In Part 1 we looked at how the pelvic floor works and came to the conclusion that although kegels can be helpful, in most cases they are just not enough. In Part II I would like to explore the effect of lifestyle and “natural movement” on pelvic floor health, and suggest some tips to help you incorporate a strong pelvic floor as part of a healthy, functional whole-body.

Natural Movement and Lifestyle Factors

When we want to figure out if something is “Natural” for the human body (like a kegel for example), we have to take ourselves back to our “natural” environment.  Our bodies evolved to a time and place where we hunted/gathered our food, lived in a tribe, walked miles every day, squatted to toilet and rest, and lived without the modern conveniences that now rob of us of most of this “natural movement”. 

It is safe to say that our genetics have not changed much since this time, but our world certainly has.  Office work, driving cars, heeled shoes, and doing an hour of crazy exercise each day to make up for the lack of movement in the other 23 hours is what our bodies currently experience.  Vastly different to our ancestors.  What would their bodies be like if we could study them now? 

The closest we can get to observing our ancestors in action is to look at the few hunter-gatherer populations that still exist.  Some very cool researchers took a look at the pelvic health of around 400 women from the Xiangu tribe in Brazil[i].  These tribal women live as close to nature as you can get, living in huts made of grass and mud with their giant extended families, collecting their food, squatting to toilet, and surviving without any of the modern age’s “helpful” technologies.  The women of the Xingu tribe, with an average age of 33 and 4.3 children, average a 5% incontinence rate across the female population.  Compared to our 50% incontinence rate in the developed world. 

The women in the study still saw average rates of minor prolapse when examined by researchers, but most were asymptomatic (they didn’t notice), and their pelvic floor muscles were found to be very strong compared to the female "norm" of western culture. Another interesting finding of the study was that 90% of these women had their babies at home in a squat position (but before you run and attempt this birth position please remember that these women squat ALL THE TIME).  
As the author puts it:

“Instinctively, through their lifestyle, indigenous women have been protected against POP (pelvic organ prolapse) during their daily activities. In contrast, we have a sedentary lifestyle and require physical therapy sessions for training our PFM (Pelvic floor muscles)”[i]

A separate study looking at incontinence in Chinese women found that place of birth (mainland China or Hong Kong China) was the biggest predictor for stress urinary incontinence, suggesting that the environment women were exposed to early in life can play a role in continence later on[ii].  Here is another author’s take on how modernization affected pelvic floor health in this study:

“The old diet based on fibers and grass plants has been replaced by a diet rich in carbohydrates; the preferred delivery position is no longer squatting but rather supine; and a sitting position has been adopted for urination and evacuation. Apparently these changes may have caused increased prevalence of prolapse and urinary incontinence”[i]

There are so many variables at play in these studies that make it impossible to come to any real conclusions.  They do, however, provide evidence that our lifestyle could be playing a role in the high incontinence rates in our population.  And the evidence fits with the logical thought process that if our bodies were living in their natural environments we wouldn’t need to keep doing our kegels to maintain pelvic floor function.

Now before you decide to sell everything and go live in a cave in the mountains, I believe there are some practical, whole-body solutions for pelvic floor health we can try first.  We need to look at what parts of our modern lifestyle are holding us back from the pelvic health we were designed to have, and what we can introduce into our lives to live closer to our natural state.  The closer we can align our bodies with what they really need to thrive, the better we can function as happy, healthy, whole-body people.

Whole-Body Pelvic Floor Treatment: the long term solution?

Please don’t give up your kegels just yet.   Especially if they were prescribed to you for continence help, back pain, etc, as the research shows they can help.  For your long term pelvic floor health, I would ADD IN these tips to help the pelvic floor function as part of a happy, healthy WHOLE you.

1.     Treat the body as a whole:

Your pelvic floor is only as functional as the rest of the body, and the rest of the body functions best with a healthy pelvic floor.  Everything from tight neck/shoulder muscles to tension in the bottom of the feet can effect the workings of the pelvic floor so we need to look at the WHOLE picture. Which leads to point #2…

2.     Alignment:

When your bones are in the right place in relation to each other and gravity (correct body alignment), the core muscles should function naturally as a unit creating dynamic stability throughout the body.  Our modern lifestyle and lack of natural movement is forcing us out of our natural alignment and robbing the core of the work it could be doing (automatically) all day.

