Pilates Teacher Training

Advice On Cueing The Core: More Muscles Than You Imagined

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Brent Anderson and Shelly Power discuss the muscles that comprise “the core” – and it may be more muscles than you thought! Join us LIVE on Thursdays at 3 PM eastern to participate in the discussion in our #PilatesHour webinar. Watch #PilatesHour Episode 124 “Optimizing Cueing of The Core” Here.

BA:  How do we think about cueing the core? For starters, the “core” muscles also include the muscles that connect the extremities to the core.  I always say that “core control is the appropriate amount of stiffness for the anticipated movement”. Oftentimes in everyday activities, and in Pilates, the load to our core comes from our extremities. With the exception of putting weight directly on your chest, most core load comes from the extremities; head, arms, and legs.

We could then put a significant number of muscles into the category of “core control muscles”. Everything from the hip extensors, psoas muscles, hip abductors and adductors to pectoralis and latissimus muscles. All of these muscles are related to controlling and contributing to core control.

THE MYTH OF THE “CORE WORKOUT”

One thing we really want to debunk is the concept that core control is governed by the rectus abdominis. I get scared when someone says “I did a really hard core-workout”. In reality, all they did was work on the anterior pillar of their trunk.  Then they often expand a little bit and say “well I also did obliques”.  

We have to understand where we dilute the word ‘control’, because we want to bring that word back to life. My definition of control is “having the appropriate amount of stiffness for the anticipated load of activity”. It really depends on the activity you are planning on doing. If your client wants to lift weights, maybe you can utilize some of Stuart McGill’s cueing.

We might use an engagement or bracing cue. There might be some benefit to breath holding. Possibly some controlled valsalva to be able to get maximum intra-abdominal pressure while doing a deadlift with 400 pounds for example. This is also completely acceptable in training.

CUEING THE CORE & PELVIC FLOOR

SP:  I think it’s also important to recognize that yes, we are cueing the core muscles, and yes, we are cueing the pelvic floor – we are cueing all of these muscles. We are just not doing it by saying ‘now contract your pelvic floor’, or ‘now contract your abdominals’, “hollow your belly”, or “navel to spine”. Those ways of cueing the muscles are a bit outdated and I think this is where some of the misunderstandings reside. 

We are absolutely cueing the body, the whole body, so we’re trying to think of it a little bit more as a system. There are ways that I will cue that will get certain muscle groups to be a little bit more active. A big part of this concept is moving away from the idea that only one muscle has a job at a time.

The more you can get the whole body to work as a system, the better off your clients are when they leave your class. Great, you did an hour of Pilates, but what happens when you need to go out and run around a soccer field and play a sport? It’s not that we’re not cueing specific muscles, but that we’re also trying to do it in the most intelligent fashion.

DISTRIBUTION OF MOVEMENT EQUALS DISTRIBUTION OF FORCE

BA:  Most of you who follow Polestar know the phrase ‘distribution of movement equals distribution of force’. Shelly puts this into some very clear words, which I’d like her to share because I think this ties into efficiency and how important mobility is. 

SP:  As Pilates teachers, we have all likely encountered a student in class saying ‘I can’t do a roll-up because I am not strong enough’. The teacher might say ‘Ok, we will get you stronger’, but the client is likely perfectly strong! 

The working model in my head is the way our bodies are constructed, all the different joints, ligaments, tendons, muscles, and fascia, are all built to function the way they were meant to function. Unless something significant happens, like an accident or surgery, we are built to move and to be strong.  

BA:  I love that! That is one of Eric Franklin’s great phrases “we are built to move well”.

SP: Of course sometimes life can get in the way. We maybe don’t move as much as we could, or we move too much in a certain way. All of the different habits and behaviors of life happen. A lot of those “movement places”, the joints, don’t move enough, and some move too much. The muscles become deconditioned and we don’t utilize them in all the ranges of motion. Now we are relatively weak in comparison to when everything moved well.

Six Tips To Better Cue The Breath in Pilates

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By Polestar UK Mentor Kristin Loeer. If you are interested in learning more about Kristin’s approach to working with the breath in Pilates you may be interested in the upcoming workshop “The Movement of Breathing” which will be hosted by Polestar Pilates UK in November 2022.

