6 Reasons Why the Diaphragm may be the Coolest Muscle in the Body

I have a small confession to make– I love the study of human anatomy. Always have. It was studying human anatomy and physiology that made me shift my undergraduate degree at Gordon College away from “Biology” and into “Movement Science” (which has now become “Kinesiology”… Who would have known that years later, “Movement Science” would have been the coolest name for a major ever? Am I right fellow PTs?). The human body is fascinating and incredible. So, it should come as no shock to you that I have favorite muscles. In PT school, my favorite muscles were the ones with the most fun names… like the Gemelli brothers (who are small hip external rotators) or Sartorius (a thigh muscle…best, if sung to the tune of “Notorious“). Of course, you know that now the pelvic floor muscle group ranks pretty high on that list…but the diaphragm, well… it just takes the cake. Here are some of the reasons why the diaphragm really is so cool.

1) We can contract our diaphragm voluntarily–but it also will contract without us consciously telling it to. How cool is that? You can activate your diaphragm by taking a long, slow, breath expanding your ribcage 360 degrees and allowing your belly to relax. But, before I brought your attention to your breath, you were using the diaphragm without even thinking about it!

2) The diaphragm helps to mobilize the ribs, lumbar spine and thoracic spine. The diaphragm attaches to the 1st, 2nd, and 3rd lumbar vertebrae, the inner part of the lower 6 ribs as well as the back of the sternum at the xiphoid process. The central tendon of the diaphragm then attaches to the 3rd lumbar vertebrae. During inhalation as the diaphragm flattens to allow the lungs to fill with air, the diaphragm will “pull” slightly on each of those attachments, effectively giving you a gentle mobilization. The ribs will also move during inhalation and exhalation to allow space for the lungs to fill.

3) The diaphragm is a key member of a team of muscles which help to create dynamic postural stability. You knew that would be one of my bullets, right? I think I mention this in almost every post…but… the diaphragm works together with the pelvic floor muscles, abdominal muscles (transverse abdominis) and low back muscles (multifidus) to pre-activate and provide support to the body during movement. Together, these muscles make up our “anticipatory core” and are important muscles for healthy pain-free movement patterns. Now, no post on the diaphragm would be complete without an excellent video explanation by Julie Wiebe, PT, who is amazing and has done so much to help advance the understanding of dynamic stability in PT practice.

4)Retraining proper firing of the diaphragm can help to reduce urinary incontinence AND low back pain.  Now, that is pretty cool, right? Excellent research by Paul Hodges and colleagues has shown altered firing patterns of the diaphragm in people with low back pain or urinary incontinence.  Amazingly, when people re-established proper firing of the diaphragm leading to full excursion, both low back pain and bladder problems reduced   This is likely due to the relationship between the pelvic floor and diaphragm in controlling intraabdominal pressure within the abdomen and the pelvis.  Proper breathing helps to restore the optimal pressures needed to control movements and support the pelvic organs. This relationship is so huge that problems with breathing and continence are more correlated with low back pain than obesity and physical activity. 

5) Slow breathing with the diaphragm can calm down the nervous system.  The breath is so connected to the autonomic nervous system. When a person is fearful or anxious, the sympathetic nervous system (fight or flight response) is activated, and a person will take quick shallow breaths to bring oxygen to the muscles as quickly as possible (think: being chased by a bear)  the parasympathetic nervous system (rest and digest) is activated when in a more calm or relaxed state (yes, I am oversimplifying all of this… I know). In that state, a person will take slow calm breaths (think: sipping a cup of tea after a great massage).  The cool thing is that we can use our breath to help us move toward a more relaxed state. Slow breathing will help calm stress, anxiety and promote a person being in a more parasympathetic state. And guess what? There’s an app for that! The Breathe2Relax app for iphone/android allows a person to program in his or her breath and then takes you through a guided breathing exercise.

6) Slow breathing with the diaphragm can reduce pelvic pain. As we discussed previously, the pelvic floor and diaphragm are coordinated and work together to control pressures through the pelvis. As the diaphragm is activated during inhalation, the pelvic floor relaxes to accept the contents of the abdomen/pelvis. As we exhale, the diaphragm returns to its rested position and the pelvic floor activates slightly. Long slow breaths then encourage complete relaxation of the pelvic floor and thus can help decrease pain for people with tender pelvic floor muscles.

