I hear this a lot from both medical providers and yoga practitioners.  I also hear people who shy away from yoga due to not being flexible enough (more on that in a later post!).  My favorite thing to tell people on either end of the spectrum is that yoga is all about balance.  If you are super flexible (or hypermobile in your joints) you can work on strength and control through yoga, if you are on the stiff side, you can work toward a healthy degree of flexibility through yoga.  

Why would a healthcare provider prohibit yoga?  Often, the person who can put their palms flat on the floor with no resistance is more than flexible in their muscles and tendons.  They have what we call hypermobility, or more than “normal” motion of the joints.  Conversely, not all hypermobile folks are outwardly flexible.

“Is that me?” You likely fall in the hypermobile category if you answer yes to any of the following questions:

• Have you ever been called “double jointed”? e.g. your knees or elbows hyperextend, you can touch your thumb to your forearm, your pinky finger bends backward more than 90 degrees
  
• Can you easily touch your toes in a forward bend or further? (palms on the floor, or past the feet)
  
• Do you get certain poses “for free” (with minimal effort) such as full wheel or camel or full shoulder binds?
  
• Do you love to have your joints popped (either by a professional or yourself) but find the relief temporary?
  
• Do you find it difficult or painful to remain in any one position for a prolonged period of time?
  
• Do you feel stiff and usually feel better if you move around or exercise?
  
• Do you feel stiff and crave stretching, but sometimes feel worse afterward?  
  
• Have you injured the same body part more than once, and each time, the precipitating incident more and more trivial?
  

Some of the uber flexible have a genetic connective tissue disorder called Ehlers-Danlos Syndrome in which the collagen tissue (which makes up much of the soft tissues in the body) is more elastic, or less able to resist tensile loads.  Whatever the cause of the hypermobility, there isn’t an easy fix to restore the joints to a more normal range of motion.  The best way to prevent injury and pain is to avoid taking the joints into their extremes of range of motion and strengthen muscles around the joints. 

If you are one of those hypermobile folks, what do you do?  In most cases, you don’t have to give up your yoga practice, but you will be better served by approaching it differently.  These are some basic suggestions to get you started, but as usual, if you are injured or have difficulty with these suggestions, seek out some private instruction with an experienced teacher and/or a PT who loves yoga! (like me!) 

Use caution with heated classes.  Some of our constitutions thrive on heat.  Heat feels great and allows you to stretch more.  However, if you are already hypermobile, adding heat to the mix may allow you to stretch past your healthy range without noticing it.  So, I’m not saying avoid heated classes altogether, but approach them mindfully.

Don’t take every pose to the most “advanced” variation.  The hypermobile person will often be instantly “good” at yoga.  They will be able to achieve the extreme shapes with relative ease.  Do not confuse this for being an “advanced” yogi.  What you don’t see in those experienced yogis is the incredible amount of work their muscles are doing in the poses.  Your pose may look similar on the outside, but if you’re not doing the work inside the pose, you could be abusing your body rather than nourishing it.  Most yoga teachers will offer “bus stops” or several variations of each pose.  Experiment with taking a different variation than you usually do and work on the following suggestions…

“Hug in.”  or “Hug muscle to bone.”  This is yoga speak for using your muscles in poses.  This achieves several outcomes.  1. It gets you focused on your body and moving with intention rather than achieving some outward ideal of the pose.  2. Activating the muscles around your joints in a balanced way helps create stability.  3. Over a long period of time, consistently activating those muscles will create “hypertrophy” – the muscles actually add more fibers in parallel.  This creates passive stiffness and helps protect your joints even when you’re not actively engaging them.

Move slowly.  It may be tempting to walk into those fast-paced level 3 vinyasa classes because you can achieve the shape of the poses, but being hypermobile often means your sensation of your body position and joint position (kinesthesia and proprioception) is more difficult to connect to, especially when moving at a faster pace.  The easiest sensation to connect to is that of muscle stretch – at this point, you may have already taken the pose too far.  Also, many of us have adopted resting positions of our joints which are already on the extreme side.  In that case, you can’t expect your body to magically find the optimal position on its own, certainly not when moving fast.  Instead, slow down and learn to connect to the sensation of the boundaries of your muscles and the subtle movement within your joints.  It’s quite fascinating and will transform your practice!