I have never met a client who was not confused or insecure about the nature and function of their breathing. In fact, I have never met a client who, when asked about it, did not assume that they are “probably breathing badly”. People are exposed to plenty of breathing cues in Pilates and Yoga classes. Outside of the studio, there is also an abundance of breathing practices and breathing apps.

So why is there such confusion and lack of confidence about breathing? And secondly, I dare ask, do we, as movement professionals who cue breathing all the time, feel all that confident about it ourselves?”

After all, we may have learned that thoracic breathing is the way to go. Or we were told that deep diaphragmatic breathing is important. We may feel compelled to remind people to take deep breaths during movement because we see their tendency to hold their breath. Then again we may wonder about the exhale because if we do not breathe out we can not take in fresh air either. When we add Pilates to the equation and start talking about inhaling and exhaling in relation to movement we can easily overwhelm our clients, if not ourselves.

The Breath as Autonomic and Conscious Process

The reason why the subject of breathing causes never-ending confusion is that breathing is both a very finely tuned autonomic process, as well as under our conscious control. Hence it can be altered, but we may wonder whether it should be. This will always have a very complex impact on the rest of our being. 

Just like digestion or heart rate, breathing is orchestrated largely by our autonomic nervous system. The autonomic nervous system is influenced by our life experiences. It is constantly responding and adapting to external and internal changes. Its main concern at all times is homeostasis and survival.  

The Breath As A Tool

As mentioned, unlike heart rate and digestion, breathing is also under our conscious control. I can choose to lengthen my exhale or to hold my breath. I do not have the same control over my heartbeat or digestive processes. This makes breathing such a powerful tool. We can use it when we want to become calmer or more alert and of course, it gives us the opportunity to optimize movement through breath. 

I am a practitioner, who specializes in somatic trauma work. My belief is that it is important to remember that while we can alter our breathing and create powerful change through it, breathing is a carefully and deliberately orchestrated nervous system process. No matter how inefficient or dysregulated a client’s breathing pattern may seem, in my experience, it is never random. There is no such thing as “lazy breathing”, “wrong breathing” or “I forget to breathe”.

There is nothing the nervous system does without good reason or without its key concern being survival. 

This does not mean that we should not work with our breath. It means that we need to go about it gently and respectfully. We need to be aware that there is a reason for the client’s current breathing pattern, and that if we try to alter it, there may be pushback from the client’s nervous system. We can bring about positive change indeed if the nervous system recognizes that this change in breathing is helpful. On the other hand, if we are not careful we might promote a messy interference with the nervous system’s autonomic process, which does not serve the client well.

Here are my six top tips for how to work with the breath in both private Pilates sessions and group classes:

1. Observe The Breathing Pattern

Particularly in private sessions, we have the opportunity to observe our client’s breathing both in stillness and motion.

Let’s not be too hasty with our wish to help them use their breath better. Let’s be curious about what their body is naturally doing. Also, consider how breath might change automatically as we work with using other cues. It is very possible that your soothing voice or their awareness of their body’s movement against the ground settles their nervous system. This alone might regulate their breathing without you having to address it directly.

2. Make Breathing Cues Relevant To The Client.

As with movement, respond to what you are observing rather than using generic, popular cues.

Some people do indeed breathe shallowly. Others have already been told they do so and are now stuck in compensating patterns of excessive abdominal breathing. Many people inhale more than they exhale, however, there are also a fair few people who stretch their exhales and barely feel the need to inhale. The point is that no one person breathes the same and we need to be careful not to generalise and give people cues that are not useful to them.

3. In Group Classes: Offer Different Breathing Cues To Explore.

In group classes, it is much harder to observe and attend to individuals of course.

We need to be aware that not one breathing cue will work or be right for everyone. Let’s provide different options so that they can explore and be inspired by the cues that feel good to them. You might ask them to become aware of how much they breathe in compared to how much they breathe out. You might suggest they try out opposite options within an exercise to let them decide what feels right for them. Also, give people the option to ignore the breath-related cues altogether. They may simply not be in a place where they feel safe to explore their breathing patterns. 

4. Use Positive And Invitational Language

Whether you work with individuals or a group, when it comes to breathing I strongly recommend using invitational language.

Let’s remember that the nature of our breathing is closely linked with our sense of survival. It is important to put the client in charge of their breath. Encourage them to be present and curious with their breath. Reassure them that while they may want to try out making changes, their natural breathing is not wrong and they can return to it whenever they want.  

