pregnancy

As we approach International Women’s Day on March 8, I would like to share a few observations regarding gender and health made over the past three decades of teaching posture. 

Does gender affect back pain?

Back pain and the posture distortions behind it are very democratic—people of all ages, activity levels, geographic locations, and gender are affected by cultural postural distortions. That said, some modern posture guidelines and expectations are gender-specific, and some of them affect women disproportionately. We will discuss posture guidelines for men another time. In this post, I’d like to address some of the messaging that is relentlessly addressed towards women and girls, and the consequences of this messaging. 

In our society back pain affects people across all social groups. Different groups can be affected disproportionately in particular ways. Image from Pexels

Fashion and posture

I think it’s fair to say that women are more subject to fashion and to its extremes than men. 

Conformity to fashion, and rebellion against it, has women, more than men, stuck with uncomfortable, biomechanically unhealthy, and impractical garb. Examples are: 

• High heels that deform the feet and prevent mobility
• Tight clothes that distort body alignment and restrict range of motion
• Eating lightly to be thin and retain teenage proportions 
• Encouraging women and men to unduly judge women by their appearance

 
Most fashion role models for women encourage an emaciated, weak physique, a tucked or forward pelvis, internally rotated legs, and forward shoulders and head. Images from X, Pixabay

One of the most damaging distortions perpetuated by the fashion industry is tucking the pelvis. This pose exploded onto the scene in the 1920s, and has been a look ever since. Perhaps a reaction against corseting and “stiff” pre–World War 1 fashions, it encouraged a relaxed but slouched posture, with a tucked tail, rounded shoulders, and forward head. 

This 1920s portrait shows the new “relaxed” posture which translates as tucking the pelvis, rounding the back, and jutting the head forward. (Photo of Eileen McCahon, New Zealand). Image from Unsplash

While tucking the pelvis is a problem for everybody vis-à-vis spinal health, when it comes to pelvic organ health, women have much more to lose! In addition to the rectum, which is at risk of prolapse in all genders, women are additionally at risk for a prolapsed uterus, vagina, and bladder, as well as urinary incontinence. Women also have a more vulnerable pelvic floor due to the stresses of pregnancy and childbearing. The wider female pelvis is also at higher risk of instability, with this effect amplified by the pregnancy hormone relaxin.

An anteverted pelvis (left) gives optimal support to internal pelvic organs and the connective tissues that hold them in place. A tucked pelvis (right) makes us more vulnerable to organ prolapse.

Pregnancy and the nursing of babies can bring with it yet more musculoskeletal challenges. The extra weight requires additional strength and resilience throughout the body. For example, weak abdominal muscles cause the spine to be pulled into a compressive sway, dangerously loading the spinal discs and nerves. While nursing and caring for an infant, it takes a strong inner corset and posture wisdom to lift, hold, and carry an infant well, or these actions too can cause significant damage. 

Several of our teachers, including myself, came to the Gokhale Method for solutions to pregnancy-related trials. These past blog posts reflect some of our experiences: Esther Gokhale and Julie Johnson, Esther Gokhale and MommaStrong, Esther Pohl, Janine Farzin. 

This young mother in Burkina Faso (left) is using her inner corset to remain tall, stable, and relaxed while carrying on her head with her baby on her back . Gokhale Method teacher Esther Pohl (right) found that traditional posture principles really work, and carried her second child much more comfortably.  

Outside of the physiological and anatomical considerations mentioned above, in my experience women are also disproportionately raised to be “good girls” and people-pleasing, and to conform to current social norms. Postural examples would be: 

• Craning the neck forward to signal empathy and attentiveness
• Turning the legs inward to be “modest”, which forces the pelvis to tuck, cultivates internal rotation of the legs and feet, and compromises circulation to the lower body
• Sitting and standing in ways that diminish size and surrender space, such as rounding the shoulders and stooping.

Body language and fashion norms for women often result in posture that diminishes their size, space, and sometimes, self-confidence. Image from Pixabay

Unless we have been subject to protection from poor posture by exposure to a strong and healthy postural tradition, we are likely to have acquired at least some of these disabling habits. When women set out on a journey into healthy posture it often awakens indignation as they gain awareness of the reasons for some of their aches and pains. This reaction can act as a useful spur to positive action. A healthy strategy going forward is about repairing the situation—and celebrating being an active woman enjoying a pain-free body. 

Aline was able to start making many empowering posture changes during her weekend Gokhale Foundations Course, and continues her journey of discovery.  

On March 12, 12 p.m. PST, my colleague Julie Johnson and I will be offering a special free online workshop called Women’s Empowerment Through Posture. Join us to discuss the issues raised by our many thousands of female students over the years—some of them mentioned here, and many more besides. 

We are excited that this workshop is the kick-off for a brand new Women’s Empowerment Through Posture campaign. For those joining our free online workshop live we will also have a special offer and will be unveiling a brand new offering! 

Best next action steps 

If you are new to the Gokhale Method, get started by booking a consultation, online, or in person with one of our teachers. 

You can sign up below to join any one of our upcoming FREE Online Workshops…

Podcasts are one of my favorite media. It’s hard to reimagine a time when you couldn’t take your pick and enjoy their entertaining and compelling content. Over the years I have been invited to be interviewed for many podcasts about the Gokhale Method®, and for this blog post I would like to introduce you to three of my favorites, which I hope you will now enjoy if you haven’t done so already.