So, there you have it! I bet the diaphragm just moved up a few notches on your favorite muscles list (you know you want one!). If you need more reasons, and enjoy “nerding-out” with Anatomy, check out these studies:

What’s YOUR favorite muscle? Did I miss any reasons why the diaphragm is amazing? Let’s chat together in the comments below!

~ Jessica

TBT: “Do you need to go potty?” 5 Tips to Improve Your Kiddo’s Bathroom Health

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Today’s throwback (yes, I know it’s Friday– I’m sorry, I was busy yesterday!) comes from a post I did a year ago on improving bathroom habits in children. This has been modified from my original post to reflect my most current thoughts and current practice patterns. Hope you enjoy! 

As you may know, I have advanced training in working with children with bowel and bladder dysfunction in pelvic physical therapy. Often times, this is shocking to many people to hear as most of us are somehow under the impression that children don’t have these sorts of problems. But the truth is, these problems are SO common in children! Amazingly, there are many easy things parents can do to make huge differences for their children!  I often here my adult patients say,

“But you don’t understand, I’ve been constipated since I was 5 years old– it must run in my family! ” 

What if we changed the habits of our children early to promote healthy bowel and bladder habits? Could we truly make a difference for them later on in their lives? Could we prevent them going in to their physical therapist and having to say statements like the one above? I believe we can do just that!

Here are your 5 tips to start making those changes today!

1. Encourage adequate fluid intake (mostly water!) and fiber intake!

The average person should consume 5-8 8-oz cups of fluid per day–and your child is no different! Fluid is SO important for both the bladder and the bowels! For the bladder, having adequate fluid decreases the risk of urinary tract infections, encourages normal bladder urges, and allows for a normal light colored urine instead of a dark concentrated urine. As an aside, taking in too many sweet sugary drinks, caffeinated drinks, and carbonated drinks will actually irritate the bladder and is something we want to try to avoid. (Note: Remember this if your child has difficulty with bed wetting!). For the bowels, adequate fluid allows for a soft stool that is easy to pass! If your child is not getting enough water, he or she will likely have a  more firm stool as the intestines have worked to absorb the fluid your child needs for normal bodily functions. Many a patient has been “cured” of constipation simply by drinking more fluid!

Fiber is also very important to encourage a good bowel consistency. The American Academy of Pediatrics recommends children take in between their age + 5 and their  age +10 grams of fiber per day (i.e. a 5 year old would need between 10 – 20 grams/day). There is some debate in this, so check with your pediatrician to get their recommendations. Good fiber sources include fresh fruits and vegetables, whole grains, oatmeal, granola, seeds and nuts! For good recipes for your kids, check out Gina’s recipes from Skinnytaste.com that are “Kid Friendly” here. Also, one of my favorite books for parents, Overcoming Bowel and Bladder Problems in Children, has a wonderful index of fiber-filled kid recipes!

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2. Encourage your child to listen to his or her normal body urges.

This goes for both the bladder and the bowels as well! Quick lesson on anatomy and physiology–We have a normal reflex in our colon that helps us hold our stool to empty at an appropriate time (Yay!). Unfortunately, if a person holds stool for too long, the normal colon response to help us poop is dampened–meaning it won’t work as well! For the bladder, over suppressing bladder urges can cause problems with emptying that bladder, daytime accidents and frequent urinary tract infections. Many times, children become distracted with playing, watching TV, etc. and will hold off on going to the bathroom when they do have that urge. Parents should try to be aware of how long it has been since their child has urinated, and try to encourage a frequency of at least once every 2 hours (this will vary some depending on the age of the child).

3. Get your kids moving! 

I’m sure you’ve heard it in the news these days that children need to get moving more! But, to take a new spin on it, encouraging your kids to move more will actually help keep their bowels more regular! Yes, it’s true, exercise is a stimulant to the bowels. So, encourage your kids to get outside and play, ride their bikes, do family walks and games– the more your kids move the better!

4. Help your child develop a bowel routine 

This one ties in perfectly with our last point. Here’s the scenario:

“8 year old Mary is not a morning person. Mom has a hard enough time getting Mary out the door in the morning, and this often means eating a bagel on the way to school. After Mary gets to school, she often needs to go #2, but is too embarrassed to go and holds it the whole day.”

