PH101: Running to the Bathroom Again?!

Fiona McMahon PT, DPT

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via Pexels

Bladder problems can be vexing, it may hurt for you to pee even though every test for infection you’ve taken has come back negative. You may find yourself incontinent after surgery or childbirth, or for no reason at all. You may find yourself waking up countless times to go, or needing to memorize every bathrooms’ location in the city because you go too often.

The bladder and the pelvic floor are intimately related and often times problems with the pelvic floor can cause real trouble with the bladder. Pelvic floor dysfunction can cause you to suffer from bladder frequency, urgency, incomplete emptying, slow stream, stream that stops and starts, bladder or urethral pain, or leaking.  By the way, it’s not just a female issue. Men and children can also have these symptoms. Learn from one of our experts, Sarah Paplanus, about how exactly the pelvic floor is related to bladder function and dysfunction, what you can do about it, and about common medical conditions affecting the bladder. Join us for this great seminar on March 26th at 7pm . Register here: pelvichealth101.eventbrite.com

And for those who can’t wait to learn about the bladder, check out our blog on bladder health here!

Location

110 East 42nd Street, Suite 1504

New York, NY

10017

Pelvic Health 101 Spring 2019

Navigating Life with Chronic Pain: Part II

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Fiona McMahon, PT, DPT

Welcome back to our discussion on chronic pain. In our last blog we discussed why one might experience chronic pain and some common missteps and pitfalls that have occurred in our understanding of chronic pain. If you haven’t yet read part one of this blog, I highly recommend checking it out first so you can get the most out of this post. Click here to read it now.

For chronic pain, we have drugs, surgery, mental health therapy, physical therapy, and what is called complementary alternative medicine (CAM), which includes modalities like yoga, acupuncture, and mindfulness meditation. We discussed earlier how some opioids may actually be harmful in treating chronic pain. Unnecessary surgery can also have risks of actually increasing pain post-surgically, because it can change the brain’s sensitivity to pain. Because, for most musculoskeletal conditions, a course of conservative treatment is recommended for a period of time before turning to surgery, we will focus on non-surgical, and non-medical approaches to chronic pain.

Before we dive into specific treatments, let’s talk about what puts a person at risk for chronic pain. We can divide these risks into modifiable and non-modifiable risks. Nonmodifiable risks are situations or characteristics about ourselves that we can not change. They include socioeconomic status, where you live or have lived, cultural background and genetic factors. Unfortunately, we can’t change these things, but things like alcohol intake, nutrition, and obesity are all things we can change and have been generally understood as modifiable risk factors for chronic pain. Now that we have that in mind, let’s explore different approaches for the management of chronic pain.

 

Mindfulness Practice as Pain Management

Have you tried mindfulness practice? I ask this question a lot. When I ask it, I am careful to frame it in a way that does not give the patient the impression that I think their pain is all in their head, but rather, I try and present it as part of an adjunct to the current physical therapy treatment they are receiving from myself or any of the other PT’s at Beyond Basics Physical Therapy, and any other medical intervention they may be receiving.

Mindfulness and mindfulness meditation are somewhat based on eastern meditation practices.  Not all mindfulness programs are the same, but the basic premise is to allow the participant to observe their thoughts, feelings, sensations, and attitudes without judgment. Giving them the opportunity to reframe their thoughts in a positive manner.

It may sound like a small change, but research is really starting to bear out that changing your frame of mind about pain can have some very real results. In a meta-analysis done by Hilton and colleagues, mindfulness programs were found to have statistically significant positive results on pain, depression, and quality of life.

There are a lot of ways you can incorporate mindfulness into your day to day life. Apps for your phone are really helpful. I recommend both Calm and Headspace. I personally like Calm a bit better, but both are excellent. Headspace is a good starter because it breaks up meditation into more digestible nuggets, which can be a good way to start your meditation practice. Calm, as the name implies, is more soothing.  There are also guided classes you can attend in your area if that’s more up to your speed.

Be patient with mindfulness, I definitely suggest giving it the old college try. Stick with it for a week or two. If it isn’t for you, that’s perfectly okay. It’s not a moral failing, or a psychological one it’s definitely a case of different strokes for different folks.