My Body Odyssey

A recent interview was for the Fluent Knowledge series, My Body Odyssey. Fluent Knowledge introduces their audience to experts who convey knowledge on important issues, topics, and trends in wellness, neuropsychology, media, and politics. It was a pleasure to discuss the root causes and solutions of modern back pain with them. 

Artwork by Emily Crocetti for Esther Gokhale podcast with My Body Odyssey for Fluent Knowledge

For the podcast I introduced Fluent Knowledge to my friend and advocate of the Gokhale Method, Dr. D.J. Kennedy, Professor and Chair of the Department of Physical Medicine and Rehabilitation at Vanderbilt University Medical Center, who you can hear in the brief audio clip below.

The podcast is an elegant production, weaving the Q&A between the interviewers and myself, along with Dr. Kennedy’s commentary and that of back pain contributors, in a well-constructed and informationally rich blend that is easy to listen to. I particularly like that it covers both the Gokhale Method’s respect for the ancient roots of healthy posture, and our engagement with modern science and technology to confirm and augment the efficacy of our teaching.

My cohosts were Brittany Thomas and Robert Pease, and it turned out that Robert was one of the 80% of Americans who suffer back pain. Hearing back from Robert recently, I am delighted to share that he is already experiencing substantial improvements by implementing Gokhale Method techniques: 

Fluent Knowledge also featured a complimentary blog post with an interesting timeline of posture pioneers which you can find here.

Screenshot from fluentknowledge.com

Listen to the My Body Odyssey podcast:  on Apple on Spotify  

Hypermobility Happy Hour

My second podcast pick goes back to June 2020 and a talk with Kerry Gabrielson, founder of the Hypermobility Happy Hour. Kerry’s podcast grew from her own experience, and is dedicated to discussing hypermobility conditions, including Ehlers-Danlos Syndrome (EDS). 

Artwork from Hypermobility Happy Hour

We talked about how COVID-19 had necessitated further development of our online teaching, giving rise to our Elements course. Kerry was quick to appreciate its potential for widening access to the Gokhale Method and enabling a greater impact on our runaway U.S. back pain statistics with a relatively low-cost, noninvasive approach.  

One of the challenges we both appreciated was the roller-coaster of raised and then crushed hope that many back pain sufferers ride. Musculoskeletal problems can be especially unpredictable for people with hypermobility conditions, and stabilizing the joints through healthy postural alignment, and knowing the techniques to get there, are key.

I was pleased to offer HHH listeners some practical posture guidance—how to engage their inner corset, the column of muscles in our torso that protects our spine from compression and jarring:

Since the podcast, we have been able to update Kerry on the launch of PostureTracker™, our 2-sensor Bluetooth wearable and app. I am particularly excited about its applications for people with hypermobility. For example, they can be particularly prone to hyperextension in the knee joint in standing, walking, and running, but PostureTracker™ can catch this in real time, giving users visual, audio. or vibration feedback and allowing them to self-correct. Kerry and I look forward to future conversations.

                 
PostureTracker™ will alert wearers when they inadvertently hyperextend their knees (a.). With Gokhale Method techniques and know-how they can then correct this habit and return to a safe range of motion (b.), preserving healthy knee joints.

Listen to the Hypermobility Happy Hour podcast:  on Apple    on Spotify    on SoundCloud

So Frickin’ Healthy 

My third podcast is Back in the Game, a podcast for So Frickin’ Healthy, hosted by Megan J. McCrory and Danna Levy Hoffmann. For this podcast I was joined by Gokhale Method teacher Julie Johnson.

Artwork from So Frickin’ Healthy

I experienced a serious episode of back pain while pregnant—in Julie’s case, her back pain started after giving birth to twins. If your posture is not as healthy and your structure not as robust as it might be, the extra stress of pregnancy or birth can be “the straw that breaks the camel’s back.” 

It is worth saying here that in pregnancy our structure has to contend not only with the additional weight of a baby (or two), but also the effect of increased relaxin. Relaxin is the hormone which helps loosen muscles and ligaments in the pelvis so it is ready for birthing, but it can also bring greater mobility throughout the body. This can leave a pregnant woman especially vulnerable to back and joint issues, including flat feet. And if you already have hypermobile joints, you can all too readily find yourself in extra trouble. 

Fortunately, as I, Julie, and the many Gokhale Method Alumni can testify, by aligning our bodies well and avoiding the pitfalls of poor posture it is possible to get “back in the game,” active, and pain-free once again.

Listen to the So Frickin’ Healthy podcast:  on Apple    on Spotify   

Spread the word

If you would like to let friends and family know about the Gokhale Method approach to back pain, please share our podcasts. 

Catch our new podcasts in the “In the News” section of our free newsletter Positive Stance (subscribe). You can find all our podcast recordings here on our website. 

Best next action steps for newcomers

If you would like insight on your posture, consider scheduling an Initial Consultation, online, or in person.

You can sign up below to join one of our upcoming FREE Online Workshops. . .

Why is it not a routine practice for podiatrists to observe their plantar fasciitis patients’ stance and gait? Let’s consider how a broader approach that considers the way people stand and walk could improve treatment outcomes for plantar fasciitis patients—and also help prevent recurrences.

