Resolution: standard / high

Figure 2.

Test protocol Sitting knee extension. Upright sitting with corrected lumbar lordosis; extension
of the knee without movement (flexion) of low back A. Correct Upright sitting with corrected
lumbar lordosis; extension of the knee without movement of LB (3050 Extension normal). B Not
correct Low back moving in flexion. Patient is not aware of the movement of the back. Rating
protocol: As patients did not know the tests, only clear movement dysfunction was rated as "not
correct". If the movement control improved by instruction and correction, it was considered that it
did not infer a relevant movement dysfunction.
Luomajoki et al. BMC Musculoskeletal Disorders 2007 8:90 doi:10.1186/1471-2474-8-90
Download authors' original image

David Kingsbury
Love sport. Love food. Love London. A Personal Trainer and Part-time (read amateur) Triathlete in Central
London
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Pelvic Posture and Back Pain Throughout Pregnancy

Posted: 22/10/2013 11:29

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Chronic Pain, Diet And Fitness, Personal Training, Exercise, Posture, Pregnancy,Pregnancy Fitness, UK
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You may not have thought about it this way before but when you think about posture,
you're actually considering the biomechanical relationship between your body and
gravity.
Although it can be interpreted in different ways, I like to think that good posture is
achieved when the body is aligned in such a way that there is minimal tension through
our muscles and ligaments.
Think about the construction of a tent - the guy ropes on each side provide equal tension
to hold the tent in an erect state. If you were to over tighten the guy ropes on one side,
the tent will lean further in one direction than the other. It's exactly the same situation
with our bodies - if one set of muscles is tighter than the other, we start to see shifts in
the centre of mass and additional stress is placed on certain groups of muscles.
As you progress through pregnancy, physical, physiological and hormonal changes occur
that alter your body's biomechanics and impact on postural control. Take weight gain.
Most women put on between 11 and 16kg during a healthy pregnancy. Because this
weight gain is largely localised in the abdomen, it changes the position of the body's
centre of mass. At the same time, hormonal changes increase the laxity of joints, which
can also add to postural instability. So perhaps it's no surprise that a significant
proportion of pregnant women end-up suffering with lower back or joint pain in the
pelvic area.

This article considers postural changes that occur in the pelvic girdle and lower back
during pregnancy, and the steps that we can take from an exercise perspective to reduce
the likelihood of back pain in the long term.
Pelvic position
Relaxation of the pelvic girdle is a normal physiological response to pregnancy. The
growing uterus rests on the surface of the pelvis, which generally becomes repositioned
into a forward tilted position.
If you imagine the pelvic girdle as a see-saw, the muscles attached to the pelvis - the
gluteals, the hamstrings, the hip flexors and the abdominals - can pull it forwards and
backwards, influencing its rotation. From a corrective exercise perspective, it is common
to see the hip flexor complex become stiff and tight during the course of pregnancy. At
the same time, the main hip extensors (the gluteus maximus and the hamstrings) are
more likely to lengthen and weaken, as are the abdominals.
Without suggesting that muscle imbalance will lead to back pain, there does seem to be
growing evidence of an association between muscle dysfunction and lumbo-pelvic pain
in pregnancy. One Swedish study found pregnant women with pelvic girdle pain +/- back
pain had lower hip extension muscle strength than those with no back pain. Similarly,
weakness of the hip abductors (muscles which also help stabilise the pelvis) has been
associated with pregnancy-related lower back pain. So working towards a neutral pelvic
position, where muscles can work together in a more balanced way, seems to be a valid
approach for physiotherapists / fitness professionals to take in order to reduce
back/pelvic pain in pregnancy.

Lumbar spine lordosis

Along with a forward tilt of the pelvis, lordosis is another postural change that can occur
during pregnancy, this time directly affecting the back itself.
Your spine has natural curves at the neck, and in the upper and lower back areas. In part
these curves act as shock absorbers, distributing the stresses that occur as you move.
When you are pregnant, you may find that your back arches more than normal, so that
your upper body moves backwards and acts as a counterbalance for your growing
tummy.
As pregnancy progresses, mums-to-be can start to feel less balanced. While they
naturally widen their stance to increase lateral stability, to maintain balance in the
forward / backward plane of movement (for example, when walking) they tend to
increase postural sway still further.
This increased curvature, known as lordosis or swayback, places an increased load upon
the spinal musculature for spine stabilisation. Interestingly, research has recently shown

that endurance of the back extensor and back flexor muscles is reduced in women with
pregnancy-related lower back/pelvic pain.
Since the pelvis is attached to the lower spine through a wedge-like section of bone called
the sacrum, the tendency for pelvic rotation is also increased as lordosis increases.

