Watch #PilatesHour episode 110 “Pelvic Talk” with Brent Anderson PhD, PT, OCS, NCPT and Pam Downey PT, DPT, WCS, BCB-PMB.
BA: Do you cue for pelvic floor activation?
PD: The good and the bad is that there is a lot of buzz around the pelvis, and pelvic floor. Then, like everything else, it gets a little diluted or a little “translated”. I always like to come back to what we really mean by certain things. That’s one aspect of what I’m really trying to put out there now. Let’s all try to have a similar vocabulary and understand really what we are after.
There are way more people coming via the internet, with more open-mindedness about how women are during the birth experience. For example, people are seeking services after delivery with different health professionals. Most people are coming into the system because of excellent trainers picking up on dysfunctions and referring them appropriately. That’s what I get really excited about. It’s not really a medical model, but it’s out there with educators.
BA: It’s such an important aspect, that continuum of care that we’ve always talked about. A lot of times people get very territorial. It’s like, “the pelvic floor is my territory, my profession, my training”. What we don’t realize is it’s a continuum of health just like everything is. At some point, clients are going to be doing at-home exercises, going to the gym, and attending movement classes. The more people are aware of that whole spectrum of pre, during, and post-rehab, the more able we are able to achieve our ultimate goal. To allow people to participate more wholly in life.
We’re dealing with things like incontinence, vulvodynia, weak abdominals, and hernia of the abdominal wall postpartum. These are all things that significantly impact people’s well-being. This is what I love about my relationship with you. When I’m screening someone, I completely understand the impact that pelvic floor pathology can have on intra-abdominal pressure with someone with low back pain, but when I rule out pretty much everything that has to do with the physiology and structure of the spine, I can say “I really think this person needs a pelvic floor consult, can you look and see if there’s something missing.”
PM: You touch on something that’s really important in the healthcare model. A lot of our healthcare professionals seeing patients on the front line have just minutes with their clients.
BA: I’d love for you to talk about the latest research out there on dealing with stress incontinence. What are some of the latest research? Do we know what is not working? What are some things you do as an internal therapist to be able to understand that better?
PD: From a functional standpoint we still don’t have a lot in the literature that is functionally driven, I’ll put that out as a disclaimer. A lot of this is still in case study format, not random control studies. But what we can talk about is just like anything else. People assume. That’s the big part, the assumption when they are told to do a Kegel (and what does that really mean?).
Arnold Kegal designed a perineometer, a device inserted into the vagina that was flexible. Women that had stress incontinence were given this device. It looks like a blood pressure cuff device, and the needle would go off when you had a good squeeze. So instead of pushing it out, which would not register anything on the device, you would get biofeedback from getting a contraction. Arnold Kegel really focused on strengthening the pelvic floor universally to help with stress urinary incontinence. Usually at the level of the urethra.
On the pelvic floor, there are layer one and layer two muscles. We have the pelvis and these small muscles, and on the other side is collagen that is very strong and not very elastic. When the pelvic floor is strong it can act like a trampoline and rebound with the intra-abdominal pressure that is coming down to meet the bladder and other organs. This is the endpoint the anatomists say. The levators are our main postural muscle; which holds our innards up as we walk around, and gives us continence.
So coming from where he identified squeezing these muscles, which led to improvement in stress urinary incontinence, we’re now fifty-plus years later still talking about Kegels. So I really call them a pelvic floor muscle exercise, because there are a lot more dynamics to it. At Herman and Wallace, where I’ve been teaching for many years, we teach an exam to look at these muscles from the vaginal side and the rectal side. We also gather a bunch of other information regarding diagnoses, moving beyond this simple squeeze and release.
We know the pelvic floor is mostly slow oxidative fibers, 70-80 percent of it. So if you’re just teaching a quick on and off, even in a cueing situation, you’re not doing the majority of what these fibers do for a living. A squeeze also has a quick component. You have to be quick to get the intra-abdominal pressure. In our practice, I would say I’ve become way more interested in identifying what part of it. It all squeezes together, but with proper tactile and verbal cueing, I can get the person to understand it functionally.
Moving into a little anterior tilt, I can say “sit in neutral, perform the pelvic floor lift, feel where that feels in your body. Is it more rectal? Is it closer to the midsection of the perineum near the sitting bones, or do you feel it up front? Then take a moment and lean back in your chair, almost with a posterior slump and squeeze again. Now, where do you register that portion of the contraction?” Remember, it’s all contracting the same but your sensory awareness is going to be different. Then finally roll forward toward the front. I give a cue like “pick up a blueberry with your vagina”, “lift the clitoris”, or in men, “lift the penis”.
If you’re looking up front, you’re going to feel perhaps the three different areas of the pelvic floor. Stress incontinence could be affecting more upfront so we can give it a more anterior cue. It has nothing to do with breath, it just has to do with the squeeze and the isolation of the squeeze.
BA: You bring up really important points. The one that’s the biggest is how little we know about our pelvic floor anatomy in general. I’ve read a couple of papers now regarding how many women have no idea what their genitalia look like, and don’t want to know. It’s sort of like a taboo, and heaven forbid you to say the words clitoris or vagina in mixed company. One thing I would love to have you explain a little bit more is the relationship of the sphincter muscles, both the anal sphincter and urethra sphincter, in comparison to prolapse and a vaginal wall breach.
We are realizing something interesting after looking at hundreds of ultrasounds. It’s not that they don’t have an active contraction of the pelvic floor. It’s that they think the vagina muscle is lifting the pelvic floor. So you might see a little bit of activity in the vaginal wall but you wouldn’t see the pelvic floor lift up. In some of them, we would see the glutes squeeze because they weren’t quite sure where the pelvic floor was or what the muscle was that they were lifting. Others were in their own minds thinking things like stopping the flow of urine.
Thinking of that integration you’re talking about, I would love to have a little more explanation on the relationship of the urethral sphincter to incontinence. What is its relation to the pubococcygeus and pelvic floor? How does it relate in the sense of incontinence, or “continence” if we look at it in a positive way?
PD: So what we really need to know is that part of the musculature is under autonomic control. This means that our urethral area is on “close” or tightened. That is mediated through loops going up to the brain and when we go to the toilet or decide to squat and pee we tell the brain “ok go ahead and relax”.
Through that complex system, the autonomic releases the intrinsic sphincter and we also release our volitional sphincters. It’s a very coordinated effort. That’s why potty training takes so long for human children and what’s important to know is that the autonomics are working to keep us continent. We don’t think about contracting them all day long. Otherwise, we wouldn’t be able to function.
What we do have control over is the override. In the volitional set, we can delay urination at any point, or with that cueing I just mentioned, getting more where the urethra is, more to layer two where all of that pouch is. Through this, you can elicit a more direct contraction and really tighten and reinforce around the urethra.
This could be utilized if you’ve had damage from an obstetrical tear, a decade of chronic coughing due to allergies, COPD, pulmonary issues, or bronchitis where you’ve blown out a lot of things over weeks. So you can reinforce the contractions and help what’s already happening in the autonomics by adding to this deeper layer, the volitional muscle set versus the autonomic set.