Reacquaint yourself with gravity.  If I were to try to sum up a multitude of movement impairments in one concept it would be an impaired relationship between your body and gravity.  When you are hypermobile, gravity’s opposite upward force doesn’t transfer quite the same from the ground into your body as it does in someone with a stiffer system.  You have to practice and train it.  For example: Feel even weight between both feet, inside-outside toe balls and inside-outside heels.  Use the muscles of the feet to connect to the earth and lift and support your legs.  When your hands are in connection with the earth, use the ring of the palm and fingertips to anchor down and support your arms.  Even starting here can make a world of difference for some!  Now, whatever is in contact with the earth, try some swaying front to back, side to side (like a metronome) or in small circles.  What I see happen in injured folks with these shifts is often the body bends like a blade of grass in the breeze, rather than a sturdy steel pole…as if the top half of the body is disconnected from the bottom half.  Making these connections is vital for your true core** strength.

Ask yourself some deeper questions.  Why do you do yoga?  Is it to push yourself to the extreme?  You may want to reevaluate.  A lot of hypermobile folks I have worked with are unwilling to back off their yoga or other activities the slightest bit in the name of mindfulness.  This is a dangerous mindset that in and of itself can be injury promoting.  Understandably, slowing down or backing off can be frustrating, but be patient and compassionate with yourself.  On another front, sometimes excessive “openness” in the body correlates with excessive openness in other layers of our person (energetic, psycho-emotional, etc).  You may be taking on more than your fair share of negative energy, emotion or stress from others around you.  Just investigate and cultivate an awareness of yourself.  It may take some time to really get to the bottom of it, but that’s what life and yoga are all about!

Here’s to finding balance in life and yoga!


**yes, I think core strength is vital for those with hypermobility just like for any of us…however, I think our traditional model as most of us understand it in the fitness and even rehab community is flawed.  More on that subject later!

So now that you've explored some kegel myth busting, what is the best way to work on pelvic floor muscle function?  Remember you’re not alone if you have difficulty accessing these muscles.   As I’ve mentioned several times, verbal cues alone are often not enough to get the muscles working properly, especially in people who already exhibit signs and symptoms of pelvic floor problems.  A study by Bump in 1991 (1) found that after a brief standardized instruction, 60% of women had an effective pelvic floor effort and 40% had an ineffective effort.  25% of those studied displayed a technique which would promote urinary incontinence.  From clinical experience, when you take a population sample of individuals who have back pain, sciatica, hip pain, knee/ankle pain, and more obvious pelvic floor related complaints, the incidence of less than ideal performance of the pelvic floor is closer to 80-90%.  I've seen 25-40% have performance that is incontinence or prolapse promoting.

I will offer a simple cue that you can try, but I encourage you to seek out a qualified pelvic health PT.  This post doesn't even come close to substituting for a thorough evaluation and treatment.  Remember this is one very small tool in our toolbox.  If you have pelvic pain (back pain, tailbone pain, leg pain, etc), or think yours may be an issue of muscles which are too short/tight/toned, etc skip this exercise and go straight to a PT.  Also, if you try this and anything hurts, or any symptoms worsen, stop doing the exercises and see a physician/PT - preferably one that looks at the pelvic floor diaphragm parallel relationship and reflexive neuromotor control, not just "kegels" or biofeedback.

Just like any muscle, the pelvic floor muscles function best when they are able to move through their full range of motion, and respond automatically in coordination with the team of helpers.  The way "kegels" are typically described, it is akin to holding your elbow at a 90 degree angle and flexing your bicep all day long - not very useful for being able to pick up a box or even bring your fork to your mouth!  That's unique about the pelvic floor, is that it's designed to be in motion all day long in concert with your breath.  The movement of the respiratory diaphragm (at the base of the ribcage) is driven by your autonomic nervous system to keep you alive.  When your postural alignment is sufficient to line your ribcage up over your pelvis, the force vector of intraabdominal pressure being produced by your respiratory diaphragm is such that your diaphragm and pelvic floor move in parallel all day long.  This was demonstrated in a cool MRI study by Talasz (2).  That full ROM is so important - another study by Vostatek (3) demonstrated that individuals with low back pain move their diaphragms about half as far as healthy subjects.

It's often easiest to learn these exercises with an empty bladder/bowel.  When first learning how to engage your pelvic floor muscles, it is easiest to do when you are comfortable and have no other distractions.  Some people find that lying on their back with knees bent (and maybe supported with pillows) works best.  Here the pelvic floor muscles don’t have to work against gravity.  Some people find an easier place to start is sitting up because it gives them more proprioceptive (body sense) feedback internally from the weight of the organs and externally from your seat (a physioball works nicely!).  If your back is too arched or bent (ribcage not aligned with pelvis), it may be hard to access this parallel motion of the respiratory diaphragm and pelvic floor.  Once you get the hang of it, you can use this breath-linked activation during yoga asana, starting with easier poses such as all fours, supta badha konasana, vadrasana, virasana, or child's pose - progressing to down dog, tadasana and other "neutral spine" positions.  Non-neutral spine positions would be considered advanced application.