What exercises can we do to encourage good posture through the lower

body?
The main goal of an exercise programme targeting pelvic and lower back posture is to
promote muscle balance. Thinking back to the tent metaphor, we want to have the
muscles in the front of the body working in equilibrium with their counterparts in the
back of the body.
This can be difficult to achieve with so much happening all at once. But lower back pain
doesn't just impact negatively on daily life, it can also increase your risk of complications
during labour. Making time for exercise during pregnancy not only decreases your risk of
pregnancy-related lower back pain, it also makes you more likely to lose the weight you
gained during pregnancy.
Several exercises are perfectly safe to perform, but here are my favourites to work on
pelvic alignment.

Exercise 1 - Stretch of Hip Flexor Complex

 Kneel down and step one foot forward, with a 90 bend at the knee
Maintain an upright body position and gently push your hips forward
You should feel a stretch in the front of the hip and thigh on the rear leg
Hold this stretch for 20-30 seconds

Exercise 2a - Glute Bridge*

 Lie on your back with your feet flat on the ground

Push your hips up towards the ceiling until there is a straight line through the shoulder,
hip and knee
Pause at the top and consciously engage your bum muscles
Slowly lower to the start position
Repeat this exercise for 2 minutes
*Lying on your back can cause dizziness in some pregnant women. This is because the
heavy uterus sits on a blood vessel, which has the potential to restrict blood flow. If you
prefer not to lie on your back, the clam is a great alternative, below!

Exercise 2b - Clam

 In a side lying position, bend your legs and stack your hips, knees and ankles on top of
one another
Roll your top hip forward slightly so that your top knee slightly overhangs the bottom
one
Lift your top knee up towards the ceiling, as high as you can go before you feel the hips
start to roll backwards
Pause at the top and then lower back down

Aim of the glute bridge and clam:

To exercise the gluteal (bum) muscles in an isolated manner
How much, and how often?
Perform your preferred exercise for around two minutes or until the bum muscles fatigue
(on each side for the clam), with a focus on quality rather than quantity,
three times each week.
Why do it?

Activating and strengthening the gluteal muscles helps to unload the lumbar spine of
excessive force when recruited properly. The gluts are also a group of muscles that are
commonly unbalanced.
Tips:
Many of my clients like a towel under their heads to support the neck, and a rolled up
towel underneath their tummy to make it more comfortable.

Exercise 3 - Split Squat

 Stand in a split stance with the back foot on tip-toes

Keep the majority of the bodyweight over the front foot
Bend the rear knee down towards the ground with a slight lean forward through the
upper body
Push up to the start position
Aims:
The leg muscles are among the largest and strongest in the body, so expect the heart rate
to rise slightly with this one. Aim to contract the gluteal and thigh muscles in synergy to
produce the movement.
Why do it?
This exercise is great for three reasons. Firstly, it will help you to maintain the muscle
tone in your thighs. Secondly, the 'isolate-to-integrate' method (which has been shown to
enhance muscular recruitment patterns) is exemplified in this exercise. And finally, it
will also elevate your metabolism, and is great for any fans of the endorphin rush.
How much, and how often?

I'd recommend always performing the split squat after glute bridges or clams - that way,
you ensure that the gluteal muscles are consciously recruited. Perform 2-4 sets of 10-20
repetitions for the best results.
Considerations:
Split squats involve moving the body up and down repeatedly, which can cause changes
in blood pressure. If you feel dizzy during this exercise, then it is likely that it is not
suitable for your stage of pregnancy. As a rough guide, you should work at a tempo of 3
seconds on the way down, pause for half a second to kill momentum, and then take 3
seconds on the way back up. The depth of your split squat should decrease as you
progress through your pregnancy.

Pelvic floor exercise

As well as the exercises above, it's important that we do not neglect the inner abdominal
muscles - they are the ones that you cannot see. While the role of the transverses
abdominis and the pelvic floor muscles in lower back pain rehabilitation is a topic of
some debate,10,11 pelvic floor muscles are clearly a pivotal group of muscles when it
comes to childbirth.
The Wave is a great exercise that can be done almost anywhere!
Exercise 3 - 'The Wave' - a double-headed exercise for the pelvic floor
Sit up tall in a quiet environment where you can concentrate
Contract your front passage to around 60% of your maximum force and hold it
Now contract your back passage to 60% and hold it for around 4 seconds
Now release the front passage slowly, followed by the back passage
You should feel the muscular contractions in a wave-like shape
This exercise should be performed little and often - perhaps 15-20 repetitions 2-3 times
per day. One of the significant benefits of pelvic floor exercise is the reduction of stress
incontinence after childbirth.12

What to do now
In summary, it is important that postural exercise forms a large part of your prenatal
training, even in the months leading up to conception. The main changes occur in the
pelvic region, followed by the upper back and neck. Keeping on top of your posture with
the guidance of an exercise professional can help to dramatically reduce the likelihood of
experiencing aches and pains, make you stand taller and increase your self-esteem!

