Conditioning the Core

In recent years, we often hear the phrase "training the core." The core is also referred to as core muscles or inner muscles, but the definition is quite vague. In medical sciences, it refers to the muscles attached to the spine and pelvis. These are primarily the muscles located deep and close to the spine, which serves as the body's pillar, and are said to be the muscles that control posture and other functions.

In Pilates, the central area of the body from below the ribs to the pelvis is called the "core." The pelvic floor muscles, diaphragm, transversus abdominis, and multifidus are the inner muscles of the core. There are various theories about the "trunk" (taikan), but it is generally considered to be a slightly broader area including the abdomen and around the shoulder blades—the body excluding the legs and arms.

In yoga, we often use the expression "axial extension of the spine," and there are many movements that focus on the muscles close to the spine, as Dr. Nagura mentioned.

I believe the correct order is to align the core before training it. If the spine or pelvis remains distorted, you cannot use your muscles correctly, so I think it is a priority to firmly align that arrangement before training.

When I heard this theme, I also thought that "aligning" rather than "training" was a good fit. This is because the history of yoga originates in meditation and was not originally intended for physical training.

I also think that aligning is the first priority.

In terms of medical sciences, is it like aligning the bones and then training the muscles?

Muscles and bones interact to control posture, so for example, it is said that a strong curvature in the lower back makes one prone to back pain. A pregnant woman's abdomen growing large, causing the back to arch and lead to back pain, is an example of that.

Even when we say "good posture," there are many variations, so maintaining a state of balance that is right for that individual is best, but if that breaks down, it leads to back pain or stiff shoulders. It is normal for the neck bones to curve forward; using a smartphone too much can lead to straight neck or slouching, which leads to severe stiff shoulders.

Professor Okuyama, I hear you teach yoga in physical education classes. Aren't there students with poor posture among them?

Yes. There are many students who tend to slouch. Everyone tends to worry about their weight, but I want them to care more about their posture.

One of the philosophies of yoga is that "a pose must be stable and comfortable." Through practice, you acquire stability and comfort. Once you find that, you can gradually align yourself. As we age, muscle strength inevitably declines, but people who can spend their time stably and comfortably without pain are likely in a state where their bodies are well-aligned.

For those who can grasp this sense of comfort and want to try even more difficult poses, I recommend strength training.

In Pilates, we aim to increase awareness of the "neutral spine" and "neutral pelvis" so that the natural S-curve of the spine and the natural angle of the pelvis can be maintained. The ideal is to train weak muscles while maintaining strong ones to align the body to its original intended form, so we approach a neutral state by saying, "This part is weak, so let's train it," or "This part is tight, so let's stretch it."

I see.

Even in the posture a person naturally takes, there is sometimes a load being placed on the body. In Pilates, we bring that as close as possible to a more comfortable state. In particular, training the muscles that maintain the posture of the core, such as the inner muscles, makes things easier. Once you can do that, you will be able to maintain a neutral posture for a long time.

We doctors analyze "unaligned states" through X-rays and such, but how do you all look at other people's bodies?

First, I look at their posture at a glance, and then I have them move their spine through flexion, extension, lateral flexion, and rotation, or have them stretch to see their range of motion. But this is a sensory way of looking at it.

I think that's amazing. In addition to being an orthopedic surgeon, I also conduct research in biomechanics at the university. Previously, in a project where we quantified the physical abilities of athletes, we did various things like measuring electromyograms and taking MRIs, but we had a hard time detecting the slight differences visible to the human eye. Currently, machines still have worse precision than human visual judgment. It is truly difficult to reproduce what you see through science; if you tried to do it seriously, you would have to buy several machines costing tens of millions of yen.

That is where I would like to see a fusion. While serving as a Pilates instructor at a studio, I also provide individual coaching to professional athletes. Medical care and Pilates are closely related, and I sometimes feel that I want scientific backing.

This is a layman's view, but someone whose posture is aligned looks beautiful in some way. I remember being very impressed by how cool former track and field athlete Dai Tamesue looked while jumping hurdles during his active days.

