Pelvic Floor Therapy for Better Gut Health

Intro:

Welcome to Dr. Ruscio, DC radio, providing practical and science-based solutions to feeling your best. To stay up to date on the latest topics, as well as all of our prior episodes, make sure to subscribe in your podcast player. For weekly updates, visit DrRuscio.com. That’s DRRUSCIO.com. The following discussion is for educational purposes only and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking with your doctor. Now let’s head to the show.

Dr Ruscio, DC:

Hey everyone. I have a treat for you today. If you have been struggling with distension, this puffed out abdominal wall, and you can’t figure out why. Well, this is the second podcast on which we investigate what muscular component might underlie this abdominal distension. Now, to clarify, the first thing one should do is improve their IBS or other myriad of gut health symptoms; if you have constipation, if you have diarrhea, if you have gas, you’re not sleeping well, right? This whole constellation of symptoms that accompany digestive symptoms in general, plus extraintestinal manifestations like depression and insomnia. Start there. But there’s clearly a subgroup for whom they’ve addressed those things and they feel pretty good, yet they still have this abdominal wall distension. So if you’re someone who is otherwise in pretty good shape, but you’re still having distension, this was a follow-up podcast building upon the podcast we had previously with Jandra Mueller, who is a physical therapist, and we discussed pelvic floor.

Dr Ruscio, DC:

Today I spoke with Dr. Deborah Bowes, who’s also a PT, and she really opened my eyes to the importance of the rib cage and how people can have adheased or immobile rib cages. And if you think of your core kind of like a […] a balloon, right? A rectangular type-shaped balloon. If you don’t have the ability of the ribs to expand, this can lead to over-expansion of other areas. Now, one of the things this can do is push the contents downward into your pelvic floor and this can cause pelvic floor weakness or pelvic floor hyper contraction. But you can also have things push outward, forward on the abdominal wall, abdominal wall inhibition, therefore looking like you’re a few months pregnant, even though you are doing all the stuff correctly.

Dr Ruscio, DC:

And what can be the antidote to this is helping to free up the mobility of the rib cage. This was probably the most insightful piece I took from this conversation. We also talked about the pelvic floor and a few other facets of how all of these muscles—the abdominal wall, the diaphragm, the pelvic floor, and the spinal erectors or back stabilizers—work together to prevent distension and prevent dysfunction and pain. But the rib cage piece was the most interesting. And as you’ll hear in the discussion, part of this is probably more problematic for those who have been taught to meditate and belly breathe, as I was, not understanding that if you’re overly focusing on pushing out your abdominal wall and not allowing the ribs to naturally expand as you breathe, as they should, over time you can lead to an immobilized ribcage and thus this problem. So this, again, was a great conversation.

Dr Ruscio, DC:

And Deborah Bowes is a doctor of physical therapy. She graduated from Columbia. She’s been in practice for over 33 years. She is also a Feldenkrais provider and [this] just was a wonderful interview. And I hope you enjoy the discussion with her as much as I did. And reminder, if you are enjoying the podcast, please shoot over to iTunes and leave us a review. Okay, here we go to the show.

Dr Ruscio, DC:

Hey, everyone. Welcome back to Dr. Ruscio, DC Radio. I am here today with Dr. Deborah Bowes and we are going to be discussing the topic of abdominal distention. And this is something that I’m sure some patients and some clinicians are struggling with. And Deborah is well knowledged in this area. And I’m really happy, Deborah, to have you here to expand on this topic of feeling like your stomach is expanding.

Deborah Bowes:

Yeah. Thank you. Yeah. You know, a lot of people have this issue of the abdominals being dysfunctional. But it sounds like it’s a lot more of an issue with people with IBS or other GI issues like that.

Dr Ruscio, DC:

That poses a good question of there’s probably just some increased awareness of your abdomen in general, when you’ve had the feeling of pain or pressure or bloating or constipation. So part of this, too, might be just increased attentiveness and perhaps some over reporting due to that. But certainly bloating is one component of IBS. Definitely.

Deborah Bowes:

Yeah. Yeah. I mean, I think, you know, with sitting so that we all—and here I am sitting right talking to you on zoom and I assume you’re sitting—when you sit you don’t really need your abdominals very much. And they don’t really work very well when you’re sitting. So, you know, how can you activate them so that you have the synergistic response that you need? Because the abdominals, they don’t work alone. You know, we think sometimes like, oh, muscle groups, they work alone, but the abdominals work with the pelvic floor. So if there has been you know, if there’s some kind of constipation or some kind of a pain in the abdomen, pain always inhibits muscle work. So, I mean, it’s complicated. If you had another kind of more specific question it might help me get going in the way that would be useful for you.

Dr Ruscio, DC:

Well, let’s maybe start with what you’re seeing in clinic, just so I have bit of a better understanding, and maybe I can frame some of my questions through that lens.

