Why Your Pelvic Floor Needs Pilates and Yoga

With all the stressors in our daily lives, we often forget about one of the greatest life forces, our breath. Performance scores in academics, athletics, jobs and our professions have driven us to be over-achievers and breath-holders! I see it in my children, their friends and other adults...so many of us are on the hamster wheel. The culture is telling us that stress is normal and we just have to find better ways to cope. This is probably the reason yoga is being taught in physical education classes, in the workplace and academic settings as a way to de-stress. An understanding of how the core works and adding both Pilates and yoga to our exercise routines makes sense in our modern world.

While breathing is automatic, subconscious and controlled by the lower centers in our brain, mindful breathing involves higher centers in our brain and requires conscious effort. Mindful breathing involves awareness of our breath and slowing down the rate of breathing, by taking slow and rhythmic breaths. It is also referred to as diaphragm breathing or belly breathing.

Shallow breathing in our daily stressed-out lives encourages the upper respiratory muscles to do the work of breathing, creating compensations and muscle tightness throughout the entire body. When the right muscles are not working correctly, other muscles compensate to do the work for us. Take, for example, the hip flexors. One study showed that individuals with chronic pelvic pain had predominately an upper chest breathing pattern with high density and stiffness in the psoas muscles, one of the hip flexor muscles (Haugstad et al, 2006). Along with good posture, diaphragm breathing decreases the tension in our neck and shoulders and throughout our entire body since the brain receives the message that we are NOT in "fight or flight", or running from a tiger in the woods, via the autonomic nervous system. This should create a sense of relaxation, a lower heart rate and a clear mind to make better decisions so we can live life to the fullest.

Breathing is tied to so many functions in our body, including pelvic floor function. Core function is important for proper balance, lumbopelvic support, continence of urine and stool and sexual function. The diaphragm and pelvic floor are parallel to one another and work like a piston. During normal inhalation, the diaphragm descends and the pelvic floor is slackened or relaxed. When breathing is restricted, it could be caused by habitual breath holding, stress or a physical restriction in diaphragm excursion caused by muscle tension or adhesions. During normal exhalation, the diaphragm is drawn back up into the ribcage, pulling the pelvic floor up with it. If there a restriction in the pelvic floor, the diaphragm will also be restricted and vice versa. It is important for both the diaphragm and the pelvic floor to be mobile and free for the core to function properly. This is where our work as a manual therapist comes in. We ensure that every individual we treat has the proper breathing pattern in order to engage the core musculature correctly. Often there are restrictions in the abdominal wall that have to be addressed. At Healthy Core, we utilize visceral mobilization, a form of fascial mobilization to deep structures to improve function and encourage normal mobilty.

Mindful breathing is what is used in yoga, with the breath focused on using the nostrils and breathing through the nose for both the inhale and exhale. Yoga is an ancient practice and has been around for centuries. Pilates on the other hand, involves using the mouth to exhale, or huff, during the exercise. Joseph Pilates used pulleys and gravity for rehab in the hospital during WWII. In our clinic, we combine both yoga and Pilates principles, and encourage breathing in through the nose, and exhaling through the mouth. Think of yoga as the lengthening on the INHALE and Pilates as the contracting on the EXHALE. The artist Plumb describes this in her song, Exhale, with the lyrics "breathe in your grace, then exhale." Taking in a deep breath creates an openness in our hearts to receive grace, praise, affirmation and even constructive criticism. Our exhale is only as good as our inhale. So many of us are just sighing. Like many of you, I have to be mindful of my breathing to avoid holding my breath and tensing my pelvic floor all day long. Thankfully, I get to practice breathing all day long with my patients.

I have been treating men and women with lumbopelvic dysfunctions since 1998. When I first began to specialize in the field of women's health, we were taught that the pelvic floor has to be isolated. We instructed patients to do Kegels (pelvic floor exercises) using biofeedback with one lead of electrodes attached to the pelvic floor and the other on the lower abdomen. Patients often overutilized the abdomen to make up for pelvic floor incoordination and we discouraged them from using this muscle. Many years later, we learned that the pelvic floor is not a muscle that works in isolation, yet many therapists and practitioners are still using this approach and instructing patients in Kegel exercises alone. There are a few things wrong with using Kegels as a first line treatment for pelvic floor dysfunction:

1) The pelvic floor is tight, not weak, in most individuals with dysfunction. Physical therapist Rhonda Kotarinos describes this phenomenon as a "short pelvic floor" in her work on treating abdominal wall separation, known as diastasis recti. Doing Kegels or tightening a muscle that is already in a maximally contracted position, only makes the muscle tighter. So many individuals with pelvic floor dysfunction have myofascial trigger points, or spasmotic muscles that refer pain to a remote location. We often recommend mastering Reverse Kegels before tightening the pelvic floor. This means focusing on diaphragm breathing on the inhale to lengthen the muscle. Our motto is lengthen before you strengthen. Once the muscle has its normal range of motion and length-tension, then Kegels are prescribed. If doing Kegels makes the problem worse, the exercise is postponed until the pelvic floor and/or other structures that pull on the pelvic floor are returned to normal tension and trigger points are abated.