I also feel an athlete-like "aligned beauty" in Pilates and yoga trainers. I feel that a state of good, aligned posture also reflects one's mental state.

I sometimes instruct students to imagine their ideal body shape, and I tell them that achieving the posture they imagine will help them gain confidence. Aligning or training the core also leads to increased self-esteem.

Is physical beauty also pursued in Pilates?

Among the general public, some people come for body makeup because "their back has started to sag."

Joseph Pilates, the founder of Pilates, aimed for the integration of body, mind, and spirit based on the philosophy that the mind and body are connected. The ultimate goal of Pilates is to train the body and enrich the mind.

Mr. Pilates was German, but when World War I broke out while he was living in the UK, he became a prisoner of war. He was involved in the rehabilitation of injured soldiers in the camp, and the exercises he devised at that time are said to be the prototype of the Pilates method. Later, he moved to New York in the US, where Pilates developed in earnest.

Compared to the US, which leans more toward fitness, in the UK there are many clinics with attached Pilates studios, and it is incorporated into medical rehabilitation. People come for various purposes, from beauty to rehabilitation.

In the medical world, rehabilitation for parts related to the core emphasizes stretching. This is because it is important for patients to be able to work on it themselves at home. In that sense, physical therapists are required to have knowledge of the core.

I believe it was Australian physical therapist Paul Hodges who first started saying "core muscles," and the term began to spread around the year 2000. Since then, physical therapists have proposed various theories, and it has actually come to be emphasized in hospitals for the rehabilitation of back pain and stiff shoulders.

Recently, the number of physical therapists who want to get certified in Pilates is increasing.

Is a qualification also necessary for teaching yoga?

A qualification is necessary. The major one is the Registered Yoga Alliance (RYT), which is the qualification of the largest yoga association. It is essential to study a prescribed curriculum including poses, teaching methods, yoga philosophy, and anatomy. There are RYT200 and RYT500; RYT200 is a qualification that can be obtained after 200 hours of training. To get 500, an additional 300 hours of training is required. I have the 200.

If it is a certified school that meets the standards set by the Yoga Alliance, you can take the training in Japan, and there are also programs to get certified in a short period in India, Hawaii, or Australia. In addition, there are qualifications issued independently by various yoga organizations, where you can obtain a qualification certified by that organization through a short-term course.

Both yoga and Pilates are spreading in various ways around the world.

Yoga has a longer history and feels more common.

Indeed, yoga has a long history, with its origins dating back to around 2500 BC. Seals depicting people meditating in yoga's lotus position remain in the Mohenjo-daro ruins, and it is said to have originated in the era of the Indus Valley Civilization.

Originally, there were no poses, and meditating by sitting in the lotus position and regulating one's breathing was called "yoga." Poses are said to have begun appearing around 1300 AD.

Pilates and yoga are often compared, aren't they?

Yes. To us, they are completely different things, but quite a few students confuse them with Pilates. Because of that, I conduct classes to deepen their understanding by including stories about the history of yoga and what yoga is.

Both are often perceived as things done by women, especially those who are highly conscious, right?

Certainly, some students have a preconception that yoga is something for highly conscious people.

Do you ever arrange yoga or Pilates, which originated abroad, in a Japanese style? I ask because I hear that Americans have stiff ankles and cannot squat in the way called "sonkyo," which is a basic posture in sumo. They say sitting in "seiza" is out of the question. I think Japanese bodies are relatively flexible and have a wider range of motion compared to Westerners.

There are many types of yoga movements, and some are unique to Japan. In class, we do basic movements called Hatha Yoga, but there are also things like Power Yoga, and recently things called Laughter Yoga have appeared, so "XX Yoga" is constantly increasing (laughs).

There is also yoga done only with the face, or yoga done only with the fingers.

There are really many such derivatives.

Since Pilates is training that strengthens the whole body with the abdomen as the core, there is no Pilates focused on a specific part, so I find yoga interesting.

Do the people who receive your instruction, Ms. Kimura, come because their performance is not good?