Deborah Bowes:

Yeah. Well, […] when I got my doctorate, my area of research was women’s pelvic floor. Especially for incontinence, right. Urinary incontinence. And what I found out when I did my research program was that improving the function of the pelvic floor and the coordination of the pelvic floor working as a system with other muscles, improved things like constipation, improved things like sexual function, improved digestion—you know, which is a kind of euphemism, like people don’t come to me for digestive problems but in our initial interview they’ll often mention, “oh, I have digestive problems.” And so it was really kind of surprising to me that improving the pelvic floor function so people weren’t leaking urine when they didn’t want to improved these other things. And a lot of it was being able to get the pelvic floor and the abdominals to work as a coordinated system.

Deborah Bowes:

So for example, if you pull up your pelvic floor now—which is easy to do when we’re just sitting here talking you know—and you contract it, like you’re trying not to pass gas or something like that, you should feel your abdominal muscles also contracting. And that’s not true for everybody, right? That whole coordination system has been disturbed for some reason. And I don’t really know all the reasons, but I think some of, a lot of, it is sitting too much. When you sit, you don’t need to use your abdominals. And when you sit, there’s a lot more pressure going down. So that’s one part. The other part is that in order for the abdominals to contract completely so that you have a full stimulation of the pelvic floor, you also need the thoracic space to change, right? That you need to be able to have the movement of the rib cage. And I think a lot of people who have pain—and that’s one of my main areas of work is with people with pain—the rib cage is very stiff and that’s kind of, it seems like a response to having pain. Like you just don’t want to move very much and you keep your rib cage stiff. So if your rib cage is stiff, then the abdominals don’t have the same flexibility because the abdominal muscles are attached to the lower ribs. So it’s a system that uses the thoracic space, the abdominal space, and the pelvic floor, and they all need to be working together, including the diaphragm, respiratory diaphragm.

Dr Ruscio, DC:

So this is, I think, referred to as the inner unit—or at least I believe it was, gosh, way back in the day Vladimir Yanda who may have referred to this as the inner unit—the pelvic floor, the diaphragm, I guess the spinal rectors and the abdominal wall are all on this kind of connected neurological loop, so to speak. Is that somewhat akin to what you’re describing.

Deborah Bowes:

I haven’t heard that term before. I mean, I call it always the, you know, the breathing space, right? That you, for the breathing to happen, you have to have a totally flexible internal volume space. So you have to have movement at the top of the space, which is, you know, the upper ribs at the base of the throat and the clavicles, just under the clavicles. You have to have movement in the bottom of the breathing space, the pelvic floor. And then you need movement in all directions of the diaphragm, the sides of the rib cage, and the back of the rib cage, and the soft belly.

Deborah Bowes:

And the role of the abdominals in that system and the pelvic floor is to help maintain the correct intra abdominal pressure, right? Which I’m sure gets really challenged by having pain there and things like that. So then you have this inhibition of the abdominals working, which […] can do two things: it can either make the pelvic floor work too much and people get a very tight pelvic floor, or it can also inhibit the pelvic floor. So my work with people is how to really establish the synergistic and normal relationships between these muscle groups, right, which is called the core. I mean, the core is all in the fashion now but it’s much more than just thinking about a lot of people think the core is, “oh, tighten up your abdomen,” but that’s not what is going to help you to have your abdomen working well.

Dr Ruscio, DC:

And that was my next question, which is people hear the word “core” and they think of, you know, gym, work hard, that whole sort of…Which is fine. But what you’re describing sounds to me more like this subtle coordination of all of these muscles on the team.

Deborah Bowes:

That’s right. That’s right. I know. People are, if you hold your abdomen in and pull it in all the time, that’s not going to help you either. You have to have the synergistic response. So I could describe a few aspects of that. If that would be helpful.

Dr Ruscio, DC:

That would be great.

Deborah Bowes:

Okay. So one is, there’s a length, right? Muscles all have a resting length. And when they’re in their normal resting length, they’re able to shorten (which is contraction) or lengthen (which is relaxation). And one way to know if the abdomen is at its normal resting length is to think about the distance between your pubic bone, the top of your pubic bone, and the bottom of your breast bone, the bottom of the sternum and the bottom of the ribs. And if you are standing and you make that distance too long, then the abdominal muscles are at a disadvantage and they’re just not going to be able to work very well. Likewise, if you crunch that part or shorten the pubic bone to the sternum length, then the muscles are going to be at a disadvantage. So it’s related to your posture, right?

Deborah Bowes:

How do you sit? How do you stand? Are you using your skeleton? Which is a big thing that I work with. Are you using your skeleton to stand so that your muscles are available for whatever action is needed? So a lot of people stand with too much curve in their low back, right? Too much lumbar lordosis. And if you have that, then you’re going to have a long distance between the pubic bone and the sternum. If you stand or sit, too, with a really flat back and you flatten the back and you remove the curve from the lower back, then your abdominal muscles are going to be shortened a lot and the whole pressure of the organs on the pelvic floor is going to shift a little bit towards the back. The pelvic floor organ’s weight on the pelvic floor helps to stimulate a little bit of that tonicity, right, the little bit of that muscle work in the pelvic floor to keep everything where it’s supposed to be.