Corrective exercise can help you get into better alignment, but more importantly you need to observe your daily habits and the postures you are spending large amounts of time in to discover what got you out of alignment in the first place.

For more information please head to the goddess of alignment and “Nutritious Movement”, Katy Bowman and Restorative Exercise.
(I would especially recommend Al Fo' the Pelvic Floor Snackbyte)

3.     See a trained professional if you need help:
Sometimes you just need an outside pair of eyes to look at the WHOLE YOU and help you retrain your funky motor patterns, put you back into alignment, and prescribe exercises that can help keep you in a place where you can be your strongest, most stable self.  I have a team of different health/wellness professionals that I use when I need an outside pair of eyes or hands to give me a fresh perspective.  We have quite a blind spot when it comes to our own bodies sometimes, so never be afraid to ask for help.

5.     Re-introduce some natural movement:  When I am outside with my son at the park we often play “What would the hunter-gatherers do?”  I know it sounds corny but we think it's super fun, and we spend our time gathering sticks and nuts, building, carrying, climbing, squatting and trying to get a decent amount of walking mileage in each day.  Squat to cook something on your kitchen floor, get rid of the furniture in one room of your house, create a work-station that allows you to get some movement into your day.

Have a play or check out MovNat for more fun ideas.

6.     WALK and Build a bum:  Walking is a fundamental human movement and a fantastic way to strengthen the pelvic floor (when done properly).  You need to be walking EVERY DAY (even if you are an athlete with an intense training regimen) as this is a movement that the human body was designed to do and needs to do a lot of to stay healthy.

The bum muscles are what hold the sacrum in place so that the pelvic floor gets an eccentric (lengthening) contraction with each step.  Without a bum that knows how to activate there is no stability to the sacrum, which can cause shortening of the pelvic floor or reduce the leverage the pelvic floor needs to function properly.

Build a bum in functional ways like walking, squatting, lunging etc.  To start your squat progressions I will send you again to the wonderful Katy Bowman:

http://www.katysays.com/you-dont-know-squat/
http://www.katysays.com/you-still-dont-know-squat/

Why do none of us have bottoms that works well? We sit on them way too much! Leading to the next two points…

7.     If you have to sit:
Sitting on your tailbone (pelvis in a posterior tilt, picture a) can put your pelvic floor in a shortened position and reduce the activation of pelvic floor if done all of the time.  Find your ischial tuberosities and learn how to sit on them, use a wedge or cushion to get rid of the bucket seat slope in the car, and invest in a proper chair that helps you stay in a “neutral” (c) pelvis position if you are going to be seated in a chair at work.
Find more details and ideas in my "sitting" article here.

8.  Explore other positions: I have nothing against rest and relaxation, honest, I’m actually really good at it.  I do however recommend varying your rest positions to place different loads on the body and ensure you are not "casting" your body in a single position. As Westerners we tend to get stuck in “sitting”, “standing” or “lying”.  Gordon Hewes in 1955 came up with this collection of other positions from studying cultures around the globe[iii].  Have a play!

9.     Mindfulness and Meditation:  A study in 2013 showed that depression and anxiety were correlated with increased pelvic floor dysfunction in a group of postnatal women[iv].  If this is the route cause of your pelvic floor dysfunction it may need to be treated first.  Mindfulness Based Cognitive Therapy can be an effective way to manage depression and anxiety, and directed meditation can help people that hold tension in their pelvic floors to learn how to relax it.  And of course, please see a professional for the best kind of help.

““To visualize how the pelvic floor responds to stress, one need only look at the movement of a dog’s tail: when the dog is happy, the tail wags loosely from side to side; when the dog is stressed, the tail is tightly under its legs. It is the pelvic floor muscles that control the tail. In fact, the pelvic floor muscles are still attached to the rudimentary tail [in man], the coccyx, which is pulled forward when contracted, thereby compressing its penetrating organs. Therefore, man’s pelvic muscles, as the dog’s, may be the ultimate representation of the mind/body connection, for they are constantly responding to fluctuations in feeling.” – Jerome Weiss, MD[v]

10. The right food choices: 
You need to make the right food choices for your body, as something as simple as a food intolerance can create bloating and gut inflammation which will affect the muscles of the core.  Chronic constipation caused by dietary issues will also affect the pelvic floor. 