The main factors in foot health

In my experience, the top three influences on the health and performance of the human foot are the architecture and orientation of the foot and leg, the way a person stands, and the way a person walks. Of course, shoes also play a big role in foot health (you can read more about this here), but while truly healthy posture can do a lot to compensate for poor shoes (extreme styles excepted), the best of shoes cannot make up for poor posture, stance, and gait. 

These African fishermen all show healthy external rotation in their legs and feet. Pexels

Internal leg rotation mechanically disadvantages our structure, and offers poor support to the feet and legs. Pexels

What gives rise to foot problems

We frequently work with people whose foot problems have been created or made worse by poor postural habits. While there can be a genetic predisposition to foot problems, frequently, what appears to be a genetic trait is actually the result of mimicking those closest to us—the person with bunions has replicated their parent’s poor posture or poor shoe choices which, in turn, caused their bunions. 

Let’s consider what can go wrong in the feet when standing. In a common modern stance where the hips are parked forward relative to the feet, the body’s weight lands excessively on the smaller, more delicate structures of the midfoot and forefoot. The ligaments that bind the bones in the feet together may no longer be able to do their job in preserving the shape and healthy function of the foot. 

 
How you stand affects your weight bearing and the forces going through your feet. This man has parked his pelvis forward, shifting his weight off his heels and onto the more delicate forefoot. Pexels

Plantar fasciitis

Plantar fasciitis is one common problem that results from faulty weight distribution overwhelming the foot ligaments. Other problems may include calcium deposits (bone spurs) at points of stress, nerve damage such as in Morton’s neuroma, inflammation such as in sesamoiditis, and stress fractures. 

Plantar fasciitis affects the strong, fibrous attachment that runs from your heel bone to the ball of your foot, supporting the medial and lateral arches. The ligament-like tissue becomes irritated and inflamed, making it painful to bear weight or use the foot, especially on initial standing. 

Plantar fasciitis occurs when the connective tissue on the sole of the foot becomes inflamed. Pexels

Treatment of conditions such as plantar fasciitis is often limited to local solutions. A common treatment for plantar fasciitis is to stretch the plantar fascia with exercise, manual therapy or by wearing night splints. This has some protective merit as it reduces the degree of tearing that can occur under the body's weight. Another measure that can offer relief is foot rolling with iced water bottles. 

After observing the shape of the patient’s foot, a podiatrist might prescribe an orthotic. The most conservative treatment with orthotics simply reflects the shape of the foot and aims to prevent further deterioration of the foot’s structure. Somewhat more sophisticated orthotics are designed to exert corrective forces on the foot, such as lifting a sunken arch. 

A root-cause solution is to learn how to stand and walk well. Instead of band-aid stretching and orthotics to compensate for weak muscles and poor body mechanics, this approach will lead to a strengthening of the foot muscles, an overall shortening of the foot, and appropriate weight-bearing on the foot at all times. When students come to us with orthotics, we encourage them to think of the orthotic as a training device that reminds the foot to practice what it needs to do, as well as being a prop for as long as they need it to do some of the lifting for them. 

Once the foot muscles have learned to grip around the contours of an arch support the foot can go beyond resting passively as shown here.

Learning to activate the feet is especially beneficial for anyone with “flat” feet. It’s also important for women during pregnancy, since both the additional weight of a baby and the hormone relaxin increase any tendency to ligament laxity. 

Key components of Gokhale Method® training in our in-person Foundations course, one-day Pop-up course, and our online Elements course will enable you to make profound and lasting changes for your feet. You can learn how to:

• Place much of your body weight on your heels. These are large, dense bones with a cross-fiber construction that are well suited to load-bearing compared with the comparatively delicate forefoot with its longer, thinner bone structure.
• Kidney-bean shape your foot, keeping its structural integrity. 
• Use your foot muscles to interact with the ground, providing stability and propulsion. 
• Coordinate your foot action with the external rotation of the leg and activation of the glutes.
• Antevert your pelvis, stack your spine, and align your upper body as part of healthy standing and glidewalking.

We pay a lot of attention to the feet in all our courses. Here I am showing a student how to kidney-bean shape their foot.

Is hi-tech the answer to foot problems?

Computer technology has enabled podiatrists to measure foot shape, weight bearing, and biomechanics with a precision that was previously unattainable. There have been exciting advances in clinical 3D scanning and modeling, and the use of sensors to measure real time movement and weight distribution. There is also an increased biomechanical understanding of how gait interacts with foot function. 

However, the medical model of foot and gait health continues to arrive at conclusions based on abstract reasoning instead of tried and true historical and anthropological evidence. It therefore continues to encourage modern distortions like a “straight” foot and “straight ahead” feet. We would love to see a shift in the medical perception of healthy feet and gait that weaves in ancestral wisdom. 

The Gokhale Method has developed two wearables that help refine students’ stance and gait. The five-sensor SpineTracker™ wearable is used by many of our teachers in a classroom setting to allow them and their students to monitor and track real-time changes in spinal shape during gait. The two-sensor PostureTracker™ is a consumer product that enables students to refine their stance and gait at home, work, or leisure. 