5. There Is No Failure. 

A client may simply not be able to access the shift in breathing we are encouraging them to find.

This may bring about a sense of failure in the client. Let’s remember that the nervous system always has the final say and if it does not deem a change safe it will not allow it. You can communicate this to the client by explaining how their body is “saying no” to this today and how over time it can change its mind”. Encourage the client to explore and “play with this again later.”  

6. Bring Awareness To The Impact

If the client’s breathing does change, allow them time to experience this without adding any further new information or cues.

It can take a few minutes to explore this and to become aware of the holistic impact this change has had. They may feel calmer, stronger, or experience more flow in the movement. This positive shift is really worth exploring! It has the potential to integrate and perhaps become the new normal. They may become emotional, anxious, or irritated and feel their movements ‘disintegrate’. It is important for the client to experience whether this shift is positive for them or not. They can revert back to their previous way of breathing if they need to. 

If you would like to learn more about my approach to working with the breath in Pilates you may be interested in my upcoming workshop “The Movement of Breathing” which I will be running for Polestar Pilates UK in November 2022. For more information please contact me @kristinloeer_movement .

Kristin Loeer

5 Ways Pilates Can Support Your Mental Health

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“If you can relate to overwhelm, anxiety, or perhaps being ‘tired and wired’, then read on for ways in which Pilates as a practice can help you, and support your positive mental health.”

Sarah Edwards is a Doctor of Education and Comprehensive Polestar Graduate of Polestar Pilates UK.

Pilates is often promoted as being great for ‘core strength’ or ‘reducing back pain’, both of which it certainly can do. (I know, as back pain was the main reason I took up Pilates in the first place). Through personal experience and in teaching clients in private and group settings, I now know that Pilates has consistently supported me in managing my own anxiety. The practice can be instrumental in supporting the positive mental health of others.

Prior to teaching with Polestar and while I attended my weekly Pilates class, I was working as a Teaching and learning director in higher education. I completed a Doctorate in Education, raised a family, and I also experienced a number of traumatic experiences regarding my children’s health. Not surprisingly, I was diagnosed with Generalised Anxiety Disorder. 

Thankfully, Pilates really brought me out of that very busy headspace and, at times, my overwhelm. My experiences led me to train with Polestar as a Comprehensive Practitioner. I also trained as a mental health first-aider and, safe to say, I haven’t looked back.

Joseph’s Mind-Body Method

Joseph Pilates advocated a mind-body practice much before his time. In many aspects of holistic health, the context of “typical daily life” has changed in drastic ways. Modern lifestyle habits including chronic sleep deprivation, poor nutrition, and even social media use and ‘doom scrolling’, have fuelled the anxiety epidemic. Mental Health disorders, including anxiety, have also increased as a result of the COVID-19 pandemic. While the context has changed, the practice of Pilates, for the main part, hasn’t.  

How can Pilates specifically help? If you can relate to overwhelm, anxiety, or perhaps being ‘tired and wired’ then read on for ways in which Pilates as a practice can help you, and support your positive mental health.

1. Regular Practice

Pilates as part of your regular schedule will interrupt your overthinking and helps ‘press pause’ on any overwhelm. In our digitized, and always “on call” culture, we need to step away from our devices, and literally and figuratively “switch off”.

2. Break The Cycle

In turn, positive movement experiences can help break the chronic stress cycle. Chronic stress affects the nervous system, and influences related anxiety disorders. Stress can also have profound physiological effects. The long-term stimulation of the fight-or-flight response leads to the constant production and secretion of hormones such as cortisol. Long-term excessive cortisol is associated with a variety of consequences, including diabetes and cardiovascular disease.

3. Connect With The Breath

Pilates focuses on breath (it’s the first Principle of Polestar Pilates). Focusing on the breath, and particularly an extended exhale can help access the parasympathetic nervous system. This sends signals to the brain that all is well. The parasympathetic nervous system is responsible for the “rest and digest” function of the body which is why you can likely hear your digestive system at work once you relax!