Deborah Bowes:

So posture is a big thing. Posture is probably really significant for getting your abdominal muscles in a position where they can work, where it’s possible for them to work. So that’s one thing I work on is, what is the distance between your pubic bone and your sternum? And it’s easier for people to notice something that’s in the front of them than in the back of them. The back of them is kind of an unknown zone. The other thing is the ability…You have to have flexibility of the rib cage and the spine so that the volumes can change internally. And so many people have incredibly stiff rib cages. You know, stress will tighten you, you’ll change your breathing and make your rib stiffer. Pain will tighten your breathing and make your ribs stiffer. Emotional trauma, all kinds of traumas, you’ll hold it in your ribcage.

Deborah Bowes:

So there is a movement, you know, my training for all of this is, comes from Feldenkrais method. And in Feldenkrais method, we have a process of learning movement called “awareness through movement.” And there’s a particular movement that I found very useful, and we in Feldenkrais call it the “seesaw movement” of the abdomen and the chest. So the seesaw movement is if you pull in your belly now and expand your chest, right? So you can pull in your belly and expand the chest, not just forward and backward, but also in width. So you pull the belly in and you expand the chest in all directions, then you flatten the chest, narrow the chest, and let the belly out. And generally I would suggest that people do this lying down because when you’re lying down, your posture’s probably going to be better than when you’re sitting and standing trying to do it. And you’re not really concerned with being upright, you’ve kind of eliminated the need to adapt to gravity in the upright position. So the seesaw movement seems pretty simple, but for people who have a stiff rib cage and any kind of dysfunction of the pelvic floor, it’s a real challenge for them to get this. So I can tell you a few more details about how to get there if you’d like.

Dr Ruscio, DC:

Yeah, no, this is great. I have a few follow up questions that I want to try to tie in for people but this is…Well, let me ask one right here because I think this might be pointing to the seesaw.

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Dr Ruscio, DC:

One of the things I remember back in my college years when I was studying a lot of corrective exercise rehab was the importance of belly breathing, or sometimes known as diaphragmatic breathing. But one of my colleagues, Mike Nelson, pointed out to me (and I’m partially paraphrasing his statement) but that if people are overly focused on belly breathing they tend to over breathe from their belly and inhibit or reduce the amount through which they breathe through their chest and thus expand their rib cage. And that seemed like such a foreign concept to me because it was beaten into my head people are stressed out and everyone breaths into their chest, because they’re so stressed and no one’s breathing through their abdomen. And then that totally turned everything on its head, but it kind of made sense when I thought about it more. And it sounds like you might be seeing some of this and this might be an observation of overly belly breathing that has caught wind to some extent and effects a decent number of people.

Deborah Bowes:

I’m totally with your friend on this one. So, first of all, I have a little bit of a problem when people say, you know, “do diaphragmatic breathing.” All breathing includes the diaphragm. All breathing includes the diaphragm. You cannot breathe without your diaphragm. You’re going to, I mean, you’re going to use such effort that you die if you don’t use your diaphragm. I have found, so I’ve done a lot of work with martial artists and with meditators—those are two of my communities—and you know, in martial arts there’s this thing about sinking your Chi and breathe into your belly. And people can do that and really get like this huge belly movement, they inhale, the belly moves up, they exhale, the belly moves back. And how do they do that? They stiffen the chest, right?

Deborah Bowes:

So you have to think of the breathing space as one volume, like a balloon, right? If you squeeze one end of the balloon, the other end’s going to move a heck of a lot. Likewise if people have a very contracted abdomen. They pull their belly in, they don’t ever let it move, then they’re going to have all this chest movement. 80% of breathing, right, happens by the action of the diaphragm. The other 20% happens from the action of the ribs. And the ribs, they suck your lungs open, right? There’s this little sticky fluid between the inside of the rib cage and the lungs themself. So as the ribs widen, it sucks the lungs open and air rushes in. Okay. So the movement of the ribs is in a widening direction. And you can feel that as you’re breathing. Even in sitting, you can feel that as you inhale you can feel the ribs widen so that you might have some more pressure on the inside of your upper arms, right, and also you can feel that around your waist.

Deborah Bowes:

That the way the rib cage is made, the two pairs of ribs that are the lowest are called the floating ribs. And that’s where the movement begins with breathing. Like those ribs widen a little bit, boom, they stimulate the diaphragm to contract, boom, it goes flatter and down into the lower abdomen and then the whole breathing space is available. So your friend saying that, yeah, people can over emphasize wanting to get this movement in their abdomen, which reflects a big movement of the diaphragm. And if you stiffen your chest, you’re going to get a huge belly movement, but you don’t have free breathing. I think it’s also important for people to know that the diaphragm, only the excursion of the diaphragm is very small. It’s only a couple of centimeters.

Deborah Bowes:

And if you’re running full out the movement of the diaphragm downward to pull the air in, if you’re running can be maybe, you know, four to six centimeters, but in normal breathing like we’re doing in our conversation or reading or working, the diaphragm only moves down one to two centimeters. Right. And what happens though? It gets the widening of the rib cage. And that widening of the rib cage requires flexibility. And if you can do different movements to get the rib cage to move, and then your breathing will just be more balanced without too much happening in movement of the belly and inhibition of the movement of the rib cage. This is complicated.