  
The PostureTracker setting Piston Walking can tell you if you are successfully straightening your back leg while walking (a) or not (b); this is relevant to the healthy function of your feet. 

Free Online Workshop: “Fix Your Feet”

On Wednesday, May 24, 1pm PT, we will be offering a Free Online Workshop, Fix Your Feet. If you would like to volunteer for a mini-consultation in this workshop, please email teamesther@gokhalemethod with a brief description of your foot condition. If you would like to support friends and family who suffer from foot problems, please feel free to email them.

Best next action steps for newcomers

If you would like insight on your foot issues and posture, consider scheduling an Initial Consultation, online, or in person.

You can sign up below to join one of our upcoming FREE Online Workshops. . .

Posture and pregnancy have always been closely linked for me. As you may know, my own journey to create the Gokhale Method and a life free of back pain began with my development of crippling back pain during pregnancy. So it’s always a special gift to get to connect with other mothers who understand the deep relationship between posture and health, and to help other women learn to navigate the many changes that come with pregnancy and childbirth.

That’s why I’ve teamed up with MommaStrong to bring you this discussion between me and Courtney Wyckoff, the founder of MommaStrong. She’s a Certified Personal Trainer and Corrective Exercise Specialist, with 16 years experience in the field of fitness, nutrition, and injury prevention/treatment. She has been working exclusively with pre- and postnatal women for the last 9 years, which has allowed her the opportunity to see how seldom women in this country get the sort of support and information they need to truly re-integrate their core, nervous system, and biomechanical performance after childbirth. Her programs for core rehabilitation are vetted by leading physical therapists in this field. I love working with Courtney as our approaches have so much in common: we both want to help people live without pain, in which they stay functional and active throughout the many changes life brings.

Join us for our discussion of the concept “Function over Appearance,” and discover how moms and moms-to-be alike can reclaim a sense of empowerment and poise in their own bodies.

Learn more about MommaStrong here — and consider sharing with the moms (and other parents!) in your lives!

During my first pregnancy in 2011–12 I had — compared with other women — only a little trouble; I felt relatively fit. At the time, the occasional pain in my lower back and my permanent shoulder/ neck pain seemed normal because I had suffered them since I was in school. This fit with my modern comprehension of being healthy. Some aches and pains are not unusual. Upright posture? So not cool...

Here’s how I used to sit some years before my first pregnancy. I already suffered from occasional pain in my lower back and from permanent shoulder/ neck pain.

At the end of my pregnancy, my lower back pain became stronger. I started to suffer from sciatic nerve pain, which eventually covered the whole side of my left leg, down to my foot. It became more and more uncomfortable to sit. To avoid pain, I slowly got into the habit of only sitting on my right buttock.

Some days before my first delivery. My habit to stand with a sway back intensified with the growing weight in my belly. This malposition is seen as something normal in our society, as you can see in the following pictures.

Presentations of pregnant women on packages of dietary supplements.

When my water broke one early morning we went to hospital.

After some steps through the labor room and some belly dance movements I changed to half sit/half lie on a hospital bed because I was tired. The top of the bed was angled a little upward. At every contraction I woke up and pulled on the triangle above my head to round my back and to make the pain in my belly more bearable. At some point, the midwife told me to move onto the delivery table — an extra wide chair, also with an angled top which again put me in a C-spine shape that I was told to reinforce during every contraction. To enhance the pressure, two midwives took my feet to give me counterforce. I didn’t really feel the last contractions. I was only pressing when my midwives told me to do so.

During the ejection phase, I was told to move my pelvis a little to the left. At this point in time I realized that I had totally lost any feeling in the center of my body. My pelvis had to be moved by the midwives — I was absolutely not able to do so for myself.

Our daughter was born in the late morning hours and everything seemed to be fine. I was very glad that birth had not taken too long and that she was a healthy baby. But it was to be the beginning of a lot of trouble for me...

At home again, I still felt discomfort in my left leg. The longer I had to care for our daughter, the more pain I felt in my lower back. When my husband had to go back to work after two weeks, I got attacks of dizziness during which I had to lay down our daughter for fear of falling over. Some months later, my sciatic nerve pain was so strong that I wasn't able to bend without tears in my eyes. The doctors I visited gave me cortisone injections (although I was nursing) and told me to visit a physiotherapist. After six weeks with physiotherapy, my pain hadn't changed at all. My orthopedic specialist initiated an MRI examination. The images were unambiguous: my L5-S1 disc was herniated and protruded 2cm. The disc above it was bulged. My doctor told me that this diagnosis at the age of 28 was “nothing unusual.” My prescribed therapy: go swimming two times a week. Unfortunately, he was very busy and had only a few minutes on the phone for me…

My MRI picture from May 2013. My L5-S1 disc is herniated. The one above that is bulged. Our daughter was one year old when this MRI was taken.

I was totally desperate and sad. I felt ill and disabled from doing what nature wanted me to do. I pondered the reasons for my situation and I couldn’t help but feel like something had gone really wrong. I even had the vague idea that it has something to do with my habits. But no one was able to tell me more about that. Instead I was told that my condition was “nothing unusual”...

For another period of 6 months I was taking pain relievers, and I became more and more aware that no one was able to help me. It seemed clear that this would be my only child and that I would have to relinquish any physical training for the rest of my life. Doctors and therapists left me desperate — in my case, as in many others, there was no explanation and no solution from academic medicine.