Psychological Intervention

In a study performed by Macrae and colleagues, it was found that patients who engaged in catastrophizing type behaviors experience post-surgical pain at a significantly higher rate. Catastrophizing is envisioning a situation to be far worse than it actually is. A good example for this blog would be a patient with low back pain, jumping to the conclusion that her back pain will prevent her from being able to work and she would end up on the street, secondary to her lack of ability to secure an income. Although this is a possibility, it really isn’t a realistic one and it fails to entertain the possibility of the back pain remaining stable or getting better.

Mindfulness meditation can help with catastrophizing behaviors, but sometimes you need a little extra help. Psychological interventions, like talk therapy and cognitive behavioral therapy, can help you get a handle on these thoughts and address your current loss of function, secondary to pain in a more productive manner. Cognitive behavioral therapy as well as other forms of therapy have shown improvement in pain symptoms and quality of life in adults and has shown even more robust effects in children.

Acupuncture

Acupuncture is an ancient form of eastern medicine that is gaining a stronger and stronger foothold in the States. It has been shown to be effective in managing a number of conditions, and chronic pain is no different. Reviews of acupuncture in scientific literature have found that acupuncture can improve pain and function. The same review found that electroacupuncture had even more robust results for pain and stiffness.

Yoga

Yoga is super hip right now. In fact, it now has its own international day on June 21st of each year. It does for good reason. A consistent and solid yoga program has been shown to improve conditions such as low back pain, myofascial pain syndrome, fibromyalgia syndrome, osteo- and rheumatoid arthritis. It can be a great option to continue to add consistent exercise and pain management into your life.

Physical Therapy and Exercise

Exercise is good for you, even if you have chronic pain. The old way of thinking was to put someone on days of bedrest when they have chronic pain. No more. Evidence has shown gentle movement progressing into more functional training can really help with chronic pain. In fact, the National Institute for Healthcare Excellence’s (NICE) osteoarthritis guideline is  “exercise should be a core treatment… irrespective of age, comorbidity, pain severity and disability. Exercise should include local muscle strengthening [and] general aerobic fitness”(NICE 2014) . Geneen and colleagues found in their review and meta-analysis of the current literature that just receiving the advice to exercise alone is not sufficient to produce improvements in pain scales. That’s where the professionals like physical therapists come in, PTs have the knowledge and expertise to prescribe exercise that is not only safe and functional but hopefully kind of fun. PTs also can diagnose and treat issues such as tissues with reduced mobility and poor alignment to ensure you get the most out of your exercise.

Data show that a prescribed and monitored exercise program by a physical therapist can have good effects on pain symptoms and can help facilitate the production of your body’s own natural painkillers.  Additionally, exercise can help individuals lose weight, which can reduce the pressure on one ’s joints and further improve pain.

Aside from exercise and hands-on work, we can use modalities like Kinesio tape at physical therapy. Kinesiotape has been shown to improve not only pain but decrease trigger points, improve range of motion and improve disability rates in individuals suffering from myofascial pain syndrome.

Conclusion

Chronic pain is complex. Rarely is there a silver bullet that will cure it. Treatment requires a multidisciplinary approach, which has been shown to be more effective than traditional treatment alone. Start small, where you feel comfortable when adding something new into your treatment approach. You will find what works best for you. A good place to start is here at Beyond Basics. Our staff not only has the expertise to treat you from a physical therapy perspective, but they also have the ability to guide you towards other traditional and complementary treatments/practitioners that can help you reach your goal. Your treatment for chronic pain does not have to be and should not be passive, please call and make an appointment today to start your journey.  

 

Sources:

 

Achilefu A, Joshi K, Meier M. et al. Yoga and other meditative movement therapies to reduce chronic pain. J Okla State Med Assoc. 2017;110(1):14-16

 

Andersen T, Vægter H. A 13-Weeks Mindfulness Based Pain Management Program Improves Psychological Distress in Patients with Chronic Pain Compared with Waiting List Controls. Clin Pract Epidemiol Ment Health. 2016;12: 49-58

 

Ay S, Konak H, Evick D, et al. The effectiveness of kinesio taping on pain and disability in cervical myofascial pain syndrome. Rev Bras Reumatol. 2017; 57(2) 93-9

 

Eccleston C, Crombez G. Advancing psychological therapies for chronic pain [version 1]; referees: 2 approved]. F1000 Faculty Rev. 2017

 

Geneen L, Moore R, Clarke C, et al. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews ( Review).  Cochrane Database Syst Rev 2017; 4

 

Hilton, L, Hempe; S, Ewing B. Mindfulness Meditation for Chronic Pain: Systematic review and meta-analysis. Ann Behav Med. 2017. 51:199-213

 

Kamper S, Apeldoorn A, Chiarotto A, et Al. Multidisciplinary biopsychosocial rehabilitation for chronic pain ( review). Cochrane Database Syst Rev. 2014; 9.