Unfortunately, kids like Mary often develop constipation from over suppressing those urges! The sad thing with this is that if a child suppresses urges for bowel movements, the stool will often become hard and may even cause pain when the child does go to the toilet. Over time, children can end up with overly stretched colons and may even need to use laxatives/medication for a period of time to loosen the stool and help the colon return to it’s normal position. All of this can be minimized by building a routine for your kids in the morning (or evening) to help encourage a normal bowel movement.

This video from the Children’s Hospital in Colorado helps to shed more light on bowel problems in children:

We know that the colon LOVES consistency, so try to encourage your kids to spend some time (at least a few minutes) on the toilet at the same time each day. We also know that the colon loves fluid (hot especially), hot food, and exercise! So, a good bowel routine would look like this:

“To help Mary’s bathroom habits, Mom started waking Mary up 30 minutes earlier. Mary starts her day with a warm bowl of oatmeal, then plays with her pet dog.  After they play, Mary heads straight to the bathroom to have a BM.”

Yes, building a routine takes some extra time–but it is well worth it to prevent constipation in your kiddos!

5. Encourage proper toilet positioning and breathing on the potty

Yes, there is a right way to sit on the toilet. For children, most toilets are too tall and this makes it difficult for them to relax the muscles around the anal canal to help them poop without pushing hard. Kids will compensate by straining, but over time this can be very detrimental to their pelvic health. To help them out, get a small stool to go in front of your toilet seat which will help encourage them to fully relax their muscles. Encourage them to lean forward and relax on their knees. This will help straighten out the rectum to encourage easy emptying.

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Image from our good friends at squattypotty.com. Check them out!

Then, and most importantly, make sure they have time. Encourage them to read a book or magazine and give their colon a few uninterrupted minutes to “do its thing.” I recommend they spend this time doing slow breathing (Potty Yoga) and relaxing. If they feel like they need to push, encourage them to breathe while they push to avoid the typical valsalva maneuver we often see. Learning this will help them so much both now and in the future! For more information, read this excellent post from my colleague, Jenna Sires, called “Are you Pooping Properly?

What have you tried to help encourage good bathroom habits for your kids? Are your children having problems not addressed above? Feel free to comment below! Here’s to a healthy upcoming generation!

~ Jessica

Learning Summary: Becoming the Best Event- Interview with Jessica Drummond

As you may know, part of my goal in writing this blog was to have a forum to process things I learn, and of course, to allow you to benefit from my nerdiness in learning. This week, many of my physical therapy colleagues from across the nation are traveling to Indianapolis for the American Physical Therapy Association’s Combined Section Meetings—basically a week of excellent presenters, networking, and seeing old friends. Of course, my heart is SO sad that I won’t be there this year—so I just had to find a way to learn on my own!

Thankfully, Jessica Drummond clued me in on Twitter to the Becoming the Best Event– a week long summit of (FREE) interviews with top holistic health professionals in the country! I read the bios, and I was in. I have been following Jessica for years (Didn’t know you had a stalker, did you Jess?:) ) and I have truly enjoyed learning from her. Jessica is a physical therapist and the CEO and founder of the Integrative Pelvic Health Institute. She has created a unique model of treating the whole person—managing the hormonal and dietary aspects as well as the physical—and she is pretty awesome at doing it! I was fortunate to collaborate with her this past year in caring for a wonderful woman who was experiencing sexual pain, and I can say from my experience that Jessica really did make a difference in her life!

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So, here is a summary of what I took from Jessica’s Interview:

  • In treating women, Health Care Providers (HCPs) must work to normalize women’s health issues. We should all ask about a woman’s menstrual cycle and reproductive history the same way we ask about diet, bowel movements and sleep habits. For some reason, women are taught from an early age that our normal cycle is something to hide and be embarrassed about. However, it is so important and can be one of the only clues to us that something is off! Did you know that an abnormal menstrual cycle could even be an indicator of Celiac’s Disease? I didn’t, until today.
  • Just like we individualize nutrition based on the person, exercise and fitness recommendations should be individualized based on the person. Jessica said this awesome statement during our interview, and I absolutely agree: “I actually don’t think there is any specific form of exercise that is bad—it’s the way, the intensity and your body’s readiness for it.” 
  • What about high impact activities (running, jumping, gymnastics)? Not “bad” either but can put women at risk for problems if they do not understand how to adequately use their pelvic floor muscles.  Increasing pressure on the pelvic floor without adequate timed recruitment can lead to problems like incontinence/prolapse. Jessica recommends that all athletic women should be mindful of their pelvic floors (not always Kegels!) and all HCPs working in wellness should ask questions and encourage seeking help when needed.
  • Women often ignore the benefits of our hormonal cycles—we are always encouraged to hide it from the time we are 12 years old! Estrogen and testosterone are at its highest right before ovulation (2nd week in the cycle). Women actually have more energy at this time, and will burn more fat when exercising these days! We can capitalize on that by eating a higher fat meal a few hours before we exercise to encourage our bodies to burn more fat. So, at mid-cycle- we should eat less sugar, healthy protein and good fats to encourage our body to utilize the natural hormonal environment. In the second half of the cycle, the body actually prefers using protein as energy! If a woman has a big fitness event at the end of the cycle- she may need to eat more often and will probably need more support since hormone levels are at their lowest. And what about running with gels and gus? Jessica actually says that doing this does not encourage our body to use the right fuels but rather pushes a simple sugar energy.
  • Women exercising intensely daily without modulating for hormonal cycle can end up being a negative thing—this does not necessarily allow for adrenal recovery and can negatively impact the system. Estrogen can become lower and this will put someone at risk for cardiovascular dysfunction (and poor bone health too!- JR add)
  • What about for pregnant women? There are some specific things that can be done to tweek a fitness program and get maximum benefits. First, it is important to recognize that the uterine environment is a very important environment to build. That environment can pre- program the genetic expression of the fetal genes. Weight issues, DM, PCOS, Metabolic issues can impact the environment. Clean eating (low sugar) with regular, healthy eating. Insulin sensitivity decreasing as pregnancy progresses can lead to big blood sugar swings which are also not ideal for womb environment. Eating healthy foods at regular intervals can help- focusing on eating nutrient dense foods, healthy fats and minimal sugars. Exercising (even just walking 30 minutes per day) can also help to control blood sugar and promote healthy blood sugar for the baby. Of note, pregnant women should be careful of actively detoxing during pregnancy and while nursing. Stored toxins are “hidden” from the baby and trying to “release” them can actually transmit those things to baby. That being said, a more intense detox before pregnancy can actually be a good thing.
  •  Hormones are of course significantly impacted during menopause. Did you know we can help prepare for menopause? Jessica recommends women focusing on building strong adrenal function during their 30s and 40s, emphasizing addressing stress, nutrient density, and controlling blood sugar. Doing this can impact the entire hormonal environment and create better health for women as they age. During menopause, women lose the estrogen support from ovaries–but having healthy adrenal glands can help a woman make enough estrogen to minimize menopause symptoms (including hot flashes, discomfort and brain fog!)
  • And lastly, what about us health care professionals? How do we avoid adrenal burn-out? It is essential for us to create a fairly strict list of priorities focusing on our vision for our life: What do you want life and work to be like? What must your health be to support this life? Jessica encourages prioritizing self-care and in an oh so inspiration way, encouraged us to “Be an inspiration for patients rather than being the person resposible for ‘fixing them.'” She also encouraged eliminating the guilt we often feel from being unable to cure everyone. She said, “You are not everyone’s healer.” We cannot heal everyone, but there are specific people out there who need our specific skill sets. Our goal should be to provide the knowledge, wisdom and skills patients need to allow themselves to heal. When they see us as an inspiration, they will take the responsibility to own their healing, wellness and healthcare. And this is a total mindset shift! We don’t have to feel guilty when we cannot help someone! And this frees us to really be what we need to be for the people who need us.

Thanks so much Jess for all of this great information! Please check out Jessica’s website for more information about her and the awesome work she is doing! If you would like more information on the Becoming the Best Event, please feel free to check it out here! You can access all of the interviews for free for 24 hours after they air, or you can pay $97 to access them whenever you would like!

Hope you enjoyed this summary! Please let me know any thoughts/comments you have below! ~ Jessica

Partners in Health: Building a Strong Patient-Provider Relationship

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In my mind, one of the most important aspects of patient care is building a strong patient-provider relationship. I find that treatment outcomes truly depend on the patient being able to trust the provider and the provider truly listening to the patient. For many patients, seeking treatment can be intimidating and produce fear—of the unknown, of what the diagnosis could be, etc! This fear can lead to patients feeling a need to hold back thoughts or beliefs and can ultimately create barriers in treatment which leads to frustration by both the provider and the patient. Providers, on the other hand, can often contribute to fear or stall progress without intending to by not individualizing treatment and partnering with patients.