In fall of 2013, my salvation was published in the German language: 8 Steps to a Pain-Free Back (Nie wieder Rückenschmerzen in German) by Esther Gokhale. After reading it I immediately started to learn the 8 Steps that are described because the whole approach seemed to be so logical. Since I was in parental leave I fortunately had the time to work with Esther’s book every day. And really: after two weeks I didn’t need to take any pain reliever! I couldn’t believe that the incredible became true: I was pain free and totally astonished at how mobile I was getting!

Doctors and therapists hadn’t been able to help me anyhow — but this book even told me how to heal myself! Now I got my optimism and my energy back, and I was so excited that I was eager to learn more. In May 2014 I took my little family to travel to Bristol in Great Britain. Since in Germany there had been no teacher yet, I joined the Foundations Course with John Carter who gave me useful hints and self-assurance concerning my posture and the feeling that I am doing every step correctly. And another idea was triggered by John: what if I would be the first Gokhale Method teacher in Germany to help all the people who are suffering like I was and for whom doctors only have useless tips because they don’t know what to do against “non-specific backpain”? One and a half years later I quit my job as an engineer in the automotive industry and became a Gokhale Method teacher full time!

Me and my posture in 2017, a few months before my second pregnancy.

In 2017, during the first trimester of my second pregnancy, I felt again how my joints became looser due to the hormonal changes associated with pregnancy. Every small wrong movement could cause dragging and stabbing pain. My SI-joint especially reminded me that there had been something wrong with my pelvis some years ago. I decided to regard this state as an opportunity. If all my joints are loose, I thought, my skeleton must be particularly changeable — and old issues like my aching SI-joint can be changed or even healed by healthy posture. I started to adapt my posture to my changing body. Kidney bean shaping my feet gave me a strong base for my growing weight. I especially enjoyed deep hip-hinges. They felt like medicine for my SI-joint. My plan worked. At the beginning of the second trimester I was pain-free, just like before pregnancy.

The technique that helped me most to cope with the growing weight in my belly was the rib anchor. As shown earlier, a sway back is a very common shape in pregnant women as the spine gets pulled forward. For me, as someone who had already had trouble with her discs, it was necessary to anchor my ribs against the increasing force.

The comparison of my picture diaries shows additionally which effect the change of the spine shape has on the shape of the baby bump. This is one example from week 34:

Two pictures of me at week 34 during pregnancies. On the left, during my first pregnancy, I permit my back to sway. On the right, during my second pregnancy, I engage my "rib anchor" to create a J-spine. Note that with a J-spine (right), my baby seemed to sink better into my pelvis and be more vertical.

I wondered if I might be able to affect the position of my baby through the shape of my spine. In my opinion the baby lies more vertically in the picture on the right. Does this maybe mean that with a J-spine, gravity can help the baby sink better into the mother's pelvis at the end of pregnancy? In my case, my gynecologist was very astonished every time she checked the position of my uterus. Already in week 34 the head of my baby was well settled in my pelvis.

Another point that made a big difference for me was the changed position of my pelvis while I was sitting. As you can see in the very first picture in this post, it had been my habit to retrovert my pelvis. With an anteverted pelvis I felt like there was much more room in my belly. In the second pregnancy I never suffered from pyrosis (heartburn) like I did in my first pregnancy. I also wonder if an anteverted pelvis gives a baby more of a chance to move and to turn itself to rest with the head downwards. How many babies don't rotate in time and have to be rotated by a therapist?

Although I was carrying about 3 kilos in my belly, my last pregnancy trimester was free of trouble. I had to lie down more often to save my energy and I enjoyed stretchlying on the side a lot. I remember that I hated lying down at the end of my first pregnancy. It was just impossible to find a comfortable position. Now the quality of my sleep was as high as it had ever been, even the days immediately before the birth.

The beginning of the birth was as you can read in pregnancy books. My contractions started one day in the morning about every hour and came closer over the course of the day. In the afternoon we went to the nearby hospital and they told me, after examination, that it would surely take some more time and that I should consider going home again. Since all the delivery rooms were occupied, my husband and I had to spend our time in the registration area. My contractions came closer and closer and I had no chance to lie down in between. We decided to stay. Gravity was pulling relentlessly and suddenly, at dinner time, I had contractions every 3 minutes. I asked for a delivery room and at last we got one with a huge delivery table. I'd sworn to myself that I definitely wouldn’t give birth on such a table again. I asked for a birthing stool and told the midwife that I would like to stay upright. The CTG machine (which records fetal heartbeat and uterine contractions) showed how heavy my contractions were but I grabbed the hanging cloth and concentrated on my breath. And I was astonished how bearable my contractions became! During each contraction I was half hanging/half standing with my pelvis retroverted to straighten the birth canal — one of the few times retroverting the pelvis is desirable. I was that much master of the situation and felt so good between the contractions that I was able to tell the attendant midwife student some things about posture, the Gokhale Method, and the book I'd read recently about posture during birth (“Die Gebärhaltung der Frau” by Lieselotte Kuntner). She was very interested and totally fascinated by my state. The CTG showed that the baby’s beating of the heart was constantly ideal.