4. Practice Embodyment 

A skilled teacher will give you both internal and external cues that allow you to move in a mindful way. When you focus on the internal sense of your body (interoception) you cannot be thinking about your overwhelming to-do list. Teachers who have also embraced an element of psychological fitness training (such as with Polestar) can also help clients come out of their ‘thinking brain’ by stimulating the vagus nerve. This can support reducing stress, anxiety, and even depression.

5. Empowerment

The benefits in strength, posture, and mobility you gain from Pilates can help your self-confidence (we call this self-efficacy) and your self-esteem. Any positive movement experience will release endorphins, and hormones that will reduce pain and stress, and improve your mood.

Sarah Edwards @positivepilateswithsarah is a Doctor of Education (with specializations in Teaching and Learning), a Comprehensive Pilates Instructor with Polestar, and a Mental Health First Aider. She is particularly interested in promoting Pilates for mental health and runs one-to-one, and on-demand classes from her recently completed garden studio in England (gardening being another of her passion projects)!

References:

i Vora, E. (2022) The Anatomy of Anxiety. Harper Collins publishing.

ii Mental Health First Aid England, 2020.

iii The Parasympathetic Nervous System (2022) Brittanica Science. Available at : Sciencehttps://www.britannica.com/science/parasympathetic-nervous-system (accessed 8th August 2022).

iv The Counselling Directory. What is the vagus nerve? Available at http://www.counselling-directory.org.uk/member-articles Accessed 24th August 2022.

v As a Mental Health First Aider (1) I am trained to recognize when someone is struggling with an anxiety disorder, depression, or psychotic episode and to signpost them to appropriate help. It is not within my scope to diagnose these conditions.

How To Maximize Neuroplastic Processes: Keep Your Clients Focused!

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Watch #PilatesHour Episode 120 “Neuro-Concepts And Pilates” with Brent Anderson and special guest Kate Strozak MSc Applied Neuroscience, LMT, NCPT. New to Neuro-Concepts? Check out the blog “Fascinating Neuro-Concepts You Need To Know As A Pilates Instructor”.

BA:  As Pilates teachers, how do we make what we do in one or two hours a week potentially influence a positive neuroplastic change? We know that one or two hours a week may not be enough to influence this. What else needs to happen, and what needs to be influenced in that one or two hours a week? 

KS:  Giving people good appropriate challenges is really important for this process.  Also, I try to stimulate them in multiple ways.  The use of imagery is incredibly impactful and profound for people to help them embody these new experiences. Imagery helps them build different relationships between a movement and their perception of that movement or their relationship to that movement.

Many of these things are built into the Polestar curriculum actually!  Utilizing imagery, utilizing tactile cueing in order to tie in sensory nerves and proprioception thus integrating the brain on another level.

Kate Strozak

Now more than ever I talk to my clients about their sleep habits. I remind them it’s out of the scope of my practice, and that I am not a professional sleep consultant. I encourage them if they feel like their sleep could be better quality than it is right now to reach out to a sleep professional and get some help in that arena. It’s when we are in our deep states of sleep that a lot of these neuroplastic changes occur in our brain.  

Being “Chatty” With Clients

Another important thing is mindfulness. Prior to studying neuroscience, I was inclined to be chit chatty and casual with my clients. In part, thanks to Alexander Bohlander and my experience with him in his meditation workshop at the Polestar experience I dove deep into studying mindfulness and meditation. It’s fascinating the effects of these on the brain and profound in terms of stress reduction and sleep quality.  If you are doing something that supports the quality of your sleep you are, therefore, hopefully then supporting the process of neuroplasticity.  So it’s a very long-winded answer to say there is a lot!

BA: That is excellent Kate!  I just learned this year from an Andrew Huberman podcast about the idea of neuroplasticity occurring typically when we’re sleeping.  We challenge the body and challenge the nervous system during the day, challenging ourselves to learn.  I’ve been using this with the students at the university as well. Especially the ones who are struggling with retaining information or integrating and synthesizing information.  It’s so interesting that it’s the sleep that is going to allow you to synthesize this information.  This leads into the “interleaved” learning where we’re stressing you a little bit to recall information to make it challenging and difficult.  At first, you can’t remember what it is, but when you go back and look at it again after the stress of trying to remember it (and a good night’s sleep), it is amazing the amount of synthesis that happens on the following day or two of processing that information.  