Dr Ruscio, DC:

[…] But it’s also fascinating. This has me wondering how common is it that you will see ribs that are immobilized? Because I’m just picturing, as you’re saying this, someone who complains of abdominal distension, who maybe is also doing stress management and watching the videos, “breathe into your diaphragm, breathe into your belly,” and they’ve been doing that for years and they also, at the same time, had IBS, had abdominal pain, had bloating. And now the bloating and the abdominal pain in the bowels, let’s say, are all regular but they’re still noticing their belly sticks out. And I’m picturing these contracted ribs and the only place to fill the cavity, so to speak, is by pushing out where the abdominal wall. So how common is this?

Deborah Bowes:

Oh my God. It’s a kind of joke that I make with anybody who comes to see me. It’s always the ribs. […] If you have back pain, your ribs are stiff. If you have foot pain, your ribs are stiff. If you have neck pain, your ribs are stiff. Like the ribs, people think that the it’s called a cage, right? So it even gives that image like of something that’s stiff and doesn’t move. Where in Scandinavia, it’s called the rib basket. And the rib cage could be thought of more like a Wicker basket that you, it has a shape, but you can deform and change the shape by pushing on one side or the other. So that’s pretty much the major of work that I do. I call it boingability, your ribs need to be boingable. Like if you have a dog or a cat and they’re lying down and you press on the side of their rib cage, it is amazing the amount of movement that they have. Or children. Adults don’t have that kind of movement. So the Seesaw breathing, I can explain a little bit how people might be able to try it and be safe doing it.

Dr Ruscio, DC:

Please. I’m sure people would love to give that a try. And I also want to ask you as a follow up, other techniques that people can use to try to soften up their ribcage. […]

Deborah Bowes:

And it’s a hard thing to do to try to describe it all. But you know, that’s kind of my work too, is using verbal description with Feldenkrais to describe the movement. But one really quick and down and dirty thing people can do is hold their breath. Which of course, everyone tells you don’t hold your breath. But if you exhale all your air out, stop your breath until you want to breathe in again—not so you’re going to turn blue—but you just breathe out, exhale, hold (stop the breath we call it, not hold the breath but stop the breath), and then wait until the carbon dioxide changes in your bloodstream and you have to breathe in. And when you breathe in to feel the widening expansion of the ribs.

Dr Ruscio, DC:

And this pairs nicely with something that we’ve discussed on the podcast in the past, it’s traditionally known as tummo breathing, recently popularized by Wim Hoff, who does the hyperventilation, full exhale, hold your breath for as long as you can, and then, sure, yeah, when you go to breathe it’s a big, I guess if anything’s going to expand you, that gasp of air would probably be it.

Deborah Bowes:

Yeah. It’s a great way to do it. Also, if you feel anxious and you can’t seem to catch your breath, exhale all the air out. And then you’re really using the physiology, right, you’re really using the buildup of carbon dioxide. But I think the thing, I don’t know about what Wim Hoff does with that, but the way I use that is to have people become aware of the movement of the ribs widening. So that’s the big thing. It’s not like you just gulp air, but you breathe out, you stop the breath for a few seconds, and then when you breathe in to think that you can expand sideways. For women, I think, you know, you can feel that you can expand sideways into the bra strap, right? There’s women always have this kind of thing around the middle of them telling them “don’t move there, don’t move there.” But for women it’s really easy—or men can imagine that they, or even put your hands around the, just below your breast so that you feel when you inhale this incredible vitality of getting wider. So that’s a really quick thing that I teach people to do to be able to start to sense the widening of the ribs.

Dr Ruscio, DC:

That’s great.

Deborah Bowes:

Okay. So then to do Seesaw breathing, first, you lie down comfortably. You can have your knees bent or long, and then you start to you put your hands on your belly, below your belly button, right? So the lower belly. And you start to feel the movement of the breath of the belly, moving the belly. And some people think the air is going into the belly, but it’s not your air going into the belly, it’s the movement of the diaphragm massages the organs, right? And the organs get a little bit pushed forward. So you first you feel that normal movement. And for most people breathing in will be, there’ll be an expansion of the belly, and breathing out there’ll be a flattening of the belly. So you do that a few breaths. You breathe in, you expand, feel the expansion. Don’t push it, just feel expansion of the belly, breathe out, feel the contraction or the letting go of that, the flattening of the belly. Then you do the same movement of the belly as you exhale. So now you change the breathing pattern, you exhale, you feel the belly expanding as you exhale, you inhale and you pull the belly in. So this begins the Seesaw. You exhale, expand the belly, inhale, pull the belly in.