1. Start and end with the breath - always the breath!  

• Slow the length of your breath if possible so you can be mindful of how the muscles are moving.  The diaphragm and pelvic floor will both move down on the inhale and up on the exhale.
• Imagine as your air comes in it descends all the way down to the base of your pelvis and helps the muscles relax, lengthen, open or drop. Other helpful mental images for relaxing the pelvic floor on the inhale is to think about softening, melting, opening the sphincters or widening the distance between your two sitting bones.  Make sure not to push/bulge out like you are trying to pass gas or birth a baby.

• As you exhale, allow the muscles to move naturally (ideally eventually you feel them draw up and in just a bit).  Don't work at this part, just use the mental image of down on the inhale, up on the exhale.
• Practice this breath by itself for a few days or a few weeks to see if you can start to feel the uplift on the exhale automatically.  
• Also, try remembering the cue "blow before you go".  I'm not talking a forced breath or even making any sound - Begin your exhale just before you move and continue through the movement.  This is great for rising from a chair, lifting, pushing or pulling and starts to retrain your natural, reflexive pre-engagement of the pelvic floor with movement (without doing any kegels!!).  *this is great for learning, but eventually, we want the pelvic floor to respond naturally to movement no matter what cycle of the breath we are in.
• Doing just this breath portion is generally safe for folks on all parts of the pelvic floor dysfunction spectrum.  See also this post for more on the breath.  Do not attempt step 2 without guidance from a PT if you think you might have a problem of tightness/shortness/overactivity of the pelvic floor.

2. If you've been working with the breath and still can't seem to feel the uplift/recoil on exhale, you may benefit from adding a more purposeful pelvic floor action on exhale as an exercise. 

• I like Julie Wiebe's imagery of "bean lifts".  The bean lifts are nice because they encourage a gentle fine control rather than an all out gripping of the pelvic floor.  For many folks it's easier to start with the external anal sphincter because we are more familiar with stopping a fart in an elevator than they are any other action of the pelvic floor!  Because of this, you start with an imaginary bean just outside the anus.  On the inhale you relax the pelvic floor muscles, on exhale, gently close the anus around the bean and lift it up inside through the remainder of the exhale.  On the next inhale, allow the bean to drop back down and open and release.  Once this is easy, ladies can try a 2 bean lift - with the 2nd bean outside the vaginal opening, men's 2 bean lift imagine the 2nd bean drawing into the urethra, or lift the scrotum - again, exhale close and lift the bean, inhale drop and release the bean.
• Some people find the image of an elevator helpful because just like an elevator must close its doors before it goes up to the next floor, a healthy pelvic floor contraction involves a coordinated closure of the external sphincters first before the lifting/drawing in.  In order to balance the front-back action of the pelvic floor, it's helpful to think about the elevator moving diagonally toward your lower back rather than straight up toward your nose.
• Also, like an elevator can stop at various floors, the pelvic floor can have a graded contraction.  It doesn’t have to be an all-or-nothing gripping of the muscles.  Ideally, you eventually develop a fine control over a 10%, 25%, 50%, 75%, 100% contraction AND importantly also an ability to fully relax back to 0%
• So try: Inhale to relax and prepare, exhale close, then draw up and in
• Inhale let the muscles come back down, then open and release.  Spend a few breaths breathing and focusing on the descent/relaxation before you do another contraction.

4. Start small.  Anyone can practice the breath portion, even folks dealing with pain issues because the breath is about getting full range of motion in the pelvic floor in coordination with the respiratory diaphragm.  See this post for more.  I always recommend folks do at least 5 minutes per day of just the breath by itself with no distractions, with a goal to come back to it as often throughout the day as possible.  If you do decide to add the conscious close and lift (bean lifts or elevators) to the breath, this is more of an awareness activity.  Make sure that you spend time breathing to fully release the muscles before you go on with other activities without maintaining a gripping in the pelvic floor.  Again, please stop and see a pelvic PT if any of these suggestions causes you pain.

Want some help? You also don’t have to figure this out alone.  That’s what we (pelvic health PTs) exist for!  Contact me, and/or check out the previous post with info on how to find a pelvic health PT in your area.  As an intermediate suggestion, I highly recommend checking out Julie Wiebe PT's DVD or e-course.  She's also got some great free resources on her YouTube channel that may help you get started, or help you screen your potential PTs to see if you like their approach!

This article was updated 5/20/15 to add additional research references and new ideas.

