My Back Hurts & You Want Me to Squeeze My What?!?

Surprised young woman with hand in front of her mouth

First of all — this is a real thing.

In fact, physical therapists (PTs) have been telling their patients to do this for years. Well, maybe they don’t use words like coochie or cojones, but they have been telling their patients to do Kegels since the 1990s. This is based on research that shows this is the best way to engage certain “core” muscles deep in the stomach and back, muscles that are essential for back protection.

What is a Kegel?

Kegel exercises diagram

Kegel (/ˈkeɪɡəl/, /ˈkiːɡəl/) — The name given to an exercise that involves squeezing or lifting of the pelvic floor, just as you might do to stop your pee mid-flow. This applies to both men and women. The name “Kegel” comes from Arnold Kegel, an American gynecologist who invented the exercise and first described it in 1948.– Bliss’ Translation

If you have been to a gym or watched TV late at night, you have probably heard that you must strengthen your core. The core being the large stomach and back muscles we can all see — think Usher without a shirt.

While these muscles are important (and nice to look at) there are muscles that you can’t see that can play an even larger role in protecting your back: the transversus abdominis muscle in the belly and the multifidus muscle in the back. Together they are sometimes referred to as the “inner core” or the “real core.”

The transversus is the deepest of the abdominal muscles. It is large and flat and pretty-much spans the entire abdomen (see image below left). The main job of this muscle is to hold your guts in and to keep your trunk steady during movement. You can feel it engage when you cough or sneeze.

Transversus abdominis muscle (TrA)

The multifidus muscle is the deepest of the large back muscles. Located on either side of the spinal column, with little finger-like projections, it checks movement at each level of the spine (see image below right).

About 20 years ago, researchers in Australia began to find that the multifidus and transversus tended to be atrophied (smaller) and less active in people with low back pain. These muscles seemed to go to sleep in the presence of pain and they stayed asleep, sometimes for years. This is a phenomenon called “reflexive inhibition” and it occurs with other muscles in different parts of the body too, like the knee (I’ll save that for another blog, though).

So, why do these muscles shut down? No one really knows, though there are some theories that involve energy conservation and our reptilian brain. What is known for sure is that when a muscle is inhibited like this, it atrophies and becomes visibly smaller/thinner, and that can be seen with medical imaging like an MRI or ultrasound.

Multifidus muscle
Multifidus muscle along the spine

This seems to be true even when all the other muscles in the back and belly are normal, if not extra-normal. In other words, these muscles can be puny even in well built people like athletes or professional dancers when they have back pain.

Australian researchers, Paul Hodges, Julie Hides, and Jan Gildea looked at professional dancers recently and confirmed this. In their paper, published last month in the Journal of Orthopaedic & Sports Physical Therapy, they reported that the dancers in their group with back and/or hip pain had smaller multifidus muscles than those without pain, even when other postural muscles were equal. They also saw that the multifidus muscle was smaller on the same side of the body as their pain.

So, if being a professional dancer or working out like an athlete doesn’t strengthen these muscles, what does?

The Kegel exercise turns out to be the perfect way to wake up these sleepy muscles. Researchers and practicing PTs alike know this because they have seen it. Using ultrasound technology (like a sonogram used to see a baby in her mother’s belly), they can see the multifidus and the transversus contract right along with the Kegel in real time.

The Kegel is particularly useful because when done in a relaxed position, the multifidus and transversus will contract alone. That is, they contract while the other postural muscles in the stomach and back stay relaxed.

Doing this exercise in isolation, like this, seems to be an essential first step to rehabilitating these muscles. One way to look at it is that when the multifidus and transversus are not pulling their own weight, the surrounding muscles get really good at compensating for them. So, to really get them going again, they have to be trained alone at first.

The good news is that once the muscles are awake, though, they get back to work in concert with the rest of the trunk muscles. This means that you don’t have to do Kegels for the rest of your life, though it doesn’t hurt and if you have back pain again you should start them back up.

What is the best way to do a Kegel?

1. Lay flat on your back with your knees bent.

  1. Take a deep breath and relax. Place one hand on your belly. This hand is going to make sure that your belly stays soft and relaxed while you do the Kegel.
  2. Now, squeeze your cootchi or, if you are a man lift your cojones, in the same way you would to stop your pee mid-stream. Hold for a slow count of ten. Don’t tighten your belly, tuck your pelvis, or squeeze your butt. With this exercise, less is more.

Note: Many people say the exercise gives them a “creepy feeling.” This will get better over time.

  1. Hold each Kegel for ten seconds, breathing normally. Repeat ten times. Rest as long as you like between reps. It can take some time to figure out how to do the exercise and breath normally at the same time.
  2. Repeat once in the morning and once at night.

Once you have mastered this, you will have officially kick started your inner core and you can start doing the Kegel in lots of other positions, like sitting at your desk or standing at the sink. You can then move on to doing Kegels any time, any where, especially since no one will know you are doing them. Just remember, as Snow White and the Seven Dwarves might sing (if they read this blog), “Kegel while you work…la la la la la la la.”

The science behind the blog:

Gildea J.E., Hides J. A., HODGES P. W., (2013). Size and Symmetry of Trunk Muscles in Ballet Dancers With and Without Low Back Pain. journal of orthopaedic & sports physical therapy. 43(8):525-533

Hides J.A., Belavý D.L., Cassar L., Williams M., Wilson S.J.,Richardson, C.A. (2009) Altered response of the anterolateral abdominal muscles to simulated weight-bearing in subjects with low back pain. Eur Spine J.18(3): 410–418.

Hodges, P.W., Sapsford, R., Pengel, L.H.M. (2007) Postural and respiratory functions of the pelvic floor muscles. Neurourology and Urodynamics, 26(3):362-71.

Smith, M. D., Coppieters, M., Hodges, P.W. (2007) Postural response of the pelvic floor and abdominal muscles in women with and without incontinence. Neurourology and Urodynamics, 26(3):377-85.

Kader D.F., Wardlaw D., Smith F.W., (2000). Correlation Between the MRI Changes in the Lumbar Multifidus Muscles and Leg Pain. Clin Radiol. 55(2):145-9.

Hodges, P.W., & Richardson, C.A (1996). Inefficient muscular stabilization of the lumbar spine associated with low back pain: A motor control evaluation of transversus abdominis. Spine, 21:2640-2650.

Hides, J.A., Stokes, M.J., Saide, M, Jull, G.A. (1996). Multifidus recovery is not automatic following resolution of acute first episode low back pain. Spine, 20, 2763-2769.

Ng, J., & Richardson, C.A. (1994). EMG study of erector spinae and multifidus in two isometric back extension exercises. Australian Journal of Physiotherapy, 40:115-121.

Hides, J.A., Stokes, M.J., Saide, M, Jull, G.A., & Cooper , D. H. (1994). Evidence of lumbar multifidus muscle wasting ispsilateral to symptoms in patients with acute/subacute low back pain. Spine, 19:165-177.

Rantanen, J.,M. Hurme, et al. (1993). The lumbar multifidus muscle five years after surgery for a lumbar intervertebral disc herniation. Spine 18:568-574

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