Q: WHAT IS THE PELVIC FLOOR?
In the female pelvis, the pelvic floor muscles are a sling of muscles forming a muscular support around the front (urethra), middle (vagina) and back (anus) passages in the pelvis. These muscles are called coccygeus (ischiococcygeus), levator ani (iliococcygeus and pubococcygeus), as well as deeper sphincters and the perineal body.
Pelvic floor functions:
- Continence: controlling the contraction and relaxation of the bladder and anal sphincter.
- Childbirth: firstly bearing the weight of the baby and secondly, to allow for the expansion required for vaginal birth.
- Pelvic and hip stability: as you can see from the images below there is very close proximity of the deep hip and pelvic muscles such as obturator internus and piriformis (which control hip internal and external rotation respectively).
- Sexual function: these muscles assist with sexual function.
Many people wait until they have problems before incorporating exercises into their daily routine. But that is just way too late to do something about it. So I’m am passionate about teaching you how to activate these muscles and incorporate them into a regular routine every week.
Q: HOW DO I ACTIVATE MY PELVIC FLOOR MUSCLES?
The most important part of completing pelvic floor exercises is the technique. To correctly activate these muscles you need to 'squeeze and lift' the sling of muscles around your front, middle and back passages. Often squeezing without the lifting leads to a bearing down of your pelvic floor.
Like most other muscles, the pelvic floor responds well to progressive strength training. Initially start by mastering the 'knack' of a squeeze and lift without activating your gluteal or abdominal muscles. It is also important to continue breathing normally and avoid holding or drawing in your breathe. This technique can be performed in lying, sitting or standing.
Lying down will be the easiest as there is less gravity on your pelvic floor. Once the technique has been established build up the repetitions to about 10 repetitions.
- To always switch on and let go with control.
- Don't allow your muscles to fade out during the hold.
- Allow just as much rest break as activation time.
- If you can't feel the letting go or feel that the strength of the lift is reducing, your muscles are most likely fatiguing so have a rest.
- Only progress one variable at a time; length of hold, number of repetitions or position of exercise.
- The aim for dosage is a 3-10 second hold, repeated 5-10 times, and completed 3 times a day.
THE FOUR PHASES OF TRAINING YOUR PELVIC FLOOR MUSCLES.
- Phase 1: Learn to switch on your pelvic floor and slowly build up your endurance (length of hold) and repetitions until you are able to comfortably hold up to 10 seconds.
- Phase 2: progress the exercise into a functional position such as sitting and standing.
- Phase 3: add in arm or leg movements such as floating your arms above your head or performing a squat on a swiss ball.
- Phase 4: progress to a normal exercise routine and try to involve your pelvic floor during your strength or floor based exercises.
PHASE 1: YOU'RE IN THE COGNITIVE LEARNING STAGE LEARNING ABOUT TECHNIQUE.
Learn to switch on your pelvic floor and slowly build up your endurance (length of hold) and repetitions until you are able to comfortably hold up to 10 seconds. The aim is to strengthen the pelvic floor muscles and to do that you need to create fatigue. So once you get the correct technique, try engage these muscles at 80% strength and work towards the dosage of 3-10 second holds, 5-10 receptions, 3 sets.
Pick a posture which feels right for you - lying on your back, side, sitting, standing.
SQUEEZE AND LIFT the muscles around your FRONT, MIDDLE & BACK PASSAGES.
The lift needs to stay up... don't hold it so long that your contraction drops off without your control.
The length of rest is the same if not longer than the time of contraction. You're pelvic floor is a muscle - give it time to recover.
You have to continue to breathe normally - NEVER HOLD YOUR BREATH.
Its also a good idea to avoid starting the contraction by breathing in.
PHASE 2: PROGRESS INTO A FUNCTIONAL POSITION OF SITTING & STANDING.
Changing the posture changes the load of gravity on the muscles. In sitting you can feel the support of the surface you are sitting on. This is a great way to get some proprioceptive feedback about your technique. I often say in sitting 'Squeeze and lift equally from front to back, lifting off your underwear...'