1. Bump, RC, Hurt, WG, Fanti, JA, Wyman, JF, 1991, 'Assessment of Kegel pelvic muscle exercise performance after brief verbal instruction', American Journal of Obstetrics and Gynecology, vol. 165, pp. 322-327.
2. Talasz, H, Kremser, C, Kofler, M, Kalchschmid, E, Lechleitner, M, Rudisch, A 2011, ‘Phase-locked parallel movement of diaphragm and pelvic floor during breathing and coughing—a dynamic MRI investigation in healthy females’, International Urogynecology Journal, vol. 22, pp. 61-68.   
3. Vostatek, P, Novak, D, Rychnovsky, T, Rychnovska, S 2013, ‘Diaphragm Postural Function Analysis Using Magnetic Resonance Imaging’, PLOS ONE, vol. 8, no. 3, e56724. doi: 10.1371/journal.pone.0056724. Available from: < http://www.plosone.org> [3 December 2013].

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I often ask women what they already know about pelvic floor exercises, commonly known as Kegels.  Some typical responses include they either know very little, or they were told a long time ago by a doctor to do Kegels and never did, or they know they’re either supposed to stop the flow of urine or squeeze around the vagina.  I'd like to offer you a little more...

Dr. Kegel was  a surgeon who performed thyroidectomies and when he became unable to perform surgeries, became more interested in the contractibility of the pelvic floor muscles in the mid-1920s.  In 1951 he reported that “in more than 30% of women, however, no contractions, or only weak or delayed contractions, can be elicited in spite of diligent efforts.”  This early research is fairly consistent with what we know today.  Dr. Kegel also found that his patients would “invariably try to substitute contractions of extraneous muscles, especially those of the abdominal wall and gluteal region.”  He invented a biofeedback device to help women see when they were contracting the proper muscles and found much greater success.  

Fast forward to today, and more sophisticated biofeedback machines are only one tool in the toolbox of pelvic health physical therapists to conservatively treat urinary incontinence and more.  But among the general public, there is still a lot of misunderstanding about what to do with these muscles.  Because of all this misunderstanding, I actually hate using the term "Kegels" when educating my patients or other therapists.  

Here I will discuss a few of the most common myths:

• MYTH #1.  The best way to do Kegels is to stop the flow of urine while on the toilet.  
• Fact: Doing pelvic floor contractions on the toilet is NOT a good idea – it can cause urine to flow back up the ureters toward the kidneys and can lead to urinary tract infections (which are a major precipitating factor for urinary urgency, frequency and incontinence)
• Fact: A full excursion of the pelvic floor muscles involves more than just the urinary sphincter in coordination with your breath and other trunk muscles

• MYTH #2.  Squeezing as if around a tampon is the best way to do Kegels
• Fact: Again, a full excursion of the pelvic floor muscles involves more (see the next post: One way to access your pelvic floor muscles)
• The way Kegels are typically described, it is akin to holding your elbow at a 90 degree angle and flexing your bicep all day long - not very useful for being able to pick up a box or even bring your fork to your mouth! 

• MYTH #3.  You should do Kegel exercises as often as possible (every time you’re stopped at a red light, waiting at doctor’s office, bank, etc)
  
• Fact: Many men and women with pelvic floor dysfunction (including incontinence) actually have a hard time relaxing their pelvic floor muscles.  For these folks, this would be bad advice.  The pelvic floor muscles are already too short and/or too fatigued from being “on” all day long to do their job when they’re needed.

• MYTH #4.  Holding the pelvic floor tight all the time (or mula bandha for yogis) will make me strong and invincible
• Fact: It is true that having a strong pelvic floor is crucial for overall core functioning and can help yogis do really neat things like floating in sun salutations and arm balances, but for the same reason as in myth #3, holding the muscles all day everyday is a bad idea.
• Fact: holding the pelvic floor contracted all the time can disturb your breathing patterns.  The pelvic floor is designed to descend (relax) when your diaphragm descends (on the inhale).  Keeping the pelvic floor constantly braced can restrict the excursion of your diaphragm, limiting oxygenation, creating a “stress” feedback loop, and changing the way your abdominal muscles function.

• MYTH #5.  If I just focus on my “core” my pelvic floor will automatically get stronger
• Fact: Having abdominals that are much stronger, more active, or shorter than the pelvic floor muscles can create problems in both the pelvic floor and breathing patterns.  Rather than reinvent the wheel on this subject, I will refer you to an excellent post by Julie Wiebe, PT. 
• Fact: Pelvic floor problems are essentially an issue of mind-body disconnect.  Any suggestion that just focusing on something else will fix the problem is misguided.  On the contrary, we need to make friends again with this shamed and forgotten area of the body. (see this post by Sarah Haag, PT)
• Food for thought: If what we were doing for our "core" in fitness, yoga, and pilates was working, wouldn't you think the incidence of urinary incontinence among instructors would be much lower than the general population?  This isn't the case.  Research shows that the incidence of urinary incontinence in instructors is the same as the general population.