 

Macrae W. Chronic post-surgical pain: 10 years on. Br J Anaesth 2008;101: 77-86

 

Mayer F, Scharhag-Rosenberger F, Carlsohn A. The intensity and effects of strength training in the elderly.  Dtsch Arztebl Int 2011; 108(21):359-64

 

Neira S, Marques A, Pérez I. Effectiveness of aquatic therapy vs land based therapy for balance and pain in women with fibromyalgia: a study protocol for a randomized trial. BMC Musculoskelet Disord. 2017; 18(22)

 

Perry R, Leach V, Davies P, et al. An overview of systematic reviews of complementary and alternative therapies for fibromyalgia using both AMSTAR and ROBIS as quality assessment tools. Sytematic Reviews. 2017. 6(97)

 

Saxena R, Gupta M, Shankar N, et al. Effect of yogic intervention on pain scores and quality of life in females with chronic pelvic pain. Int J Yoga. 2017. 10(1): 9-15

 

Singh P, Chaturvedi A. Complementary and Alternative Medicine in Cancer Pain Management: A Systematic Review. Indian J Palliat Care. 2015. 21(1): 105-15

 

     

 

PH 101 Something’s Wrong with my What?

 

You’ve waited and waited, now finally Pelvic Health 101 is BACK!

On March 19, 2019 at 7pm we will be kicking off our fall semester of pelvic health education classes. We have a lot planned this year, so get pumped. In our first class, we will be introducing you to the pelvic floor muscles, where they are, what they do, and how they relate to the health as well as the function of your bowel, bladder, and sexual muscles and organs. We will also be covering how things such as alignment, posture, muscle tone, and nerves can affect your symptoms. This course is a great starting point to help you understand your pelvic floor and pelvic floor symptoms.

Please join us at our office at:

110 East 42nd Street, Suite 1504

New York, NY 10017
Register at: pelvichealth101.eventbrite.com

Here is our line up of this and future classes:

Pelvic Health 101 Spring 2019

 

Do You Speak Pelvic Floor? Guide to Anatomy Part 1: Female Genital Anatomy

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Photo by Dương Nhân on Pexels.com

Fiona McMahon PT, DPT Pronouns (She, Her, Hers)

Do you speak pelvic floor? I do. There is so much going on in the pelvic floor, that unless you are thinking about it every day, it can be difficult to find the right words to describe exactly what you are feeling where. Today we are going to focus on individuals with female anatomy.

Your Genitals: Your 3 V’s

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When we refer to female reproductive organs many times we say vagina to describe the whole kit and caboodle down there. The truth is the vagina is just part of it. There’s much more going on.

Vagina: The vagina is the passageway from the uterus to the external world. It can expand to accommodate a penis, toy, or allow for the passage of a baby. It can do this shape-shifting because it has folds called rugae, which can stretch out like an accordion to allow the vagina to stretch as needed. Neat, huh? We call the opening the introitus, but we may also interchange it with simply, “vaginal opening”. Either is fine. The introitus can be an area of pain with penetration, so in Pelvic Floorland, we use that term a lot.

Vulva: The vulva is usually what people are referring to when they say vagina. The vulva encompasses all the external genitalia. Including the labia majora and minora (the lips), clitoris, vagina, and urethra.

Vestibule: The vestibule is the area in between the labia minora (small lips) and vagina. This is another special area, that can become painful with certain conditions

Other Vulvar Components

Urethra: This is the exit of the urinary system and is where pee comes out. Between the anus, vagina, and urethra there are three holes “down” there.

 

clitorisClitoris: This part is pretty cool. The clitoris provides sexual sensation. Did you know it averages four inches in length! Externally we can only see a small bit of it. We call that part the glans. Covering the glans, is the clitoral hood, which helps to protect it. Most of the structure of the clitoris is not viewable from the outside. Branching off the glans and traveling underneath the labia are the bulbs of the clitoris and the cura. These elements are erectile and fill with blood during arousal.

