor physios

Thinking Girl

Who should I see about my problems?

FAQ: Who should you see if you have problems with your pelvic floor?

This is a great question. Ideally, you would see a physiotherapist who has had extensive Musculoskeletal (MSK) Physiotherapy training AND training in Women’s Health (WH) Physiotherapy. Unfortunately, there aren’t too many of these physios around. They are definitely out there but not all MSK physios know about the pelvic floor very well and not all WH Physios know about the rest of the MSK system.

Also, in my opinion, a thorough understanding of the thorax and pelvis is lacking among physiotherapists. I know for a fact that most Masters programs do not address these 2 areas very well. As an exercise (if you are a health professional), close your eyes and imagine the anatomy of the knee – most physios can picture this in good detail with bones, ligaments, cartilage and muscles all in the right place. Now do the same with the thorax…not so clear huh? Can you name all 13 joints that exist for the 4th Thoracic Ring (T3, T4, L+R 4th rib, Sternum)? I rest my case!

What I am good at…

I look at a person holistically – for a review of this, click here – and consider what regions are important to look at. For example, a patient might come in with difficulty controlling the bladder during exercise. Is it a joint, muscle, nerve, visceral or brain/beliefs problem? Is their pelvic floor strong enough? Does it relax enough? Is it on too long or too hard? Is it under pressure from other muscles or joints? Is the pelvic floor actually damaged?

All of these things are important to identify and investigate.

How I am Incomplete…

Now, the way that things work is this: If I want to be trained in Women’s Health, I have to do courses. However, whilst they would let me do the theory, it has been suggested to me that it would be highly unlikely that the other participants would allow me to do the internal examination practicals that I would need to do to learn. In theory, there are male obstetricians so male WH physios shouldn’t be a problem. In theory, it is sexist and discriminatory. In reality, I don’t mind. There are plenty of good female therapists around who I can refer to. I don’t need to be able to do internal examinations to be a good physio. I can live without the fear of being sued or charged with sexual assault!! There is enough work for everyone so let’s just share the love!!

Sharing the Love – I refer patients to good WH physios!

So, when there is a patient who looks like their primary problem is a damaged pelvic floor, I refer them to a WH physio I can trust. I will always check all the MSK systems to make sure that I have taken care of everything I need to make the WH physio’s job easier. I also write a letter explaining what I have found and what I think the potential problems may be and specific issues I would like an opinion on.

What I would like to see from WH physios…

Too often, patients get categorised into a WH physio problem or a MSK physio problem. This is an issue because it isn’t a holistic approach.

The type of WH patients I can help are those that don’t seem to be improving their bladder/bowel control, have an endurance problem, have pain…basically anyone who is not improving!

If you are a suffering from pelvic floor issues and your treatment doesn’t seem to be working, then ask your WH physio for a MSK physio referral. If you need help finding one, just ask me!

A holistic approach - is your therapist using it?


Better understanding between MSK physios and WH physios needs to occur. Thankfully, the last 15 years has seen a great improvement in the communication between the 2 groups!

If you are a women’s health physio, I invite you to comment below and make sure you add your website or FB/Twitter page to your comments. That way, patients can locate you!

If you are a patient who has issues with your pelvic floor, please feel free to ask questions below about who you should see. Any good physio would be ok with you asking if a referral to a MSK or WH physio would be helpful 🙂

Remember, 1 in2 to 1 in 3 women will have pelvic floor issues in their lifetime. Let’s solve the problem, not just use panty liners!

Exercise and the Pelvic Floor – How Do I Switch It On Exactly??!!

Is this you?

Have you had a baby and scared to jog? Can’t jump on a trampoline with the kids? Can lift heavy weights but can’t do skipping?

A Common Problem

These are really common problems that I see regularly. In fact 4.8million Australians have had trouble with their bladder or bowel in the past! 50% of women in the mid to late 40s have had some form of urinary incontience. 70% of people who suffer from it DO NOT SEEK TREATMENT!!! (source)

Unfortunately there is a lot of information and advice out there, often unhelpful advice. Do I squeeze hard or do I go gently? Do I hold it on for 10secs or is on/off quickly enough? Do I need to do it every day or 3 times a week enough? All of these questions are good – and to a certain extent they are all correct.

Image courtesy of Continence Foundation of Australia

Image courtesy of Continence Foundation of Australia

Where is my Pelvic Floor?

Basically the pelvic floor muscles attach to the bottom of your pubic bone and go under the pelvis towards your tailbone. They are the muscles that control to 2 passages in the male pelvis and the 3 passages in the female pelvis.

So What’s the Problem?

Here is the thing – in most people, the pelvic floor works without you needing to think about it. most people are able to walk around or sit or go about their daily lives without wetting their pants. But when it comes to exercise, people do all sorts of funny things to turn these “core” muscles on…”navel to spine”, “squeeze hard”, “hold your breath”, etc etc. These are inefficient strategies.

What Really Happens – How Does It All Work?

I like to think of the body as working in 3 steps to do an exercise or movement.

Step 1: Think about what you are going to do – this is obvious! You form a thought about what you want to do and your brain gets everything ready…but sometimes the brain’s processing is not quite right

Step 2: Prepare for action – you consciously and unconsciously prepare to do something – you change your posture and your little stabilisers (your “core” for want of a better word) preactivates.

Step 3: You do it! This is when you use your big muscles to generate the movement you want to do.

Too many people use their big torque-producing muscles to do  the work of the little muscles – e.g. Squeeze your gluts, tighten your abs, tense your back, etc – these muscles are not designed to hold you together – they are designed to M O V E.

Your little stabilising muscles are designed to keep all the joints in your body (from your little finger to your little toe) in an optimal joint alignment so the big muscles can produce lots of torque (force) around the joint.

Your Pelvic Floor is just one part of the team that keeps you together. If it doesn’t do its job properly, then you end up with wet underwear, a prolapse, a herina or worse!

What Should I Do?

You need 3 key ingredients to make your Pelvic Floor work properly.

1. Isolation and Dissociation – these are fancy words but basically I want you to be able to use your pelvic floor without having to squeeze other muscles to get them to work. Please note that other muscles will also work when you do the Pelvic Floor Contraction correctly!

2. Activation – This is not just the amount of strength you have but how you can control that strength. You need to be able to contract your Pelvic Floor from as low as 5% contraction up to 100% contraction strength. So you have to practice being able to do this. It is no good owning a car that only works well when it is traveling 80km/h and you live in the city. In the same way, you Pelvic Floor is not that useful to you if you can only get it to work when you squeeze really hard! Learn to control how much you can squeeze it so your brain can choose how hard it needs your Pelvic Floor to work.

3. Endurance – You need to be able to do lots of contractions at various activation levels. One popular program is 10sec hold x10reps x10 sets  – this takes forever and you will be tired – i give this from between 5% activation level up to 100% activation level – most people can’t do 10 sets…I am nice and just get them to do it for 3 sets throughout the whole day!

Important Points:

1. It is a common problem – seek advice and help if this happens to you!

2. Before doing exercises, prepare your posture and choose the right activation level for the task – as little as possible, as much as is necessary.

3. You should switch on the Pelvic Floor BEFORE switching on the big muscles that move things!

A video…

I came across this video today which I thought was quite good.

For More Information…

  • Visit me at The Physio Detective – http://www.myphysios.com.au – and find out more about how we use Physiotherapy, Massage Therapy and Pilates and Exercise Rehabilitation to help you get your Pelvic Floor right
  • Visit http://www.continence.org.au
  • Seek advice from a medical professional – it may be common but it doesn’t have to be normal!!!

Why don’t you leave a comment below and continue the discussion?

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