Enjoy sweating!

1. Jang J et al. Balance (perceived and actual) and preferred stance width during
pregnancy. Clin Biomech 2008; 23: 468-76.
2. Borg-Stein J, Duggan SA. Musculoskeletal disorders of pregnancy, delivery and
postpartum. Phys Med Rehabil Clin N Am 2007; 18: 459-76.
3. Vllestad NK et al. Association between the serum levels of relaxin and responses to
the active straight leg raise test in pregnancy. Man Ther 2012; 17: 225-30.
4. Foti T et al. A biomechanical analysis of gait during pregnancy. J Bone Joint Surg Am
2000; 82: 625-32.
5. Bewyer KJ et al. Pilot data: Association between gluteus medius weakness and low
back pain during pregnancy. Iowa Orthop J 2009; 29: 97-9.
6. Gutke A et al. Association between muscle function and low back pain in relation to
pregnancy. J Rehabil Med 2008; 40: 304-11.
7. Noon ML, Hoch AZ. Challenges of the pregnant athlete and low back pain. Curr Sports
Med Rep 2012; 11: 43-8.
8. Brown A, Johnston R. Maternal experience of musculoskeletal pain during pregnancy
and birth outcomes: Significance of lower back and pelvic pain. Midwifery 2013; doi:
10.1016/j.midw.2013.01.002.
9. Duckitt K. Exercise during pregnancy: Eat for one, exercise for two. Br Med J 2011;
343: d5710
10. Stokes IAF et al. Abdominal muscle activation increases lumbar spinal stability:
Analysis of contributions of different muscle groups. Clin Biomech 2011; 26: 797-803.
11. Lederman E. The myth of core stability. J Bodyw Mov Ther 2010; 14: 84-98.
12. Price N et al. Pelvic floor exercise for urinary incontinence: A systematic literature
review. Maturitas 2010; 67: 309-15.

Assessing and Correcting Excessive Lumbar Lordosis to

Minimize
By: Justin Price, MA
The human body is designed to be upright. Whether you believe in
evolution or creationism, the same runs true. We are bipedal creatures
designed to stand erect with the spine on top of pelvis, and the pelvis on
top of the legs. Our bodies have two very important elements to assist in
maintaining an upright posture. First, large gluteus maximus muscles push
the hips forward into extension. Secondly, a curvature in the lumbar spine
arches the spine upward and backward to lift the torso on top of the hips.
Environmental Changes and Excessive Lumbar Lordosis

Over the past century, the environment in which we live and activities of
daily living have changed dramatically. Prior to the advent and availability of
modern staples such as automobiles, televisions, computers and stationary
bikes, people spent much of the day engaged in varying types of physical
activity and movement. Such technological advances, however wonderful
they may be, mean that most of us now spend the majority of time sitting
down. When seated, the butt and hips are behind us (supported by a chair
or seat) and the entire spine bends forward into a rounded and flexed
position. The gluteal muscles do not have to work to support the hips and
spine; the chair we are seated upon does all the work. Therefore, when
required to stand up, the glutes are not strong enough to push hips forward
to form a quality base of support for the spine. In addition, the thoracic
spine (mid to upper back), which has a natural slight forward curve, suffers
from prolonged seated positions. After long periods of sitting, this forward
thoracic curve can become excessive, thereby causing part of the spine to
lose its ability to arch backward and assist in standing erect.
These hip and upper back dysfunctions mean that the responsibility for
lifting the torso upright falls mainly on one structure in the body, the lumbar
spine. There is a natural curvature in the lumbar spine designed to lift the
torso upward. But, when used exclusively to achieve and maintain upright
posture, the lordotic curve becomes excessive (a.k.a. excessive lumbar
lordosis). Excessive lumbar lordosis can cause disc degeneration, nerve
root compression and wear and tear to all structures of the lumbar spine
and surrounding soft tissues.

What Else Causes Excessive Lumbar Lordosis?