Labia Majora: The labia majora are the outer pair of lips when looking at the female vulva. They protect the delicate tissue of the vulva.

Labia Minora: The labia minora are the smaller set of lips and are contained within the labia majora. The labia minora can come in all different shapes and sizes and still be completely normal. Some women have long labia minora which extend past the labia majora, while others may have shorter labia minora which stay tucked within the labia majora. Variation is normal between women.

Having the words to describe where the pain it can be useful to both your pelvic floor physical therapist as well as your doctor. Stay tuned for future additions of “Do you speak pelvic floor?” where we will discuss male genital anatomy as well as the muscles of the pelvic floor itself.

Pelvic floor physical therapists are specialists in this area and have been added in the last decade, to urological and gynecological guidelines as the first line of treatment for various pelvic and sexual pain and weakness disorders.

ACOG Guidelines on Pelvic Pain:

https://www.acog.org/Patients/FAQs/Chronic-Pelvic-Pain?IsMobileSet=false

AUA Guidelines for Pelvic Pain

https://www.auanet.org/guidelines/interstitial-cystitis/bladder-pain-syndrome-(2011-amended-2014)

Yeast the Inflammation Beast

 

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Fiona McMahon DPT, PT

You are what you eat. Trash in equals trash out. You can’t exercise yourself away from an unhealthy diet. These adages are often on my mind as I make my food choices because of the myriad health professionals who have taken time to come to our practice to tell us how we can improve our own and our patients’ health by taking more time to look at what we are consuming in our diet. Lately, many of these clinicians have been focusing on candida overgrowth and diet, which can contribute to pain and inflammation conditions.

What we eat can directly affect the bacterial and fungal makeup of the gut, AKA the gut microbiome. The gut requires a certain level of good bacteria to help us digest what we eat. Over time a poor gut microbiome can affect how efficiently the gut works. The function of the gut goes beyond just digesting food but also is vitally important for the production of neurotransmitters, which help to spread messages within the brain and throughout the whole body.  The microbiome also plays an important role in our hormones and immune system. When the microbiome of the gut is not balanced, it is called dysbiosis.

One of the most common culprits in gut microbiota dysbiosis is candida, (Yeast!). Candida is a naturally occurring inhabitant of the body and when it’s at appropriate levels, it doesn’t tend to be noticed, but anyone who has experienced a yeast infection knows that if this little guy is allowed to go unchecked, it can do a lot to make you miserable. Besides plaguing women with itching, burning vulvas, a yeast overgrowth may cause many other ailments.

Science has pointed to the role candida can play in contributing to chronic and inflammatory conditions. In one study by Kumamoto in 2011, candida overgrowth was associated with delayed healing of inflammatory lesions and was associated with pro-inflammatory cytokines (chemicals) and increased incidence of inflammatory bowel disease like ulcerative colitis and Crohn’s disease.

Yeast overgrowth can also affect the bladder along with over colonization of Saccharomyces (another form of fungus). In fact, yeast and Saccharomyces were found to be higher in women during a flare of interstitial cystitis than when their symptoms were low.

Yeast is not the only organism that can get out of balance and affect our bodies in harmful ways. There are many other players that can get out of balance. Some signs of an altered gut microbiome is a history of allergies, eczema, or repeated fungal infection.

 

What to do?

It all seems pretty dire, right. How do you control who is colonizing your gut, when you barely have enough time to make it to the gym after work? There are a few simple steps you can start with.

Avoid antibiotics, unless your doctor thinks you need them.

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The medical community has become a lot more aware of the dangers of over-prescribing antibiotics from their perspective, but it is important to keep in mind that a powerful antibiotic can wipe out good bacteria and bad bacteria in one fell swoop. If the good guys in your gut are reduced, the bad bacteria have a better chance of taking over. Take antibiotics only when recommended. Keep in mind antibiotics will not help treat viruses like the flu, they can only treat bacterial infections.

Modify your diet

close-up-cooking-cuisine-629093.jpgIncrease your consumption of good fats (omega 3’s) to help reduce inflammation.