Deborah Bowes:

Okay. So then the other part is the chest. So you can put your hands on your chest and you can feel the movement of the chest. And for most people, as they breathe in there would be some movement of the chest. So as now you go back to being aware of the belly, right? So you’re breathing in, the belly expands, the chest can get flatter. You breathe out, you pull the belly in and expand the chest. You breathe in, the belly goes out, you flatten the chest, you breathe out, you pull the belly in and expand the chest. I find that for many…So that’s the Seesaw. One goes down…

Dr Ruscio, DC:

It’s great. By the way, I’m doing it as you’re saying it and it’s so opposite to what I’ve been kind of inculcated into doing, which is breathing in and feeling the belly go out. But I can already feel it. It feels intuitively like something that my body needs and probably it’s because my ribcage, also. It’s, you know, it seems like the stats here are probably in favor of me having a somewhat stiff rib cage and it feels like, yeah, this is something my body is saying, “yes, this is good.”

Deborah Bowes:

Right. Now, the thing is, so you don’t want to breathe like that. You just want to use this exercise as a way to stimulate the movement. So you can also do it holding the breath. So if you breathe this or you do on an inhale, you breathe in, you hold the breath, and then you push or allow the belly to go out. Then you pull the belly in while you’re holding the breath. And notice the change in the chest that as the belly goes out, the chest goes flat. As the belly pulls in, the chest gets bigger. And I remember doing this as a child in the summer, drinking lots and lots of water and then holding my breath and squishing my diaphragm up and down like that in order to slosh the water in my belly. It was one of our big activities of the summer.

Deborah Bowes:

So it’s kind of a thing that everyone can feel. But so again, you don’t want to use that for breathing. You just want to use that as an exercise to get your breathing space available and then allow your breathing to include widening. Because normal breathing will include the belly getting a little bigger and the ribs getting wider and then as you breathe out everything gets narrower and flatter. So that would be the second stage after you can do the seesaw breathing of these four parts: the chest getting expanding in all directions and flattening and narrowing in all directions, the belly expanding in all directions and flattening in all directions. So then you just change whether or not you’re breathing in or breathing out with that. I mean, I make it seem maybe simple, but it’s kind of complicated for most people to do. And it can take a long time for someone to be able to feel that they can do the seesaw.

Deborah Bowes:

If you’re lying on your back, when you do this, you’ll feel movement against the floor, right? You’ll feel the ribs moving against the floor. The ribs are attached to the spine in the back. They come around the sides and then they’re attached to your breast bone in the front. Some people don’t know they’re attached to the spine, right? They are. So if you move your ribs, you’re going to have movement around your entire body. And each rib, except for the top two or three, the two. Each rib is attached to two vertebra. So if you get movement of the ribs, you get movement of your vertebra, and that’s the link to back pain.

Dr Ruscio, DC:

Would you think that hanging from a pull up bar…I know the shoulder girdle mobility will be enhanced by this. I’m assuming it also has some decompression and elongating impact on the ribcage. Is that something that would also be worthwhile for people to experiment with if they had a pull up bar?

Deborah Bowes:

Yeah, I don’t know. I mean, the people I work with couldn’t do that. I work with people who have very, very complicated and complex medical conditions. So hanging on a bar would just not work. But I mean, I think what would work better than that would be being on your hands and knees and lowering your head to the floor. So you’re on your hands and knees and then you keep your pelvis higher than your head. And again, people with glaucoma, stuff like that, they can’t do this. But if you’re young and you can do that, you’re on your hands and knees, you lower your head, your butt stays up in the air, and start to notice how you breathe then. And what will happen then is that usually the inhale is very short and the exhale is long. What will happen when you’re upside down is that the inhale will start to be long and the exhale will be shorter. So being…it’s like the awareness, being able to feel that. I mean, I think, yeah, I like that position a lot for being able to feel the movement. I mean for getting shoulder girdle movement and the shoulders to be more free…and they have a different kind of exercise for them.

Dr Ruscio, DC:

Well, sure. And I don’t want to derail us too much from the central concept so I’ll keep us on the ribcage just for a moment longer because through the course of our conversation, starting to piece together a few observations, not only of patients I work with, but also of myself. Mike Nelson (the gentleman I mentioned earlier) he did a physical assessment on me a couple years back and he remarked, now that I’m thinking back and you’re helping me reignite some of these memories, that my rib cage didn’t move enough when I breathe. So, you know, probably suprise, surprise given some of my earlier incorrect overly diaphragmatic breathing training that I went through.

Dr Ruscio, DC:

One of the things though that I’m wondering, and I’m assuming this is probably a pseudo assessment one can do, he did just some kind of trigger point assessment on my sternum and just dug his fingers into my sternum where the sternum kind of meets the ribs and holy hell did that hurt. And he said, “yeah, you’ll see this area of the sternum rib interface become lit up with trigger points when someone doesn’t have enough mobility in their rib cage.” So if someone wanted to do a self-assessment is this one, or are there any other self-assessments people could do to try to figure out if they have an inhibited rib cage?