Although the cervix opened very fast and the ejection phase started about two hours after we had entered the delivery room, my water didn't want to break. The amnion bulged out with every contraction and prevented the baby's head from moving forward. Even after the amnion was opened by the midwife, the head didn't move, although I was pushing very hard. I was asked to change my position and this time it was totally no problem for me. I moved from standing to sitting on the stool and later onto the delivery table to kneel down. I had a very clear perception of my whole body and each contraction. At last I was asked to turn around and to sit on the delivery table. At this point of time I would have done everything because I wanted to finally see my baby! But I tried to absolutely avoid C-shaping my spine while sitting on the table. I tried to sit as upright as possible with the support of my arms. After suffering some uncomfortable maneuvers, our son was born, exhausted but healthy, one hour before midnight.

Now, he is six months old. I have had no trouble with my back at all. I have been recovering from delivery very fast, in part because my pelvic floor isn't additionally loaded by bad posture. I feel strong and mobile. I've gotten my trust in nature back. And my understanding of being healthy has totally changed. Today I know that the human body is a fantastic construction, totally functional and strong — if it is used correctly. And I have experienced the enormous effect the state of my body has on my psyche.

I am deeply grateful that five years ago, somebody was able to tell me what had been wrong: Since I changed my posture to be more healthy, I have to admit that for the first time in my life I really feel cool — in the meaning of being relaxed and full of energy…

My son and me. Without the Gokhale Method he wouldn't be in the world.

All photos are courtesy of the author, Esther Pohl.

I'm reaching out to pregnant women today, because I've been reflecting on a clinical study that captures the scope of the problem of lower back (lumbar) pain in expectant mothers and because I have all too vivid memories of how lower back and sciatic pain affected me when I was nine-months pregnant with my first child. This crippling pain continued for a year, at which point I had back surgery that provided only temporary relief. This painful chapter in my life is what started me on my path to understanding the causes and treatments for back pain.

Lower back pain and pregnancy--it's a problem!

If you're pregnant and have lower back pain, you're not alone. A 2004 study (Low back pain during pregnancy: prevalence, risk factors, and outcomes) published by Yale researchers in the American Journal of Obstetrics & Gynecology found that nearly 70% of the 645 pregnant women responding to a 36-question survey reported lower back pain during their current pregnancy. The researchers also found that:

• Pregnant women who have experienced lower back pain prior to their current pregnancy (e.g., during their periods, during a previous pregnancy, prior to ever becoming pregnant) are particularly susceptible to lower back pain
• Lower back pain disturbed the sleep of 58% of study respondents
• Lower back pain negatively impacted the daily lives of 57% of the women surveyed
• Two-thirds of women surveyed in this study did not share back-pain problems with their pre-natal caregivers and--if and when they did--only one-quarter of  these caregivers recommended any kind of treatment

Because I know that lower back pain in pregnancy is a manageable and in most instances a preventable problem, it's of course best if women who plan to become pregnant prepare their bodies for the dramatic physical, musculoskeletal, and hormonal changes that lie ahead. This, as the study confirms, is especially important for women with a history of back pain. But because so many expectant mothers are--at this very minute!--experiencing lower back pain and, in many instances, not seeking or receiving help, this is the topic I'll focus on for now.

The lumbar spine is the region of the spine between the rib cage and the pelvis

Body stressors during pregnancy

I'll start by stating the obvious: During pregnancy a woman's body undergoes a number of changes, many that are inherently stressful. These of course include:

• Extra weight
• A shift in the center of gravity
• The impact of of the hormone relaxin on ligaments

If, as we consider the lumbar region of the body, we reference the very pregnant Mandy in the photo just below, we can begin to imagine why lower back pain can be a problem for some 70% of expectant mothers.

Mandy at 39 weeks + 4 days

By allowing the weight in her expanded belly to pull her lumbar spine into an exaggerated arch, Mandy is shifting her center of gravity forward, with the result that not only is there too much arch in her spine, there's too much weight on the front of her feet. To counter the arching of her spine and to lengthen and flatten the lumbar region, Mandy would need to use her internal oblique muscles to rotate her ribcage forward. This action, which is vital to proper alignment of the spine and good posture, is what I call "anchoring" the ribs. (Rib anchoring is discussed in greater detail and demonstrated in the video, below.)

What's healthy about Mandy's posture is that she is anteverting, or tilting forward, her pelvis. An anteverted pelvis helps prevent lower back pain because it allows for a natural stacking of the vertebrae, as well as a healthy alignment of the spine over the legs.

Extra weight

Where Does the Extra Weight Go During Pregnancy? (WebMD helpfully breaks this down.)

• Baby: 8 pounds
• Placenta: 2-3 pounds
• Amniotic fluid: 2-3 pounds
• Breast tissue: 2-3 pounds
• Blood supply: 4 pounds
• Larger uterus: 2-5 pounds
• Stored fat for delivery and breastfeeding: 5-9 pounds

   Total: 25-35 pounds

Extra weight and foot structure. I've know for a long time that weight gain from pregnancy (in concert with the effects of the hormone relaxin) impact the feet and can increase a woman's shoe size by half a size or more, so it was interesting to review results of a study published in the March 2013 issue of the American Journal of Physical Medicine & Rehabilitation. The study, Pregnancy leads to lasting changes in foot structure, reports that for 60% to 70% of the 49 participants, their feet became longer and wider and, on average, the height and rigidity of their arches significantly decreased. Study authors also observed that the loss of arch height seems to be permanent, and that the first pregnancy may have the most significant impact on the feet.