Food high in omega 3’s includes flax and hemp seed/oils, fish (the fishier the fish, usually means more omega 3’s, for example, herring is higher in omega 3 than a milder fish like snapper). Also, reduce your consumption of processed foods which can increase inflammation levels and eliminate simple sugars and fried foods. If this is only minimally successful, try a gluten and dairy free diet.  

If simple changes are not helping consider seeing a professional

Find a naturopath, functional or integrated MD, or nutritionist who can investigate more fully whether or not you have SIBO (Small intestinal bacterial overgrowth), candida overgrowth, or other gut microbiome disorder. Or perhaps you are lacking certain ingredients, vitamins or mineral.  These professionals can tailor a diet and medication regimen to help return your gut microbiome to tip-top shape.

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Fiona McMahon is currently seeing patients at our Midtown Location

 

If you have questions about orthopedic, pelvic, or sports physical therapy, BBPT is offering free phone consults to those living in the greater NYC area for a limited amount of time!

Beyond Basics Physical Therapy

212-354-2622 (42nd Street Location)

212-267-0240 (William Street Location)

 

 

Sources:

Kamamoto C. Inflammation and gastrointestinal candida colonization. Cur Opin Microbiol. 2011;14(40): 386-391

Be a Bladder Whiz! Healthy Bladder Tips for All!

Fiona McMahon PT, DPT and Amy Stein PT, DPT

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So we busted some myths in our last Pelvic Floor Myth Buster Blog, where we discussed whether or not holding your pee causes urinary tract infections. If you haven’t gotten a chance, check it out here. People living with bladder conditions, like pain, hesitancy, frequency, post void dribbling, and incontinence know that an unruly bladder can be really disruptive. In this blog, we are going to take some time to discuss some practical tips and tips you can employ right now to tame an unruly bladder. Many of these tips come from Amy’s book, Heal Pelvic Pain, available here.

So what are we working with?

Male or female, we all have the same basic structure of the bladder, with a few exceptions. Here’s what everyone has in their lower urinary tract.

Detrusor Muscle: Forms the body of the bladder and is responsible for squeezing the bladder to empty its contents. It spends most of its time relaxed in order to allow for bladder filling.
Trigone Muscle: Forms the neck of the bladder, and is a powerful sensory organ. When the trigone stretches in response to the filling of the bladder, it sends a message to the brain that it’s time to pee.
Internal Urethral Sphincter: Smooth muscle (involuntary) which seals off the exit of the bladder and allows for continence.
External Urethral Sphincter: Striated or voluntary muscles which also seals the exit of the bladder.
Urethra: This is the tube that leads out of the bladder and is the pathway for urine into the outside world.

Sex differences:
Many men have a prostate. The prostate is a sex organ and is responsible for keeping the semen at the right pH to fertilize a waiting egg. It wraps around the urethra and lives just under the bladder. It also provides a mechanical buttress or support for the bladder, lessening the load on the pelvic floor. Because of its proximity to the urethra, problems with the prostate can cause problems with the bladder. An enlarged prostate, which can be a part of aging, cancer, or infection, will restrict the flow of urine out of the urethra, resulting in a weak stream, painful, burning urination, and difficulty urinating (however, the same thing happens with tight pelvic floor muscles with or without prostate involvement, which makes bladder issues super confusing).

Another important difference between guys and gals are the respective length of their urethras. Male urethras are a lot longer than female urethras. This is one of the reasons women are more prone to bladder infections. In a female, bacteria have a lot easier time making the trek to the bladder because of the shorter urethra.

So how do I help my bladder?

Posture

If you are having problems fully emptying your bladder or you have post void leakage (dribbling following going to the bathroom) consider your toileting posture. People with bladder issues should sit on the toilet (even dudes), to allow the pelvic floor muscles to relax and allow the bladder to fully empty.

Stretch!

Here’s a great stretch from Amy Stein’s book, Heal Pelvic Pain available here in hard copy and digital download.

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Here’s how to do the stretch

1. Lie on a firm surface-on a mat on the floor or on a hard mattress. Bring your knees up to your chest and then let them relax and rotate out to the side so that they flare outward. Use your hands to hold your knees in this position.

2. Stretch as you deep-breathe for six to eight breaths. Do not bounce, and do not push hard. Just gradually and progressively fill and empty your lungs.

