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!
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].
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.
- 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.
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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Previous posts in this series:
1. Do you pee during workouts 2.Building Better Bladder Habits 3. When might seeing a pelvic health PT benefit you? 4. The Myth and Legend of Kegels |
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