Deborah Bowes:

Yeah, that’s interesting because certainly where the ribs attached to the sternum in the front of our body, those points can be really sore. They’re also acupuncture points. I don’t do trigger point work, but they’re acupuncture points. And any place that you don’t move stores lactic acid, all those kind of byproducts of cell metabolism, because it’s not being moved out. So that could be one thing he is touching there. But I would think it’s really putting your hands on your lower ribs around your waist, and can you […] push your hands apart and as you inhale, right? So you take a big inhale, can you get wider?

Dr Ruscio, DC:

And you’re saying go to the bottom part of your ribs, almost kind of like cup upwards with your hands?

Deborah Bowes:

Yeah. A little bit where you get ticklish, where you’re ticklish. If you touch those ribs there, and sometimes that area is really sore and you push in. So I have this thing that I do a lot with children with breathing problems called the “boa constrictor.” So I put my hands around their ribcage and I follow them in exhalation and I follow it in exhalation and in exhalation even stiff ribs move in. And then ask them to try to breathe in with me resisting them getting wider. And it’s very hard for them to breathe in. It usually makes kids laugh, but it’s also another way to find, can you really expand? You know, I remember this chigong demonstration I saw once where a guy, a chigong practitioner, he had someone wrap his ribcage in wire, right? And then he took this huge inhale and broke the wires from around his ribcage to show the strength that he had. His Chi was really strong. So I don’t know about the trigger points, but certainly the feeling, can you feel yourself moving, getting wider?

Deborah Bowes:

Another way to get that side to side movement of the ribs is in sitting in the chair and lifting…Say you’re sitting in the chair and lift the right hip away from the chair and bring it towards the right shoulder so that you spin to the side a little bit. Right? And if you’re lifting, say you’re lifting the right hip and bringing the right hip and the right shoulder together, put your right hand on top of your head and help yourself bend a bit to the side so that your right elbow goes down towards the floor. And that’s going to shorten the right side of your rib cage. And then the left side of the ribcage will open and get longer. So you can do that a few times. Here’s some nice side bending with the hand on top of the head and you stay with the face forward. It’s like you’re moving between two walls. You’re not trying to go forward or backward. You’re just bending sideways where you close the ribs on this one side, you open them on the other. And then you can do a few on the other side too. You close the ribs. So you put your left hand on top of your head, you have your left elbow out to the side, you lift the left hip towards the left shoulder, the whole left side shortens. And doing a few of that can get you that movement of the rib cage that then will be used for breathing.

Dr Ruscio, DC:

So along with the ribs, we have the pelvic floor, the abdominal wall, and obviously the spinal stabilizer, spinal rectors. In that grouping, you’re finding that the ribs are the most common area of dysfunction. Is that correct?

Deborah Bowes:

Yes.

Dr Ruscio, DC:

Okay. Just wanted make sure. Okay.

Deborah Bowes:

If the ribs don’t move, it’s going to put too much pressure on the internal organs, the pelvic floor’s going to be blown out, the abdominals aren’t going to be able to work properly.

Dr Ruscio, DC:

So this is where someone might have, let’s say a tight pelvic floor, an inhibited abdominal wall, this might be just one example of how this manifests. But it sounds like the downstream or second order effects of the tight ribs can vary, but it’s going to end up with some unfavorable condensations.

Deborah Bowes:

Something’s going to happen. Yeah, exactly. So, you know, then the other thing is like, people do crunches, right? Crunches are so bad for you. You want to be able to move, like contract the abdominals, but not in a crunchy kind of way, really fast with your hands behind your head and your elbows straight out to the side. You want to be able to fold the spine, make the spine curve and be bent so that you can, what the abdominals do is they pull the rib cage, the ribs towards the pelvis, towards the belly button and the pubic bone. That’s the important movement, right? Not just, not just crunching up, up, up, up, up. Crunching up can really stiffen the ribcage and also put too much pressure into the abdominal wall. And you get the diastasis of the splitting of the rectus abdominis. And you also get too much pressure into the pelvic floor.

Deborah Bowes:

So I teach people to do abdominal exercises lying on the back. Your knees are bent, you interlace your hands and bring them behind your head. But you bring your elbows forward so you can cradle your head and carry the weight of the head with your arms. And if you do that, you have to move your rib cage down. The sternum moves down towards the belly button. Then you can do whatever sit up kind of thing you want to do, but you’re not damaging the structures, you’re not damaging the pelvic floor, and you’re not going to hurt your abdominal muscles, but you’re going to get them tonified.

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Dr Ruscio, DC:

With the transverse abdominis, this is something that I remember coming up quite a bit, you know, again, back in my years of exercise rehab and essentially pulling the belly button inward toward the spine. I’m assuming that you have people doing some degree of this because of inhibition of the TVA. Okay.

Deborah Bowes:

Yeah, that’s totally great because you know, people can feel if they’re activating the transverse abdominis by bringing their hands just inside the bones of the front of the pelvis, the anterior superior iliac spine (the ASIS). If they put their fingers and dig in there and pull in, they can feel whether or not they’re activating there. But more importantly, the pelvic floor will respond. It will contract, or should, in a normal situation. The pelvic floor will also contract and you’ll feel it pulling up as you contract the deepest layer of abdominal muscles that transverse abdominis. So I generally find that men can use the contraction of the pelvic floor to activate the abdominals. Women may not be able to do that. Women are able to more use the abdominals to activate the pelvic floor. And I think that’s due to the anatomy and women’s history of having birth, PEEP babies or not. Stuff like that.