When seated, the hips are bent (flexed), the top of the legs are closer to
the torso, and the glutes are mostly inactive. Obviously, this compressed
position can cause the muscles and soft tissues at the front of the hips
(namely the hip flexors) to become tight and restricted. Consequently, when
we begin to stand up, these soft tissue structures are so inflexible that the
hips have a hard time pushing forward to enable us to stand up straight.
This tightness in the front of the hips also prevents the glutes from being
able to do their job and push the hips forward. This pattern of dysfunction
becomes a "which came first - the chicken or the egg?" scenario. Is
excessive lumbar lordosis caused by weak glutes or tight hip flexors? The
answer does not matter. We have to address both variables to enable the
hips to extend so that the lumbar spine does not have to arch excessively
to keep us upright.
Assessing For Excessive Lumbar Lordosis

There is a very easy assessment to evaluate if you or a client has

excessive lumbar lordosis. Ask the client to stand against a flat surface
such as a door or wall. Instruct them to stand with the back against the wall
with heels, buttocks, shoulders and head touching the wall. Place your
hand, palm down, on the wall and slide it behind the lower back (see Picture 1).
Evaluate the space between the lumbar spine and the wall. When
a person has an acceptable degree of lumbar lordosis, you should
only be able to slide your fingers behind the lower back up to, and
in line with the second or third knuckle of your hand (i.e., where
the fingers meet the hand). If the space between the back and the
wall is big enough for you to slide your whole hand or arm
through, then the client has excessive lumbar lordosis. The
greater the space is between the wall and the lower back, the
more extreme the deviation or imbalance is.
If someone has a large gluteal complex and the tail bone is not in
contact with the wall during the assessment, then you will need to
make an allowance for the additional space. Use your best
judgment to determine whether the lumbar curvature is excessive.
Picture 1:
Wall Test for Excessive Lumbar Lordosis

Using the BOSU Balance Trainer (BT) to Correct Excessive Lumbar Lordosis

Where the lumbar spine, hips and tops of the legs come together is a very

important articulation in the body that enables us to stand, walk, run and
play. If there is a weakness or dysfunction in this area, then other muscles
(like those of the lower back) work harder to splint the area and keep it
stable. This is why so many people experience a "tight lower back"; the
lumbar erector muscles have to work twice as hard to make up for
weaknesses elsewhere in the body (e.g., the glutes). By simultaneously
strengthening muscles surrounding the lower back and stretching others,
the lumbar spine muscles can be taught to release and thereby reduce
excessive lumbar lordosis.
The dome shape of the BT makes it perfect for performing exercises for the
lumbar spine while lying in a prone position. It posteriorly tilts the pelvis and
flexes the lumbar spine, reducing tension to the lumbar erectors.
Furthermore, the air inside the BT dome can be used as resistance during
advanced stretching exercises to contract and relax a group of muscles by
pressing into the dome surface. This contract/relax technique mimics the
way muscles react to real life movements and allows the body respond to
specific stretches more effectively. Using the BT in this way makes it an
ideal tool to utilize when trying to alleviate back pain caused by excessive
lumbar lordosis.
Exercises

Gluteal Activation Lift

This exercise "wakes

up" the gluteal
muscles responsible
for extending the
hips. This will help
you or a client get the
hips under the torso
when standing,
thereby reducing the
compensatory
excessive arching of
the lumbar spine.
Movement Directions:
Lie face down with center of the hips over top of the BT dome. Posteriorly tilt the pelvis to decrease the arch in
the lower back. Lift one leg off the ground about 3 to 6 inches without arching the lower back. Return leg to
ground. Perform 10 repetitions on both legs.

Hip Flexor Stretch

The hip flexors are one of the main muscle groups

responsible for flexing the hips. These muscles can become
very restricted and tight in people that have excessive lumbar
lordosis. By contracting the gluteal complex on the back of
the hips while stretching the hip flexors, hip flexor muscles
are released more effectively.
Movement Directions:
Put right knee on the BT dome with the left leg forward and
left foot positioned flat on the ground. Posteriorly tilt the
pelvis by using the abdominal muscles and gluteal complex
to bring the pelvis up and forward (i.e., "tuck the tail under").
Check that the right glute is contracted. Raise right arm to
increase stretch to hip flexors (front of the hip). Maintain
posterior tilt and gluteal contraction for the duration of the
stretch. Hold position for 20 to 30 seconds on each side.

Advanced Version:
After holding the hip flexor stretch for a few seconds, relax glutes and try to pull the knee that is resting on the BT
dometoward the front leg. Keep knee in contact with the BT dome and use it as resistance. So, hip flexors are
now contracting while pushing down and forward into the pliable, dome surface. After a 2 to 3 second
contraction, relax hip flexors and engage glutes again while posteriorly tilting pelvis. This contract/relax technique
will greatly increase the ability of hip flexors to release so the hips can move more easily forward into extension.
Perform the contract/relax sequence for 2 to 4 repetitions on both sides.
If your or your client has trouble keeping the pelvis posteriorly tilted and glutes activated during either version of
the stretch, simply go back to the first exercise (see "Gluteal Activation Lift") to facilitate the required movements
and muscle activations.