I am not an expert in this area but I know that sorting out digestive issues has made such a difference for so many of my clients, so please seek help with a nutrition expert if you are struggling in this department.

As you can see, when I said the WHOLE YOU I really did mean the entire picture of your mental and physical health can affect the pelvic floor.   As a culture, as researchers, as health care providers, as people with pelvic floors, let’s start asking the right questions.  We need to think more about why our pelvic floors got so weak/tight/overused/underused in the first place and start to come up with some long term solutions to this very common dysfunction.

These tips should get you started on the road to long-term pelvic floor health.  Please get in touch with any questions and let me know how you’re traveling!

Stacey xx

p.s.  My 30 Day Postnatal Workshop “Restore your Core and Pelvic Floor” will be launching in January.  Please sign up for my newsletter here or “like” my Facebook page to get updates on the big launch!


References
[i] de Araujo M.P., Takano C.C., Girão M.J., Sartori M.G. (2009). Pelvic floor disorders among indigenous women living in Xingu Indian Park, Brazil. Int Urogynecol J Pelvic Floor Dysfunct, 20(9), 1079-84.

[ii]  Brieger G. M., Mongelli M., Hin L.Y., Chung T.K.H. (1997). The epidemiology of urinary dysfunction in Chinese women.  International Urogynecology Journal, 8(4), 191-195

[iii] Hewes, G. (1955). World Distribution of Postural Habits. American Anthropologist, 57(2): 231-244.

[iv] Khan Z.A., Whittal C., Mansol S., Osborne L.A., Reed P., Emery S. (2013) Effect of depression and anxiety on the success of pelvic floor muscle training for pelvic floor dysfunction. J Obstet Gynaecol 33(7):710-4

[v] From Chronic Pelvic Pain and Myofascial Trigger Points. The Pain Clinic, December 2000, Vol.2. No. 6:13-18

I have been teaching people to use their pelvic floor properly for years now, and the research shows us that doing our kegels is probably necessary to maintain the health of our pelvic floor.  But in the back of my mind I have always wondered WHY the human body should have to “train” a muscle that is so fundamental to everything we do. To explore this idea more, let’s start with some facts.

Pelvic Floor facts and stats

But in people with back pain or women with incontinence[i], this anticipatory timing appears to be backwards, and the core muscles only switch on after the arm muscle has moved. So the “core” muscles in these populations have adopted different activation patterns that may not actually stabilise the spine.  Which could be why 78% of women with low back pain also report urinary incontinence.[ii]  Or why balance tasks requiring "core stability" are more difficult in women experiencing incontinence versus continent women.[iii]

Incontinence rates in our female population have been shown to be anywhere up to 50%.  In the adolescent years 12% of females struggle with continence issues[iv], and it appears to get worse with age.  Pregnancy and vaginal delivery are both risk factors for incontinence, as is the amount of children a woman has. Pelvic floor changes take place during pregnancy[v], most likely due to increases in Intra-Abdominal Pressure with a growing baby as well as the hormone relaxin creating looser connective tissue.

This muscle group obviously goes through a lot of stress and strain during the baby-growing and baby delivering stages, but is the pregnancy at fault or is it the “straw that breaks the camels back” so to speak?  I often wonder if the way we are rehabilitated post-birth and the habits we adopt throughout our lives are more of an issue than the actual birthing process.  Because our bodies are meant to do this crazy child producing thing, right? 

One study found that 25% of women struggle with continence immediately post-birth, but 49% of women report continence issues 7 years post birth[vi].  To quote Physiotherapist Diane Lee:

“It is apparent that for some women, something happens during pregnancy and delivery that impacts the function of the abdominal canister either immediately, or over time”[vii]

For me it was definitely over time.  I was very happy with my pelvic floor function at 6 weeks postpartum, but it was a different story after a year of carrying a child that continued to gain weight and get more difficult to hold.  I’m sure that a combination of funky postures and carrying positions, not allowing enough time to work on myself, and "hormonal stuff" with pregnancy and breastfeeding all played a part, but my pelvic floor was getting weaker by the month. 

This led me into this line of researching and questioning…if it’s not actually the birth that directly affects the pelvic floor what is it? And what can we do to fix it and/or prevent it from happening? 

Well that’s easy, Kegel of course!  Come on everyone knows that!