Dr Ruscio, DC:

Yeah, I’m doing this right now. So for people, if you find your hip bones, and like you were saying, you slide kind of frontward of the hip bones, there’s a little drop off.

Deborah Bowes:

Towards the belly button, yeah.

Dr Ruscio, DC:

…fleshy drop off. Right. And then if you do something like a kegel or pretend like you’re going to stop yourself from peeing, you should feel a little bit of tension there and things kind of pucker inward as the, the TVA engages. And if you do that and you notice nothing, well, that’s one indicator that your abdominal wall, or at least one muscle of the abdominal wall, the transverse abdominis is a little bit asleep. Right?

Deborah Bowes:

Yeah. Yeah. I mean, I, you know, we just get these dysfunctional patterns that could have been with us for years and years, starting from early. I think a lot of it begins with toilet training, right. Where kids are told, go pee, go pee. And they don’t have to. And so they push and then the whole system gets trained to work like that. And then everything gets out of whack.

Dr Ruscio, DC:

And maybe to bring it back to distension, so I’m not sure if this is one of the primary complaints the patient population you’re working with is in possession of, sounds like maybe there’s more, chronic pain or other dysfunction. But to any extent, are you seeing people who are complaining of distension or are you seeing distension improve from the work that you do? You mentioned it and you kind of hinted at it earlier where people say they’ll have better digestion and their constipation may get better. But with this distension specifically, is this something that you’re seeing improve from the work that you’re doing?

Deborah Bowes:

Well, I have. I mean, it’s never been related to like the kind of organic dysfunctions, like IBS or distention. But certainly people start to notice like, oh my God, my belly is flatter. Especially if someone’s had abdominal surgery or done a lot of coughing and stuff like that. So I do see that, yes. Once people start to gain awareness of the whole breathing space, get the ribs to move, are able to feel the rib cage being pulled down by the abdominals, they get the distance between the pubic bone and the sternum as part of their awareness, and they can widen with breathing. Yeah, I definitely see improvement in the distension. And I mean, one of the signs of someone’s abdominals not working is that the belly sticks out way too much. It’s not related to being fat. Right. It’s just related to the lack of appropriate muscle coordination and use.

Dr Ruscio, DC:

Exactly. And this is actually, I would argue that the population that complains of this the most because they’ll say, “I’m fairly thin yet I look like I’m three, six months pregnant.” And they sometimes come in with pictures or send us pictures and ah, I believe you. But I think they’re so distraught about it. And you know, the first thing I think of as a clinician centered around gut health, more from an internal perspective is okay, overgrowth, dysbiosis, inflammation, high level of gas production, let’s resolve the IBS, and then usually you’ll see these things improve.

Dr Ruscio, DC:

But there’s a subset for whom they don’t, even though everything else is pretty much improved. You’ll still see this distended abdominal wall. And that’s why I wanted to try to tie this all together because I was thinking there had to be a muscular component to it, but it’s probably not quite as simple as, “do planks for 30 seconds, three sets, three times per week.” I mean, sure, that may help. And if someone’s inactive, any exercise, to some extent, is going to be better than nothing. But in that presentation, probably a need for a little bit more of a therapeutic approach of exercise. And I think you hit the nail on the head, especially you know, I guess the rib head we should say. Because that seems like an area that is probably overlooked. And I didn’t realize the extent to which the ribs were implicated. So yeah, this has been really insightful.

Deborah Bowes:

Good. You know, there’s some really, I just pulled this book out of my shelf, a nice book that by a French woman, who’s an anatomist. And I think she’s a physical therapist too. I don’t know if you’re familiar with it. It’s called “No Risk Abs.”

Dr Ruscio, DC:

No.

Deborah Bowes:

“No Risk Abs.” And then the subtitle is “A Safe Workout Program for Core Strength,” and it’s by Blandine Calais-Germain. She also wrote, you might be more familiar with her book, “The Anatomy of Movement” or “The Anatomy of Movement Exercises.” She has a beautiful book about the pelvic floor, women’s pelvic floor. She has a beautiful book about breathing. And “No Risk Abs” has really interesting full body movements that really are totally congruent with everything that I’m saying. That’s why I like it so much.

Dr Ruscio, DC:

That’s great. That’s fantastic.

Deborah Bowes:

But it’s a cheap little paperback. It’s only, it’s got great photographs in it to follow, it’s like 160 pages. I would recommend that book for you or to any of your readers who are interested, or listeners who are interested.

Dr Ruscio, DC:

That’s fantastic.

Deborah Bowes:

That uses breathing. That is very safe. I mean, she talks about protecting the discs and all kinds of stuff like that.

Dr Ruscio, DC:

And that’s a good lead into my next question, which was, is there anywhere, if people wanted to consult with you, are you doing consulting or that you would want to point them to?