PHASE 3: YOU'RE NOW LOADING THE EXERCISE TO INCREASE COMPLEXITY.
Add in arm or leg movements such as floating your arms above your head or performing a squat on a swiss ball. When it comes to feeling the pelvic floor muscles contract, there is not a lot of space allocated in the brain to 'feeling them' and especially when compared to our ability to detect movement in our big limb muscles. So adding in a slow squat or arm movement will a) add more complexity through increased load, and b) add more complexity through concentration and awareness. At this stage in the rehab program you should aim to engage your pelvic floor muscles at 30-40% strength and incorporate them with the exercise you are completing. Remember that the aim is now endurance and functional pelvic floor exercises. Continence Physiotherapists recommend performing isolated pelvic floor strengthening exercises (phase 1 & 2) throughout the week in addition to phase 3 & 4. This helps to maintain technique and strength.
PHASE 4: BUILD IT INTO YOUR DAILY ROUTINE.
Progress to a normal exercise routine and try to involve your pelvic floor during your strength or floor based exercises. You might try doing them in part of your weekly workouts or even just practice them every time you're blowdrying your hair if you're still working on sustaining a contraction in standing. Find an activity that allows you to perform these exercises at least 3 times a week if not more.
Now don’t worry if this all seems a little tough… I’m going to walk you through step up step in the workouts but I wanted to provide a detailed description and explanation for your further reference.
Q: HOW CAN I ASSESS MY OWN STRENGTH?
In most cases mothers will have access to a Midwife or Doctor to guide them through the recovery process post-partum. But pelvic floor exercises aren't just used during the child-bearing years. In fact, many athletes who participate in high impact sports will benefit from monitoring and training their pelvic floor. Below are some of the tests I use in clinical practice to determine strength and starting points for exercise.
DURATION OF PELVIC FLOOR CONTRACTION IN SUPINE, SITTING AND STANDING.
This has been covered above but it depends on what position you're in as to how long you'll be able to hold a good quality contraction. The way to measure is to first get the technique of the squeeze and lift and then to count how long that contraction stays at the 'top' without dropping. Count the seconds to get an idea of your duration. Then repeat until fatigue to understand your endurance. From here you can progress the length or number of contractions.
One of the tests for continence is to see what happens when you cough. Positive symptoms may include heaviness or feeling a downward pressure, urinary leakage, farting, or pain.
STAR JUMP TEST
Before returning to high impact exercise one of the tests you can do to see how your pelvic floor tolerates impact is to do a star jump. If this feels ok, add a cough into the top of the star jump. If this feels ok.... you're doing well :) If not.... you need more time to build up your strength.
Here is a great video demonstrating how you can perform the pelvic floor stress test which puts all these principles together and allows you to determine if you are ready to start a graduated running program.
Q: WHAT SHOULD I NOT DO?
Hold your breath.
Thinking that holding these muscles all day is a good thing.
Squeeze your abdominals instead of your pelvic floor.
Squeeze your bum muscles instead of your pelvic floor.
Hold each contraction until it fails and drops without your control.
Do the exercises sitting on a open toilet.
Practice your exercises while weeing.
Push down on your pelvic floor.
A word of caution.... If you are experiencing symptoms of urinary or faecal incontinence, a sensation of heaviness and weakness and definitely if there is any pain during daily tasks or sexual intercourse - I would strongly encourage an internal pelvic floor assessment with a Continence Physiotherapist, Doctor, Gynaecologist to determine the cause of your symptoms. Not all pelvic floor issues are due to muscle weakness. In some cases there can be muscle trigger points, overactivity and scar tissue from previous tears etc. It's definitely not a 'one size fits all' principle for pelvic floor exercises. Like with all other muscle injuries, you generally benefit from an assessment of the cause of the problem before commencing rehabilitation.
Images courtesty of Google Images http://www.continence.org.au/data/images/Pelvic_Floor_First_images/female_pelvic_floor_sml.jpg and http://bloomspokane.org/wp-content/uploads/2013/09/blogpic1.jpg accessed September 22nd, 2015.