That is part of it, but I also feel that Pilates itself has become a bit of a trend. Some people want to know how to move their bodies or want to learn a type of training different from weight training. In particular, injured athletes come to learn how to use their bodies because they want to correct their form.

In that case, knowledge of the sport would also be necessary, wouldn't it?

Exactly. I also participate in seminars and study in my own way. I can't go as far as to interfere with form improvement, but I try to convey knowledge such as how the shoulder blades move or what happens to the hip joints during appropriate movements.

仰るとおりです。私もセミナーに参加して、自分なりに勉強しながらやっています。さすがにフォームの改善まで口出しできないのですが、適切な動作では肩甲骨がこう動くとか、股関節はこうなるといった知識は伝えるようにしています。

Yes. If you make them too flexible, it actually becomes harder to control, so it is important to look at that person's individual state beforehand.

Sensation?

Meaning, what kind of sensation the person themselves had. It is a very delicate and difficult part, though.

We also sometimes request baseball players to record their pitching form when they are in top condition. When they are in a slump, they often cannot reproduce it, and they themselves may not know the reason. I suspect that core muscles are also related to that.

It must be a slight misalignment. The body changes every day, so I think it is quite difficult to reproduce a good state in the same way.

ちょっとしたずれなのでしょうね。身体も日々変わるので、好調な状態を同じように再現するのはなかなか難しいと思います。

Can you tell if someone's muscles are stiff just by looking at their movements?

筋肉が固まっている人というのは、動きを見てわかるのですか。

I understand.

That is amazing.

Such people often have tension in their shoulders, clench their teeth, or are in a state of tension somewhere. It is clearly different from a state where they are relaxed and using their core.

Do you instruct such people to change how they use their muscles?

For example, by saying "relax here" or "release the tension there," unnecessary force is removed, and they become able to use their bodies efficiently.

Indeed, when you look at the form of top professionals, they are very relaxed and actually don't put in much force. Conversely, unskilled people tend to be stiff and strained.

Ideally, one should always be relaxed in a good way. By the way, in the world of biomechanics, is it possible to check the softness of muscles?

There are devices that use ultrasound and other methods to investigate. We also measure muscle stiffness to investigate symptoms like stiff shoulders.

Additionally, I always ask children who have been injured to "try touching the floor while standing," but most children who get injured cannot reach. They are naturally stiff. I recommend stretching while jokingly saying, "Make sure to drink vinegar every day" (laughs). Of course, everyone's body is stiff before exercising, so as a doctor, I first recommend warm-up exercises.

There are also factors like age and innate muscle quality. Some people maintain soft muscles even as they age. If you diligently continue stretching, the quality of your muscles will change little by little, so I want those who are stiff to keep at it steadily.

What are the differences between muscle training and Pilates?

Athletes in particular have strong outer muscles, so when they start moving, the relatively large muscles in the thighs and chest switch on immediately.

However, they often fail to use their inner muscles at this time. If they could properly use the deep muscles around the spine and pelvis, the quality of their movement would improve further. Moving from the inside of the body creates sharpness. Therefore, in Pilates, we do training that focuses on the deeper parts before the outer muscles.

Past research shows data that women are overwhelmingly more likely to tear their anterior cruciate ligament (ACL) when landing on one foot during sports. Among them, those whose knees cave inward (X-legs) upon landing are particularly prone to injury. The muscles around the hip joint are important for preventing injury, but if this part is weak, it leads to an X-leg landing.

There is also data showing that training to land with a neutral leg angle strengthens the muscles around the pelvis and reduces injuries. In the field of sports medicine, knee care has been a major topic over the last 10 years. Even in the Japan national soccer team, experts have joined to implement initiatives for strengthening core muscles to prevent injuries.

Core muscles are the truly essential parts of the inner muscles, so they are particularly important for athletes.

It is scientifically certain that core muscles control human movement in various ways. Strengthening this part is the best way to reduce injuries.

It's the part around the flanks where there are no bones, the place that feels squishy when you pinch it with your fingers. If you fully extend this area as if opening a paper lantern, the spine also extends, and if you can maintain that state firmly, the core can be aligned.