3. Hold the stretch for 30 to 60 seconds. Do three repetitions, two to four times a day. 

Bladder Training

If you have bladder frequency or leakage with urge now is the time to try and train your bladder to hold more urine. Keep in mind you should start treatment to address pain with physical therapy and in certain cases, with medication, to allow you to be successful with bladder training. I always tell my patients to start their bladder retraining at home, where a bathroom is available to take the stress out of possible leaks or not being able to find a bathroom. Start by simply waiting to go to the bathroom 5-10 minutes past your first urge to urinate. Use behavioral strategies, such as deep breathing and pelvic floor drops, mindfulness, gentle stretches, distraction, and others. If you don’t have to go after 5-10 minutes, Great! If you do, go to the bathroom. As waiting 10 minutes becomes easy, stretch your time to 20 minutes and so on until you are able to go 2-3 hours in between urination.

 

Diet

This can make such a huge difference. My boss and Beyond Basic’s founder, Amy Stein, writes in her book Heal Pelvic Pain, that we should really try to get eight 8-ounce glasses of water a day, and try to finish them at least two hours before bed, to reduce your chance of needing to go at night. We call this symptom, nocturia.

As far as things we chew on, many foods can irritate the bladder, but not all foods bother everyone in the same way. It’s all about experimenting to find your triggers. Some common foods include food high in sugar, spices, acid (like tomatoes and citrus), tannins (like in wine). John’s Hopkins has a really good list, which you can access here. This list is totally overwhelming at first blush, but remember my bladder irritant may not be yours. Typically you will know shortly after eating the offender, on the same day. So the best thing to do is to try the suspected bladder irritants one at a time to see if you can identify a triggering food or drink.

Manage Constipation

The bladder does not have a lot of space, where it lives. In front of it lies the pubic bone, behind it lies a vagina for some of us, the rectum, and then the sacrum bone. The bones sandwich the bladder like bookends. Although these bones have some movement, which we treat, it’s not enough to allow for much more space for the bladder if your rectum is full of poo from being constipated. With an overfilled rectum, the bladder gets squashed against the pubic bone. With a squashed bladder, you may not empty it as well, feel urgency, or even experience bladder leakage. Therefore, avoid constipation at all costs! We advise our patients to drink more water and eat more soluble and insoluble fibers.

 

Physical Therapy Can Help Cure!

Physical therapy is considered a mainstay and the number one treatment for musculoskeletal causes of bladder disorders and bladder and urethral pain. Expert pelvic floor physical therapists (PFPTs) are clinicians who can find the cause of your bladder issues and provide you with a customized plan that will provide you with the best results possible. PFPTs can work to relax spasmed muscles, treat constipation contributing to bladder issues, improve your toilet posture, reduce tightness and shortening of tissues around the bladder, abdominal and thigh region that can contribute to bladder dysfunction, as well as strengthen weak muscles. If you are experiencing bladder issues, please come to see us. There is so much we can do to help!

fiona2018amy2016

If you have questions about orthopedic, pelvic, or sports physical therapy, BBPT is offering free phone consults to those living in the greater NYC area for a limited amount of time!

Beyond Basics Physical Therapy

212-354-2622 (42nd Street Location)

212-267-0240 (William Street Location)

Pilates Move of The Month with Kierstin! Lat Pull and Triceps

Kierstin Elliot

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Goal: To IMPROVE Posture!

Exercise: Lat Pulls and Triceps

Set up: Lie facedown on the box with naval pulled up towards the spine, chin tucked in with neck lengthened (as if you are holding a tangerine under your chin), glutes engaged, and legs extended. Pull yourself to back bars of the reformer and hold onto the poles with both hands. Use one blue spring for resistance.

Execution: Inhale to lengthen elbows, exhale to bend elbows.

Focus: The main muscle group targeted here are the lats. Think about pulling down from the armpits while the elbows bend and extend. This action will help stabilize the shoulders, keeping them out of the ears. Also, focus on releasing the upper traps and lengthening the back of the neck. The more work we can get from underneath the shoulder blades, rather than above, the better!

Importance: Improves posture! Strong back extensors lead to better posture, especially in this day in age where phones and computers are constantly pulling our shoulders forward and weakening our backs. Incorporate a few lat pulls into your routine and feel taller almost instantly!

Modifications: To make it easier, drop tension to one yellow spring. To make it harder, place a squishy ball between ankles and add hamstring curls or pulses between lat pull sets!

Here I am, demonstrating the lat pull!