What is a Kegel and do they work?

Dr. Arnold Kegel came up with a way to exercise the pelvic floor in the 1940s in hopes of giving women a non-surgical way to improve pelvic floor function. A kegel is basically just a pelvic floor contraction (think lift and close), which many describe as the “stop urinating mid-stream” contraction (if you want a great visual check out this video).  Kegels are meant to be a type of resistance exercise where you learn to contract and relax the muscle group, increasing the ability to control the muscle group (better motor patterns) and eventually increasing the strength and tone of the muscle.  Theoretically this should lead to better bladder/bowel control and prevent Pelvic Organ Prolapse (POP), which is where your organs basically drop into the pelvis due to weakness of the muscle, ligaments and connective tissue.  Pelvic Floor Muscle Training (PFMT) is still seen as the first-line defense against Urinary Incontinence and is the primary tool used to treat the condition.

I would always recommend that women see a professional when starting a pelvic floor exercise program, as a recent study showed that almost 60% of women with incontinence and/or prolapse were actually doing their pelvic floor exercise wrong[viii]; which at best would be a waste of time, and at worst could be detrimental by creating bad habits and bearing down (weakening) the pelvic floor.  If you are unsure about your ability to properly contract your pelvic floor or just want to double check that you are doing it correctly, please go and see a physiotherapist trained in Real Time Ultrasound (Women’s Health Physiotherapists are fantastic).  I think a pelvic floor check-up with your physiotherapist 6-10 weeks postpartum should be a mandatory part of postnatal care...so let’s spread the word!

So do Kegels work?

A big review study in 2015 looked at all the studies using PFMT and whether they made a difference in continence rates if used preventatively (during pregnancy) or as treatment (after birth)[ix].  Depending on the situation, the person and the program, yes, these exercises seem to make a difference. In a supervised program lasting at least 8 weeks with “strength training principles”, these exercises are shown to have a preventative effect and can be an effective treatment for incontinence[ix].

Now looking critically at many of these studies I notice two things;  the first is that the majority of people do not exercise their pelvic floor exercises under these research conditions (supervised, lasting at least 8 weeks, etc).  The second is that most studies are looking at short term effect of PFMT.  Yes these people get better after doing the exercises, but what happens when we stop doing our kegels because we feel better?  The problem most often comes back.  This is where most health professionals tell you it’s a “use it or lose it” muscle and you need to keep up your kegel training.  But I think this is where we have stopped looking at the bigger picture. 

Don’t get me wrong, I think kegels can be a great starting point for a rehabilitation program, I do them and recommend them to most clients.  So please don't give up your kegels yet, especially if they were prescribed to you for continence and/or back pain.  But pelvic floor exercise alone just doesn’t cut it when rehabilitating such an integral part of the body.

Here’s why:

1.     We need to look at the bigger picture of the whole person:
A person with a pelvic floor problem does not just have a pelvic floor problem!  Remember the "foot bone is connected to the..." song? 

If a client came in to see me with knee pain I might start by asking them to squeeze their quad muscles to make sure they have the motor pattern to actively contract the muscle group.  But then I would look at their pelvic stability (core), femur rotation (glutes), and foot mobility among other things, and put it all together in functional exercises.  I would also look for patterns, habits, and tightness in the body that may have caused the knee pain in the first place. 

That is the norm for knee rehab.  Why is it not the norm for pelvic rehab?  Pelvic floor strength is great, but without the strength and alignment of the muscles holding the pelvis and sacrum in place, how can you expect it to stick? We need to start looking outside of the box and treat the pelvic floor as part of a functional WHOLE body.

2.     Different people have different issues with the pelvic floor: 
Remember that many people have a weak pelvic floor because their pelvic floor is too tight, tense or overactive.  Some hold stress and tension in their pelvic floor like others hold tension in their neck and shoulders.  For these people a kegel may actually exacerbate the problem, and yet everyone is told to Kegel?!