So—this post is for all of us! These are a few of my thoughts—both advice for the patient and for the provider on how to better build a partnership in healthcare. But more importantly, I want to hear from you. So, read on, and comment at the end so we can all learn to work together better and improve the way we deliver and receive healthcare.

For the patient:

  1. Remember that you have control: I have had several instances where a patient will say “yes” to a prescribed medication or will feel pressured into having a surgery that he or she really did not feel comfortable in having. If a physician, PT or other healthcare provider recommends a treatment that you are uncomfortable with, don’t be afraid to speak up and say so! Remember that we as providers want to help you get better as quickly as we can. If you are unhappy with the treatment plan, that won’t happen!
  2. Don’t be afraid to speak up: Many times, we as providers forget that not everyone has the same background knowledge we do when it comes to the human body. If you are being told something you don’t fully understand, speak up! I always thank my patients when they ask me questions because helping you understand and feel understood is such a key piece of my practice. Often times, those questions help me personalize treatment approaches and often I find we end up in a better place by those conversations we have. Along with that, don’t be afraid to question the treatment approach your PT/provider is recommending. Did you read a blog or article which recommended something different? Did your friend hear of a new treatment approach? Share those thoughts and ideas! I love to have those conversations with my patients because often times there are specific reasons why I recommended what I did and having that conversation helps both of us to be on the same TEAM. Occasionally patients may suggest new treatment approaches I am not as familiar with—and that’s great! That gives me an opportunity to learn and work together with my patient to determine how we should proceed.
  3. Make sure your goals are being addressed: If your goal is to be able to walk around the house, make sure your provider knows that! Sometimes there can be a mis-match between what your provider thinks your goal is and what your goal actually So, speak up! Let us know what you hope to get back to so we can work together to help you move!
  4. Be open to new ideas: When it comes down to it, we (the providers) do genuinely care about you and want you to get better as quickly as you can! Sometimes your provider may suggest something that seems “weird” or “unconventional,” but listen to what they have to say! I have had many patients who initially were hesitant about a treatment I recommended then later were SO glad they chose to give it a try!

For the provider:

  1. Listen to your patient!: When I was in PT school, I remember having a professor say to me, “If you listen to the patient, they will tell you what is wrong with them!” Seems so simple, but often our minds jump to immediately categorizing the patient and planning ahead to our next steps. So, let’s all stop, take a breath, and give our patients a chance to tell us what they need to tell us.
  2. There is no “I” in TEAM: To truly help a patient achieve optimal results, we have to partner with our patients and develop a treatment plan that is unique to them and their goals and values. For example, if I think my patient would benefit from doing a yoga/pilates routine but my patient hates that type of exercise, our plan is ultimately not going to be successful. However, that patient may love to swim and lift weights, so we could develop a program that might achieve the same goal in a method the patient will enjoy.
  3. Don’t be afraid of “not knowing”: Sometimes we become anxious if we do not know the answer to a question a patient asks or if we reach a point where we are not really sure how to proceed to help the patient achieve the results that patient is hoping for. I am often shocked how admitting I do not know but will work to learn actually builds a stronger patient relationship! Trust is not only in being able to help, but also in knowing when you need to seek answers from elsewhere. So, be vulnerable. Admit you do not know. Seek additional consultations or refer out if you need to! In the end, the patient is the one who will benefit from your humility.
  4. Watch your language!: No, I do not mean avoid cursing with your patients (that’s a no-brainer!), but be careful with what you say and how you explain things. My sister went to physical therapy and was told, “Your rib on one side is ‘out of place’.” She totally freaked out—not knowing what that meant, she worried something was structurally wrong with her body. She was scared, and guess what? Her pain actually got worse that week. Recent studies have shown that our words do not always mean the same thing to us as they mean to our patients. Check out this awesome blog post by Matthew Low which summarizes several studies on the subject. Pay attention to what you say and make sure your words promote healing and health—not fear!

Let’s partner together and work toward better health! These are just my thoughts…. So, what do you think?

Patients- What would you like your health care providers to know to better help you in your recovery? Have you had any bad experiences with providers you would like us to learn from?

Providers- What would you like patients to know when coming to see you? What can we all do to work together better?

Cheers!

~ Jessica