Center of gravity

With pregnancy comes a shift in the center of gravity that can be compensated for with good movement patterns and by engaging the internal oblique muscles, which run along the side of the abdomen at about the level of the waist. These muscles can be used to flex the thorax forward and prevent the lower back from arching.  (The thorax is the part of the body between between the neck and the abdomen.) By rotating the ribcage forward and, once again, lengthening and flattening the lower back to "anchor" the ribs, even women well advanced in their pregnancy can maintain a comfortable center of gravity. Shifting the weight back solidly on the heels is also a good thing, because it counters distortion in alignment, while also offering the advantage of not overspreading the feet, which can result in loss of structure.

Relaxin

Pregnant women need to take especially good care of their ligaments because the hormone relaxin, which is produced by the ovaries and the placenta and which helps prepare the expectant mother's pelvis for delivery, also works to remodel other soft tissues, cartilage, and ligaments in the body. As a result, pregnant women are at risk of losing structure--for example (and as described above), in the feet.

The seated woman has made room for her belly, but by leaning so far back she strains her neck and her back. Visual cueing for poor posture surrounds this woman--as it surrounds us all!

Lower back pain and pregnancy--some solutions!

Authors of the "Low back pain in pregnancy" study, cited above, also make the point that lower back pain can start at any point during pregnancy. This means that whether a woman is one-month pregnant or on the cusp of giving birth, she may be experiencing pain in her lower back pain--pain the Gokhale Method helps address.

Healthy spinal curvature, as shown here, can be maintained throughout a pregnancy.

The good news is that by making adjustments women at every stage of pregnancy can prevent lower back pain from occurring, or--if pain is already an issue--take real steps to manage this pain.

Six tips

1. Anchor your ribs
2. Engage your inner corset
3. Hinge your hips when you bend
4. Stack your weight over your heels
5. Engage your gluteus medias muscles when you walk
6. Stretchlie on your side with supportive pillow

While the suggestions I outline in this post can begin to make a difference, much more can be gained from enrolling in the Gokhale Method Foundations Course, watching the DVD Back Pain: The Primal Posture Solution, and reading (and repeatedly referencing) 8 Steps to a Pain-Free Back. ('Where to learn more' details are provided at the bottom of this post.)

1. Anchor your ribs

With regard to the rib anchor, it's important to know that the ever-growing baby is potentially pulling the mother's back into an arch. An expectant mother who gives in to this pull will be increasingly swaying her back, which can cause lower back pain and other problems. Anchoring the ribs involves keeping the lower border of the rib cage flush with the abdomen. This lengthens the back and helps to frame and lengthen the lumbar spine. By engaging internal oblique muscles as the baby gets bigger, the expectant mother not only reduces the risk for lower back pain, she also gets very valuable abdominal muscle exercise during pregnancy. This not only negates the problem of lower back pain, it makes pregnancy an opportunity to strengthen abdominal muscles, rather than a liability to lose muscle tone.

http://www.youtube.com/watch?v=bLrBJzrMTxA

Keeping abdominal muscles nicely toned before during and after pregnancy perhaps even more ties in with engaging the inner corset, which is at the core of Tip Number 2.

2. Engage your inner corset 

Anchoring the ribs and periodically engaging the inner corset--that is, contracting the deep muscles in the abdomen and back to lengthen and support the spine--is the ticket to well-toned abdominal muscles before, during, and after pregnancy. No matter how pregnant a woman is, these muscles can be entirely engaged, which is especially beneficial, given that the usual abdominal exercises--for example, lying on the back and doing crunches--are not recommended.

© Gokhale Method: Inner-corset muscles should not be engaged all the time, however. Instead, pregnant women (and everyone else!) will benefit from contracting deep back and abdominal muscles, off and on, over the course of the day.

3. Hinge your hips when you bend

Everybody needs to hip-hinge when they bend, but this is especially important for pregnant women. This is because lowering the body by bending with the knees and curving the back (as is so common in our culture) puts added stress on the spinal discs at a time when the discs are already being challenged by the additional weight of the pregnancy.  Keep in mind that the front of each disc in the curve being formed when the back is bent is compressed, pushing the contents of the discs backward, toward the spinal nerves. All authorities agree that this is a risky direction to distort the spine. The features of hip-hinging especially important for pregnant women are to get the legs externally rotated and set apart in a wide stance, so that when they hinge forward, there's room for the belly to settle between the legs. In other words, the legs have to be out of the way, so that the belly can settle between them. If the the knees are not externally rotated, but facing in, then the thighbones will interfere with the torso settling.

Janine Farzin, soon-to-be Gokhale-Method teacher-in-training, hiphinges in Chicago

Because so much bending is involved in motherhood, a very good time to master hiphinging is before and during pregnancy. Doing so will prepare the expectant mother for all the bending that is to come.