Creating Demand And “Struggle”

The same thing is true with movement of course and some of the things you mentioned.  If I could get my client to remember what we did last week, “do you remember where your body was when we had that really good experience? “Can you show that to me again?”, and maybe they fail, that’s ok.  They are trying to figure it out and recall it, but that’s the internal feedback and the mindfulness that we’re talking about that allows information to be synthesized.  They need this demand and the struggle of the recall. And don’t just give it to them and show them, let them struggle with it, we don’t want to make it so easy.  We want them to understand that struggle is good, that failure is good, and that these are learning processes that will help them in the long run. If we don’t challenge them with that struggle we don’t challenge the nervous system to change.  

KS: Absolutely, there is no incentive to change if you are not being challenged or having that moment where you have those slight releases of cortisol and adrenaline. Your palms start sweating and we have to have those moments, it’s part of the human experience.  

I don’t know about all of you but I was very prone to just having casual conversations with my clients. When the client has done footwork a million times with me, which in and of itself presents another problem, but if I’m talking with them about something, I’m taking them out of their experience and out of their body, so I limit that.  I’m not cold or stoic and not available to them but I really get them to focus on what they’re doing and to really be present and attentive to their movement. 

If I’m talking with them about what they are doing this weekend, they start thinking about it and they are not aware of what their body is doing at the present moment in time. 

Kate Strozak

BA: I really appreciate you saying that.  Our friend Polestar Educator Juan Nieto calls it “being the butler”, and I call it “gum holding”. The point is that we get into a chatty, chummy kind of relationship with them and were really not challenging the nervous system. We become a “paid friend” in that situation.  If they are doing the same thing they always do with you, you are not challenging any improvement or any change other than maybe being a listening ear.  Even worse when we bring our own problems to our clients.  

Supporting Neuroplastic Processes

In group classes when there is flow and purpose, there is more internal reflection going on and feedback that is more likely to create change than in a chatty one-on-one session.  We can create incredible challenges and demands on the nervous system when we’re working with a group of ten people.  If we’re not having that same intensity with our clients one-on-one they are not going to have the same neuroplastic challenges.  

KS: And if you’re not supporting these neuroplastic processes then what are you doing? The neuroplastic process is just a really fancy way of saying that you’re helping to create a repatterning, working on movement efficiency, or working on a tissue adaptation.  If you’re not really supporting those processes you’re not really supporting the longevity of the Pilates work you are doing with them.  So maybe Brent, you, and I are suggesting to everyone that our challenge to you is to try to support more quiet and focus in your pilates sessions.  If your client` is really keen on talking and carrying on a conversation, you might not be challenging them enough!  There is a time and place for all of it as you know!  

BA:  Let’s see how chatty they are when it’s time for jackknife…time for hip circles!

KS: Yes! Can you juggle while doing feet in straps?  

Watch #PilatesHour Episode 120 “Neuro-Concepts And Pilates” with Brent Anderson and special guest Kate Strozak.

Do You Really Understand Osteoarthritis?

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Gain insight into osteoarthritis and discover the benefits of Pilates for osteoarthritis prevention in this exclusive conversation with Polestar faculty Brent Anderson PT, PhD, OCS, NCPT, and Beth Kaplanek RN, BSN, NCPT. Watch the #PilatesHour Webinar “Working With Clients With Osteoarthritis” and take your understanding to the next level in our online course “Osteoarthritis of the Hip & Pilates”.

BA:  We’ve been talking about positive movement experiences since the first time we met. How do we create these positive movement experiences? Osteoarthritis (OA) of the lower extremities is the best topic to talk about regarding positive movement experiences. The research all points clearly to this!

BK: As you know, osteoarthritis is the most under-recognized chronic condition out there. The wear and tear are present in almost all individuals on some level, whether you are exemplifying symptoms or not. 

59.4 million Americans have some sort of arthritis and if we look at it globally it’s much bigger. If you take hip, knee, hand, and spine, we’re talking about the fourth largest global disability. 85% of this osteoarthritis is related to the hip and knee.  

There are many different types of arthritis. We are talking specifically about osteoarthritis which tends to be more about wear and tear. But there are definitely some systemic inflammatory conditions that can cause osteoarthritis besides just wear and tear. 

What is Osteoarthritis?

Osteoarthritis is a breaking down of the articular cartilage. Exposed subchondral bone, underneath the articular cartilage, is supposed to slide and glide and move beautifully. It’s also bathed in synovial fluid. The articular cartilage needs this nourishment to stay healthy.  