That part is called the psoas major muscle, and I actually wrote my doctoral thesis on this very muscle. It is a very interesting muscle structure extending from the lower back to the hip joint that only humans possess, and it is used when doing things like knee lifts. This is closely attached to the lower back.

It is said that back pain occurred because humans became bipedal and began extending their hip joints. When I tell patients with bad backs to strengthen their psoas major through water walking, they improve remarkably. However, despite being an important muscle that sandwiches the spinal muscles, it is a part that is rarely trained.

It's a muscle that is hardly ever consciously noticed in daily life.

Speaking of back pain, I once taught yoga to local residents in a public lecture at the Institute of Physical Education where I belong, and I was surprised when a participant told me, "My back pain is cured."

I never say things like "stiff shoulders will improve" or "back pain will be cured" myself, but I received feedback that it was effective. I have no intention of using that as a selling point, but hearing this conversation now makes sense to me.

In yoga, there is something called "alignment," which involves movements to adjust the orientation of the pelvis and the tilt of the spine. The orientation of the pelvis is particularly important. Since many people today have tilted postures, in the first class, we create a neutral posture by setting the pelvis upright.

"Setting the pelvis upright" is the image of the sit bones piercing the ground when in a long-seated position. People with stiff hamstrings will have their pelvis tilt backward if they sit with their legs straight, so we have them keep their knees slightly bent to set the sit bones upright and focus on the pelvis.

It's the neutral shape of the pelvis. Since many people tilt backward in a long-seated position, I also advise them to set the pelvis upright. If you place your weight on the sit bones, or rather, feel like you are sitting on the front part of the sit bones, you get just the right neutral posture.

Can you two determine the angle of the pelvis just by looking? The pelvis is the deepest and most difficult part of the body to see.

The orientation of the pelvis varies completely from person to person, so of course, there are times when it's not obvious at a glance. In those cases, I obtain information by touching or having them move.

The angle and movement of the pelvis also change depending on muscle stiffness. Students doing yoga for the first time often ask, "Can I do it even if my body is stiff?" but it is actually muscle strength that is more important for maintaining posture. Students seem to realize this when they actually experience it, sending feedback like, "I realized I lacked muscle strength when I tried the poses."

In Pilates as well, except for those doing specialized sports like ballet, many people have stiff bodies, and nearly 90% say they want to become more flexible. In terms of range of motion, if specific muscles are stiff from overuse or, conversely, weakened and shortened from disuse, the range of movement narrows. To demonstrate good performance, flexibility around the joints must be maintained.

It is medically certain that people with stiff muscles are prone to injury. Although occasionally there are women who are too flexible and their shoulders dislocate. In that regard, if the body can be properly aligned through yoga or Pilates, it may naturally become more flexible and lead to injury prevention.

That's right. I believe that as a result of accumulating appropriate movements, the muscles naturally become softer.

Can any student take your yoga classes, Professor Okuyama?

Physical education classes at the Hiyoshi Campus are elective subjects, so anyone who wants to take them can. If the number of applicants exceeds the capacity, a lottery is held. At sports clubs or yoga studios, they often start right away with making poses for health promotion or beauty, so they don't delve into the background like history or body mechanisms. I want to convey yoga from as many angles as possible, so in addition to poses, I also teach yoga history and philosophy.

Professor Okuyama, what kind of guidance do you give to students with stiff bodies?

I tell them that being stiff makes them prone to injury, but I don't do things like pushing hard with stretches. In the case of yoga, it's important to notice things for yourself. For example, if you can understand that you can't do a pose comfortably because this muscle is stiff, you will make an effort to soften it yourself.

One of the purposes of yoga is to face your own mind and body. If you move your body and it doesn't go well, a realization is born there. The same goes for the mind; if you can notice that "I feel a bit restless today," it leads to controlling it yourself.

So you intentionally have the students try it, Professor Okuyama. While saying "try this pose," from your perspective, you probably know "they probably can't do it," right? And there you lead the students to a realization (laughs).