2) The pelvic floor does not work in isolation, but rather as a system with three other core muscles: the respiratory diaphragm, transversus abdominus and multifidus. Isolating the pelvic floor addresses only one-fourth of the problem, or only one of four muscles that are synergistic in action. Think of a straw in a cup of liquid that you plug the top of as it is pulled out of the liquid. When you release the top, the liquid comes out. Atmospheric pressure is what holds the liquid in the straw, not necessarily the plug at the bottom of the straw. According to the work of Paul Hodges, core activation must first involve the deep stabilizers including the pelvic floor, transversus abdominus, diaphragm and multifidus. It is the timing and sequencing of the muscles, not strength, that is needed.

3) Kegels are done incorrectly by many individuals. Since the diaphagm and pelvic floor work as a piston, the Kegel should occur on the EXHALE, with the diaphragm pulling the pelvic floor up, instead of down. Many individuals bear down or hold the breath, which is counterproductive and a waste of time. If the muscles are trained properly, then the timing and sequencing of the contraction happens automatically when lifting groceries, weights or during exercise, especially when involving impact such as jumping or running. To retrain the pelvic floor/ diaphragm piston, it is best to eliminate gravity and lie on your back (see diagram above). Perform 6- 10 repetitions at a time regularly throughout the day to train your muscles. It is important to note that the pelvic floor must be lengthened BEFORE it can be strengthened. Doing Kegels with tight and dysfunctional muscles is like doing bicep curls with weights and moving only a few degrees due to a stiff elbow. You are not really getting anywhere and it is time wasted trying to contract what is too tight. Other helpful hints to do Kegels correctly include:

Imagine your pelvic floor is a hammock and you are trying to draw the hammock up inside your body. Begin in a lying down position to eliminate gravity. Progress to a sitting position and eventually standing, where the pelvic floor is unsupported.
Imagine your pelvic floor is a horizontal elevator when lying on your back. At the end of the inhale, the muscle should be on the basement floor (towards your feet) and at the end of the exhale, on the 4th floor (towards your head). The pelvic floor should move up and down gradually, with each rhythmic breath, floor by floor.
Place your hand on your perineum, over a thin layer of clothing. As you exhale, you should feel your pelvic floor move away from your hand, or drawn inside your body.
Imagine you are stopping a stream of urine, as if giving a urine sample in a cup. Do NOT do this before urinating, however, or it will confuse your bladder and you will have urinary retention.
Imagine you are stopping gas or flatulence. One of the pelvic floor muscles is named levator ani since the anus is lifted with a pelvic floor contraction.

By incorporating Pilates and yoga into your exercise routine, you will improve CORE function and positively affect other systems of the body. If breathing is restricted or you need help retraining proper breathing patterns, get help from a physical therapist that specializes in the treatment of the pelvis. You can schedule a 15-minute FREE virtual consultation here with one of our pelvic floor experts. Here's to breathing well and being healthy to the core!

*Disclaimer: exercise should NEVER cause or increase pain during or afterwards. Consult with your health care provider if you are unable to exercise without increasing symptoms. If you are new to yoga or Pilates, begin with a fundamental and basic level before jumping into an advanced class.*

Illustration by Cindy Hudson

References:

Haugstad and Haugstad (2006). Posture, movement patterns, and body awareness in women with chronic pelvic pain. Journal of Psychosomatic Research.

Kotarinos and Fitzgerald (2003). Rehabilitation of the short pelvic floor I: background and patient evaluation. International Urogynecology Journal: (14) 261-268.

Hides, Jull, Richarsdon (2001). Long-term effects of specific stabilizing exercises for first-episode low back pain. Spine: 26 (11): 243-248.

Hodges P (2003): Core stability exercise in chronic low back pain. Orthopedic Clinics of North America. 2003: 245-254.

written by Janine Laughlin, PT - October 2015; revised October 2023