When you have irritated synovial fluid, in addition, to wear and tear, the breakdown of cartilage creates an inflammatory contusion. We want to work on the things we can do to create an anti-inflammatory environment. This creates the best environment possible to keep that nourishment going properly for the articular cartilage so we have less breakdown. We want to get to a place where we have a little homeostasis. This will hopefully delay and deter the breakdown of the articular cartilage.  

Osteoarthritis today is not only occurring in older people. There is a major increase of individuals between the age of 40 and 55. It is amazing how many more people are suffering from osteoarthritis these days. When it gets severe, it’s a total joint failure. One in two Americans and two in three obese people will likely get knee osteoarthritis. The knees seem to be the leading joint where osteoarthritis is found. 1 in 4 Americans, or about 25 percent of the population, will develop hip osteoarthritis, and it’s very costly. 

Not just costly for the amount of care you need, but costly to the individual. They lose work and time, and can’t make the money they need which also affects their well-being and quality of life. There’s a lot to it, and the pathogenesis of osteoarthritis can get very deep – the chemistry. What we can do is create a beautiful environment to deter or prevent further breakdown. Pilates is great for this!

BA: Something that comes to mind is the importance of students knowing the leading causes of excessive stress to the knee. Especially since the knee is the primary joint where osteoarthritis occurs. I often challenge them with this question:

Where is a place where you have decreased mobility leading to knee wear and tear? 

The answers are lack of ankle mobility, dorsiflexion, hip extension, and deceleration strength in the hip and pelvis. These are some of the leading causes of excessive stress through the knee leading to the loss of congruency. Because the knee is always load-bearing in humans, because we are bi-pedal animals, it takes a lot of the brunt of that wear and tear. If we work backward, how can we improve alignment, congruency, and distribution of force? These are the fundamental components of prevention.  

BK: Yes, lack of hip extension and dorsiflexion are the two biggies. We can also add a lack of thoracic extension and balance on the lateral line of the body to that list. These are the very things we can target in our Pilates programs.

Looking at a 2017 Study from the Journal of Orthopedic and Sports PT, we can see the highlighted reasons that are causing OA. We see that 25% of knee pain is related to obesity. We also see that high BMI has increased overall in males and females ages 15-49 which contributes to the increase in global osteoarthritis. The five major contributors to osteoarthritis are obesity, traumatic injury to the knee, femoral acetabular impingement (FAI), hip dysplasia, and sports injuries.

We see more young people playing sports and see a lot more ACL injuries early on, along with meniscal tears. Both of these can develop into knee osteoarthritis in a person’s lifetime.

The five major contributors to osteoarthritis are obesity, traumatic injury to the knee, femoral acetabular impingement (FAI), hip dysplasia, and sports injuries.

When we get into the hip we’re talking about femoral acetabulum impingement and hip dysplasia. These can have a 10-fold increase in progressing to end-stage hip osteoarthritis within 5-20 years. 

We also see osteoarthritis develop due to high-impact sports like wrestling, distance running, soccer, and weight lifting – these are definitely players as well. Of course, if you are not recovering, rehabbing correctly, maintaining the congruency in the joint, and doing all of the other anti-inflammatory things you need to do, that causes a progression as well. 

BA: A lot of our students answer running when we ask what the causes might be. I want to make it clear that although there is a stereotype out there that running is bad for the knees, humans are designed to run! I will say that jogging may not be as natural human locomotion as others, but walking, running, and sprinting are.

Jogging seems to put an abnormal amount of stress on the knee. Especially if you run with a heel strike, and more if you don’t have the ankle dorsiflexion that you are meant to have. If you visit countries where they still squat a lot, they do not have the same incidence of knee pathologies as elsewhere. These are areas where they are squatting to go to the bathroom, do work, socialize, and rest specifically with the heels down.

Register for our upcoming #PilatesHour Webinar here. Deepen your understanding of osteoarthritis in our online course “Osteoarthritis of the Hip & Pilates” with Polestar Faculty Beth Kaplanek, RN, BSN, NCPT.

Do You Really Understand Pelvic Floor Health?

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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.

Watch the #PilatesHour episode 110 “Pelvic Talk” here.