That's right (laughs). Since the ultimate goal of yoga is to calm the mind, even if it feels difficult at first, it becomes pleasant as you get used to it. A once-a-week class won't build muscle strength, but something is awakened by applying stimulation to the muscles.

It's important to lead them to aligning their mental state.

What I always say is, "Let's control our own emotions ourselves." Ideally, one should be able to create a state where the mind is similarly stable even after the class ends and they leave the mat, and I consider yoga to be one of the methods for that. It's even better if, as a result, they gain muscle or can align their core.

Professor Okuyama, what was your motivation for starting yoga?

The trigger was starting to go to a yoga studio, but when I incorporated it into my classes, many students showed interest. So, when I looked into various things about yoga, I realized it was quite a deep world and decided to study it properly.

At first, I also thought that doing poses beautifully was the most important thing, but after learning that's not all there is to it, I wanted to convey yoga to students from various angles. University life is only four years, and the time after it ends is much longer, isn't it? I also have the hope that they will be able to control their own emotions even after they go out into society.

Pilates isn't as well-recognized as yoga, so I want to spread it while creating textbooks and doing classes, but it's still minor. I'm envious.

Is the acquisition of anatomical knowledge, such as which yoga pose works on which muscle, included in the certification programs?

It is included. The RYT program also has anatomy classes. It's categorized such that if you want to train this muscle, you do this pose, so I utilize that in my classes as well.

If you study anatomy, you also have to study the form of specialized sports (laughs).

I'm self-taught, though (laughs).

But the job of looking after athletes is a heavy responsibility. Previously, we had an opportunity to have Ivica Osim, the former manager of the Japan national soccer team, give a lecture at an academic conference for orthopedic surgery that we belong to. At that meeting, a question was asked: "Mr. Osim, what do you require from a J-League team doctor?"

Mr. Osim replied, "Soccer skills on par with a J-Leaguer." He said, "Otherwise, you won't understand why a player gets injured, will you?" Hearing that, everyone realized it was impossible for us (laughs), but his thinking makes sense, and I've come to feel that I cannot lightly take on the role of a team doctor.

Conversely, the ones we ultimately rely on are the doctors. Even when it comes to surgery, that is an area that neither players nor trainers can judge. I feel that, in the end, it's difficult without knowledge of medical sciences.

When athletes get injured, they ask to be returned to play as soon as possible. A fracture takes a month to heal, and returning to play takes another year. Speeding that up is medically contradictory, but they say they want to return in six months.

I also feel that I want athletes to acquire knowledge of medical sciences. Since only the person themselves can understand their body, I think their competitive life will be longer if they have basic knowledge along with the "realization" of knowing "what state the body is in" by observing their own movements.

Athletes like Ichiro must have been excellent at looking at their own bodies. The fact that he could play actively for so long was precisely because he knew his body inside out.

Professional soccer player Yuto Nagatomo reportedly incorporates yoga before matches to increase concentration and maintain a good image during the game, and he has even published a book on yoga. Recently, the number of athletes using yoga to align their mental state to improve performance seems to be increasing.

Specifically, what kind of work is "aligning the mental state"?

In our daily lives, we take in a lot of information through our eyes and ears, but it means temporarily shutting those things out, intentionally focusing awareness on emotions and thoughts in "this moment," and facing oneself. In other words, meditation.

There are several methods, but you focus on one point and try not to let your awareness go elsewhere. For example, the method of observing your own breathing. What kind of rhythm is your current breathing, is it deep, is it shallow, etc. By directing awareness to such things, you look at your inner self. By doing so, you calm your mind and create a strong heart or a heart that is not overwhelmed by anxiety.

Breathing is one of the important elements in Pilates as well, isn't it?

That's right. In the case of Pilates, unlike abdominal breathing in yoga, it is thoracic breathing, but by properly moving the diaphragm to expand the ribs and moving the muscles called respiratory muscles, we take in more oxygen and improve circulation within the body.

Breathing is extremely important for training the inner muscles of the core in particular, and it is the most fundamental base. Inhaling deeply and slowly and exhaling for a long time has a very relaxing effect. Some people even get sleepy during the lesson.