3.     We need to look at how our pelvic floor got so weak in the first place:
For some, it may be labour and childbirth that created a weakened pelvic floor, but I don’t think the babies should get all the blame.  Remember the research shows that often the pelvic floor function gets worse with time. And women with no children still have a high percentage of pelvic floor issues. In Part II we will look at a study of tribal women that average 4.3 vaginal deliveries each and maintain very strong, functional pelvic floor muscles.  Lifestyle plays a big factor in the health of any muscle group, and exploring the parts of our lifestyle that are not conducive to maintaining strength and function may be the key to real pelvic floor health.  Leading me to my next point… 

4.     What are you up to the rest of the day? It’s like an hour of exercise at the end of the work day to make up for 10 hours of sitting.  It’s just not cutting it.  At best the kegel happens 3 sets of 10 reps, maybe 10 mintues of your entire day.  What happens the other 23 hours and 50 minutes of your day…do you have bad habits (like sitting on your tailbone) that are reeking havoc with your pelvic floor and is there a way to get more strength naturally throughout the day?

5.     Kegels are boring (that’s right I said it). This is probably why adherence rates to pelvic floor programs are so low.

6.     Is it natural for the human body to have to “kegel”? How have we got to the point that we need to squeeze a muscle (that should be working all of the time) to keep it working?  Where are we going wrong?  Are these rates similar across cultures and lifestyles?  And if we were able to look back at our hunter-gather ancestors would we see the same issues?

I think it’s time to change the way we look at this muscle group and the way we are rehabilitating women in the pregnancy and postpartum period.  There are fantastic therapists out there that integrate PFMT into a full body program that can help you recover from childbirth and show you how to find the strength you need to be a mum.  If you are having some big issues after having a baby chances are you will receive some fabulous help. 

But I would say most of us are still falling through the cracks of the healthcare system, we are doing “OK” so we are told to do our kegels, go home doing them wrong, get bored so we stop doing them, our kids get heavier and life gets busier and all of sudden we have issues that were never there before.  

So I say it’s time for a change.  Let’s explore why our pelvic floors aren’t doing their job from a whole body, holistic perspective that takes the “whole you” into account.  Please stay tuned for Part II where we look at the effects of lifestyle and “natural movement” on Pelvic floor health, and I will suggest 10 tips for whole-body pelvic floor awesomeness. 

For regular updates check out my facebook page, or sign up here to get Part II and future blog posts emailed direct to your inbox.  And please get in touch to tell me about your pelvic floor and kegel experiences!

Stacey x

References
[i] Smith MD1, Coppieters MW, Hodges PW. (2007). Postural activity of the pelvic floor muscles is delayed during rapid arm movements in women with stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct, 18(8), 901-11.

[ii] Eliasson K., Elfving B., Nordgren B., Mattsson E. (2007). Urinary incontinence in women with low back pain. Man Ther, 13(3):206-12

[iii] Smith M.D., Coppieters M.W., Hodges P.W. (2008) Is balance different in women with and without stress urinary incontinence? Neurourol Urodyn, 27(1), 71-8

[iv] Bardino M., Di Martino M., Ricci E., Parazzini F. (2015). Frequency and Determinants of Urinary Incontinence in Adolescent and Young Nulliparous Women. J Pediatr Adolesc Gynecol,  pii: S1083-3188(15)00004-2. doi: 10.1016/j.jpag.2015.01.003. [Epub ahead of print]

[v] Chan S.S. Cheung R.Y., Yiu K.W., Lee L.L., Leung T.Y., Chung T.K. (2014). Pelvic floor biometry during a first singleton pregnancy and the relationship with symptoms of pelvic floor disorders: a prospective observational study. BJOG, 121(1): 121-9.

[vi] Wilson, P.D., Herbison, P., Glazener, C., McGee, M., MacArthur, C. (2002). Obstetric practice and urinary incontinence 5-7 years after delivery. ICS Proceedings of the Neurourology and Urodynamics, 21(4), 284-300.

[viI] Lee D.G., Lee L.J., McLaughlin L. (2008). Stability, continence and breathing: the role of fascia following pregnancy and delivery. J Bodyw Mov Ther, 12(4), 333-48

[viiI] Thompson J.A., O’Sullivan PB. (2003) Levator plate movement during voluntary pelvic floor muscle contraction in subjects with incontinence and prolapse: a cross-sectional study and review. Int Urogynecol J Pelvic Floor Dysfunct. 2003;14:84-88.

[ix] Mørkved S., Bø K. (2014). Effect of pelvic floor muscle training during pregnancy and after childbirth on prevention and treatment of urinary incontinence: a systematic review. Br J Sports Med, 48(4), 299-310