4. Stack your weight over your heels

Positioning the pelvis so that it's slightly tipped forward (anteverted) allows for a natural stacking of vertebrae without muscle strain. Vertebral stacking is important for everyone, but a for a pregnant woman carrying extra weight and with an altered center of gravity, it's really essential. Not only does healthy stacking yield good posture that leaves spinal discs decompressed, it also protects ligamental integrity. Ligaments already loosened by the hormone relaxin are less likely to be taxed when bones are correctly stacked. This will also help protect the feet, which--as noted above--are at risk of losing structure.

5. Engage your gluteus medias muscles when you walk

Engaging the gluteus medius, the muscle located in the upper, outer quadrant of the buttocks, helps prevent lower back pain[/caption] Our "glutes," or buttocks, are made up of three major muscles: the gluteus maximus, gluteus medius, and gluteus minimus. Located in the upper, outer quadrant of the buttocks, the gluteus medius is the "middle" muscle, the one that moves the leg to the side and rotates the thigh. Gluteus medius weakness--a study. Because engagement of the gluteus medius plays such an essential role in a healthy kind of walking I have dubbed 'glidewalking,' and because this muscle also plays an essential role in healthy, pain-free posture, I was very interested to learn that researchers at the University of Iowa Department of Orthopaedics and Rehabilitation conducted a study that found a strong correlation between lower back pain in pregnant women and weakness of the gluteus medius. Specifically their 2009 pilot study, Association between gluteus medias weakness and low back pain during pregnancy, found that "pregnant women with gluteus medius weakness were roughly 6 to 8 times more likely to have low back pain than those without weakness." The findings confirm what I have long known from my own research and practice--that strengthening and regularly engaging the gluteus medius is really key.

6. Stretchlie on your side with supportive pillow

Stretchlying on the side--that is, lying with a lengthened back, anteverted pelvis, and knees slightly bent--represents an opportunity to restore healthy architecture during sleep and reinforce the neural pathways that will help create muscle memory for a healthy J-shaped spine (as opposed to a curved C-shaped spine or an over-arched S-shaped spine). Not only does stretchling on the side decompress discs and improve circulation when the expectant mother is at rest or asleep, it also helps create muscle memory for an anterverted pelvis and lengthened spine when she's up and about. For women unaccustomed to what good posture feels like, healthy muscle memory can be hugely helpful. Because the extra weight in the belly tends to pull the expectant mother's spine out of alignment, tucking a soft pillow in under the belly will help her resist the pull of gravity and maintain a neutral position. During pregnancy, anything that spares pull on the skin, muscles, flesh, ligaments, and spine, is a very good thing.

When pregnant and stretchlying on the side, it's important to tuck a soft pillow in under the belly

Model this!

Pregnant women experiencing lower back pain might help themselves by taking posture cues from these illustrations:

This very pregnant figure models very nearly perfect posture[/caption] The image above captures very nice pregnant posture. The woman's back is not significantly arched, her spine is more or less J-shaped, and her shoulders are rolled back.

This French anatomical drawing from 1925 depicts a healthy neutral spine

The illustration just above provides another excellent model for how a pregnant woman can stand without arching her back. Plucked from a 1925 French anatomy book, this image lets me know that the French at that time had right idea about healthy curvature of the spine!

Where to learn more?

The six-session Gokhale Method Foundations Course helps people, including pregnant women, improve their structure and function as they engage in everyday activities.  While my book,  8 Steps to a Pain-Free Back, is most helpful when it's read in its entirety, the following pages expand on the tips outlined in this post:

• Rib Anchor: 39, 84, 140, 198
• Inner Corset: 110,-127, 144, 153, 162-163, 190
• Hiphinging: 150-167
• Stack your weight over your heels:46-47, 138, 142
• Engage gluteus medius muscles when you walk: 168-194
• Stretchlie on your side with supportive pillow: 94-109

The DVD Back Pain: The Primal Posture Solution also features relevant training, including segments on:

• Stretchsitting: Use the back of your chair to decompress your spinal discs and transform sitting into a healthy, therapeutic activity
• Inner Corset: Learn to engage your deep back and abdominal muscles to protect your spine
• Hip-hinging: Protect your spine and knees by learning to bend at the hips
• Stacksitting: Learn how to sit anywhere without slouching, pain or tension
• Tallstanding: Stack your bones well and prevent wear and tear
• Stretchlying: Decompress your spinal discs and nerves while you sleep
• Glidewalking: Learn to walk in a controlled series of forward propulsions that spares the joints

Photo and Video Credits:

The Happy Mother: Johann Anton de Peters, Wikimedia Commons Lumbar Region of the Human Skeleton: Wikimedia Commons Female Back Nude: oil on canvas: Jozsef Rippi-Ronai, Public Domain Mandy at 39 weeks + 4 days: Danielle deLeon, Wikimedia Commons Janine hip hinging: Courtesy of Janine Farzan, Chicago Equadorian figure of a pregnant woman: Walkers Art Museum, Wikimedia Commons Pregnant woman seated on bench: Peter va der Sluijs, Wikimedia Commons Healthy Spinal Curvature Throughout Pregnancy: Public Domain Gokhale Moment, Rib Anchor: © Gokhale Method Gluteus Medius: Creative Commons Model Maria Pesotskaya resting on her side: Anna Kosali, www.annakosali.com, Wikimedia Commons Pregnant Woman Facing Right: Public Domain French Anatomical Drawing, 1925: Public Domain