Deborah Bowes:

Yeah, so yeah, I’m only doing online consultations now and I closed my private practice. Thank you, COVID, very much. But they, yeah, they can contact me at my email and that is [email protected]. So [email protected], or you can just Google me Deborah Bowes. And I’m pretty easy to find that way.

Dr Ruscio, DC:

You know, we also had on the podcast maybe six months ago or so Jandra Mueller who is a pelvic floor focused PT, and she mentioned and clarified for people that you can get pretty far with a virtual consult. So just maybe if people were saying, “well, don’t I need to have hands on?” Could you maybe speak to any reservation that they have about that?

Deborah Bowes:

Yeah, it’s really great. I mean you can put your camera on so I can see what you’re doing. I can direct you verbally through the movements. I mean, I’m very happy with the quality […] I’m surprised. I thought it would be like, oh second best. But I’m really happy with the quality that I can feel good about with my people who call me. And a lot of people come to see me online for just one or two sessions to get them started in the right direction because there’s so many questions. And there’s so many variables and I can often direct them to books or recordings and things like that. I mean, I have a number of recorded courses about pain. I’m thinking of doing one about the abdominals now, but nothing about that yet. I have pelvic floor courses, pain, touch for self help.

Dr Ruscio, DC:

Right. And I just want to piggyback on that because I think it can be easy in pretty much any area to focus on the point that hurts or the point that’s bothering you and you might think, well, my abs stick out, it’s got to be SIBO or it’s got to be weak abs so I’ll do crunches. Or maybe you go on YouTube and you find, you know, pelvic floor exercises, but it could be that your pelvic floor is hyper contracted or over contracted. And this is where—and I’ve been guilty of this myself so this is not a dig on our audience—but sometimes you know enough to be dangerous, as the old saying says. You know enough to put effort into the wrong thing.

Dr Ruscio, DC:

And this is where just checking in with the clinician, to your point, can get you set on the right path. And then you can go forward and do some therapy, whatever you got to do to improve yourself. But what you don’t want to do is go double down on maybe making a imbalance worse. Like let’s say someone just, you know, heard about, well, abdominal pain and bloating can be a derivative of weak pelvic floor. And here’s, you know, Johnny YouTube and he’s got a great tutorial and it’s probably a well done tutorial on how to do pelvic floor exercises, but you may not need that. So again, this is where I think checking in with the clinician. “Here’s what I have going on.” And then they can direct you and put a plan together for you.

Deborah Bowes:

Yeah. That’s a really good point. I mean, I think the biggest thing that people do that damages or is not helpful for their abdomen, is that they cannot pull it in all the way they just can’t do it. You know, their ribs don’t move to help them pull the belly in the pelvic floor doesn’t respond. And so they they’re doing work with the muscle, but they’re actually pushing the belly out. And I’m pretty careful, like before when we were talking, I almost said “push the belly out,” but I think of more allowing the belly to expand so that you can pull it in. And one other exercise I teach people to do is if they’re sitting in a chair and if you lift your arms up over your head and you act like you’re going to chop a piece of whatever, chop a log (which I’ve never done), but if you do that chopping motion, you’ll feel your belly pull in. That’s what you want to feel. You want to feel the belly pulls in. It pulls in when you lift something. It pulls in when you use your arms. It pulls in when you pick up your coffee cup. It pulls in when you grab your computer. That if that’s not happening, your belly’s going to stick out. That means it’s not working well.

Dr Ruscio, DC:

Yep. No, these are great little mini assessments for people to do. And Deborah, this has been a fantastic conversation. You really help put another aspect of this unit of muscles or anatomy onto my radar, the ribs. And I’m going to make some notes of this so that when we’re in the clinic, we can advise people on this and probably refer a few people your way. And for our audience, if you’re one of these people who is struggling here is a good resource to get checked out to see, if maybe you’re doing a lot of stuff right, presumably getting enough sleep, drinking enough water, eating a healthy diet exercising, but you could be caught in this dysfunctional cycle. And so glad to have another resource to point people to in case they need it. And again, Deborah, this was just fantastic. I really appreciate you taking the time.

Deborah Bowes:

Thank you, Michael. It’s a pleasure talking to you. I have a website…

Dr Ruscio, DC:

Oh please. Yes.

Deborah Bowes:

Yeah. I have a website. It’s FeldenkraisSF, again, FeldenkraisSF.com. So people can find me through that too. I’m pretty easy to find on the internet.

Dr Ruscio, DC:

Awesome. Well, expect a few people knocking on your door, so to speak.

Deborah Bowes:

Great. Thank you. It’s a pleasure talking to you. Yeah, it’s really, really interesting. It got me you know, reading some research studies that I hadn’t been aware of, so.

Dr Ruscio, DC:

Perfect.

Deborah Bowes:

Great.

Dr Ruscio, DC:

Great stuff. Thank you, again.

Deborah Bowes:

Okay. Thank you bye bye.

Dr Ruscio, DC:

Bye.

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