It is said that Pilates breathing techniques greatly influence the control of the sympathetic, parasympathetic, and autonomic nervous systems. Most people probably hardly ever pay attention to their breathing, but the fact that it is controlled consciously and serves as the basis for aligning the core is interesting. It is a very essential part that regulates the parts involved in human life maintenance at a level deeper than just discussing muscles.

Modern people tend to breathe only with their shoulders and don't take deep breaths, so there are inevitably fewer moments when their minds feel calm. It makes sense that people have said since ancient times that taking deep breaths is good for you.

In yoga, poses are always synchronized with breathing. In my classes, I have students practice only abdominal breathing first, and they say they realize how shallow and fast their normal breathing has been.

Because breathing is shallow, the mind doesn't settle, and because the mind doesn't settle, breathing becomes shallow. That's why I tell students that if they notice their mind is unsettled, they should try to transition to deep breathing. If an unsettled state continues all day, performance will inevitably drop, whether in work or sports.

In the field of biomechanics, do you also look at breathing?

People with a hunched back always show symptoms like headaches, dizziness, and sluggishness together. Those people usually have stiff bodies, their breathing becomes shallow, and their physical condition deteriorates. Breathing is by no means unrelated.

For patients with neck pain or severe stiff shoulders, I provide treatment to relieve tension in the neck muscles. At this time, many people find it makes sense when I explain that the autonomic nervous system is actually involved as well.

Conditioning, the mental state, and the autonomic nervous system are closely intertwined, but if you go to a mental health clinic, the direction tends toward solving it with medication. I try to tell them to stretch as much as possible, but I can't go as far as teaching breathing techniques. If we could approach it like you two do, I feel like stiff shoulders and lower back pain would heal naturally.

Stiff shoulders might partly be due to a person's habits, and I think correcting that is as difficult as correcting the hand someone uses to hold chopsticks. Unless they are truly conscious of it, it's quite hard to improve, isn't it?

I think there are many people who would get better if they were given the awareness to change their mindset, like in yoga. Conversely, people who have injured themselves through habit won't get better with surgery or painkillers. If we start by letting them know first and then adjust the bad parts, they might heal little by little.

For example, for patients with straight neck syndrome, I give detailed instructions like, "Keep your chest out regularly so your shoulders don't hunch forward."

Since those who come to us doctors are already in pain, we treat the bad parts, but even before curing a disease, maintaining correct posture is truly important.

I think it's quite difficult to keep maintaining good condition, but I believe it's very important to know your current state.

Students also seem to have their share of worries, such as relationships in clubs or part-time jobs, but for me, the main thing I want to convey through yoga is knowing yourself and stabilizing your mind and body.

The important thing there is not to compare yourself too much with others. I think it's fine as long as it's the best condition for you. I think it's good if you can incorporate things you find comfortable through exercise, diet, and sleep.

What I've been thinking lately is that "the golden mean" is very important. Even if your body has improved, if you keep repeating the same thing, it will become unbalanced again. It's important to stop just before overdoing anything and try the opposite, or if you've run a lot, properly care for your legs to return to neutral. The secret to maintaining condition is not to go to extremes.

Even among the elderly people who come to us, healthy ones walk for 30 minutes every day or exercise regularly. They are all careful themselves and are very conscious. I think those people know how to condition themselves. It makes me wonder why they come to the hospital at all (laughs), but perhaps because they understand their bodies so well, they are sensitive to even slight pain.

Going to the hospital because it hurts feels very normal to me. People who don't notice the pain and don't go to the hospital are the ones who are truly scary. I suspect there are quite a few people like that.

Those are the people for whom enduring pain has become natural.

Stiff shoulders can also become chronic to the point where you no longer realize it yourself.

It's very important for us to teach patients, athletes, and students as well. We explain that the reason pain occurs or why posture is bad is because of this or that. I feel it's very important to encourage awareness so they become conscious of it themselves. After all, those who take action definitely see their condition improve.