Contract/Relax Rectus Femoris Stretch

The rectus femoris is the only quadriceps muscle

that originates from the front of the pelvis. (The
other three quadriceps muscles originate from
the top of the leg.) So, it also acts a hip flexor
muscle. As a result, most people with excessive
lumbar lordosis have a tight rectus femoris
muscle.

Movement Directions:
Same as the "Hip Flexor Stretch," put right knee on the BT dome with the left leg forward and left front foot flat on
the ground. Lift the right foot and hold it behind you in line with the center of the buttocks. Using abdominal
muscles and gluteal complex, "tuck the pelvis under." Check that the right glute is contracted. You should feel a
stretch in the left leg and hip. After holding stretch for 2 to 3 seconds, push down (i.e., "kick") right foot into right
hand to contract the rectus femoris. Hold contraction for 2 to 3 seconds before relaxing the rectus femoris and
pulling the right foot closer toward the butt to increase the stretch. Perform contract/relax sequence for 2 to 4
repetitions on both sides.
If you or your client has trouble keeping the pelvis posteriorly tilted and glutes activated during either version of
the stretch, simply go back to the first exercise (see "Gluteal Activation Lift") to facilitate required movements and
muscle activations.

Toe Touches with Pushdown

The lumbar erector spinae muscles that lie on either
side of the lumbar spine are largely responsible for
arching the lower back. As such, these muscles
become tight and restricted in clients that have
excessive lumbar lordosis. The opposing muscle
group of the erector spinae is the rectus abdominus
which is responsible for flexing the spine. Contracting
the rectus abdominus while stretching the lumbar
erectors facilitates the lower back muscles to release.

Movement Directions:
Stand behind the BT and reach down so that both hands are flat on the dome surface. Bend knees if you or your client has
trouble reaching down that far. Gently push down into the BT dome. This engages the rectus abdominus muscle and releases

the antagonist muscles of the erector spinae. Hold stretch for 3 to 5 seconds, return to starting position and repeat.

About the Author:

Justin Price is co-owner of The BioMechanics, a private training facility

located in San Diego, CA, that specializes in providing exercise alternatives
for sufferers of chronic pain. He is also the co-creator of The BioMechanics
Method which is a method for pain reduction that combines structural
assessment, movement analysis, corrective exercise and life coaching that
teaches trainers how to help clients alleviate chronic pain and improve their
function. He was named International Personal Trainer of the Year in 2006
by the worlds' leading organization of health and fitness professionals,
IDEA Health and Fitness Association, and has helped thousands of people
around the world overcome pain and injury through his methods. For more
information about Justin or The BioMechanics Method go
to http://www.thebiomechanicsmethod.com/.
References:
Golding, Lawrence A. and Golding, Scott M. Fitness Professionals' Guide
to Musculoskeletal Anatomy and Human Movement. Monterey, CA: Healthy
Learning, 2003.
Gray, Henry. Gray's Anatomy. New York: Barnes & Noble Books, 1995.
Kendall, Florence P., McCreary, Elizabeth K. and Provance, Patricia
G. Muscles: Testing and Function. Philadelphia, Lippincott Williams &
Wilkins, 1993.
Myers, Thomas. Anatomy Trains: Myofascial Meridians for Manual and
Movement Therapists. Edinburgh, Churchill Livingstone, 2001.
Price, Justin. "A Step-by Step Guide to Corrective Exercise Program
Design". Lenny McGill Productions, 2008.
Price, Justin. "A Step-by Step Guide to the Fundamentals of Corrective
Exercise". Lenny McGill Productions, 2006.
Price, Justin. "A Step-by Step Guide to the Fundamentals of Structural
Assessment". Lenny McGill Productions, 2006.
Price, Justin. "A Step-by Step Guide to the Understanding Muscles and
Movement". Lenny McGill Productions, 2008.
Schamberger, Wolf. The Malalignment Syndrome: Implications for Medicine
and Sport. Edinburgh: Churchill Livingstone, 2002.
Taylor, Paul M. and Taylor, Diane K. (Eds.). Conquering Athletic Injuries.
Champaign, IL: Leisure Press, 1988.
Whiting, William C. and Zernicke, Ronald F. Biomechanics of
Musculoskeletal Injury. Champaign, IL: Human Kinetics, 1998.