According to physiotherapist Dr Pauline Chiarelli, pelvic floor problems can effect as many as one in three women. If you came to see us for advice on rehabilitation and help with an injury you would quickly notice that we ask questions that are not just related to your present concern but also questions about your health in general. We do this for a number of reasons; primarily we does this so that we can put your current concern into context but also it allows us to see if you have any other problems that you might have thought were “just normal”. When we ask these questions our clients frequently mention some sort of pelvic floor dysfunction with which they have just learned to live.
Is pelvic floor dysfunction more of a female than a male problem? Scientists, Ireland and Ott, say the male pelvis is denser and the bony part of the pelvis is generally smaller in diameter allowing faster coordination between all the muscles. This denseness combined with the smaller area means that the male pelvic floor is less likely to become dysfunctional. Conversely, the female pelvis is less dense and wider, as the bony structure is designed to house and deliver a baby. This means that the female pelvic floor is more susceptible to decreased strength and coordination between the pelvic floor muscles.
How is your pelvis meant to work and why do people get problems e.g. incontinence? In normal posture the pelvis should be anteriorly tilted allowing the bones of the pelvis to provide support to the internal organs, muscles, ligaments etc. In females the bladder is supported by the pubic bone at the front, which, in turn, creates support for the uterus. A large proportion of women with problems stand with a posterior pelvic tilt and decreased lumbar spinal curve. This puts more pressure on the pelvic floor by taking away the bony support from the bladder and uterus and creates pelvic floor problems. The good news is that this can be helped learning to correctly move your pelvis…. I will discuss a little later how to correct pelvic floor problems with exercises that are much more comprehensive than Kegals.
When looking at the muscular support of the pelvic floor it is useful to look at other muscles involved in its correct function: the abdominals, the spinal muscles, the hip and the respiratory diaphragm. These muscles work as a functional group. For example, as the respiratory diaphragm contracts it lowers, drawing air into the lungs, as it lowers it causes the organs that are underneath it to move downwards. This increased pressure in the abdominal cavity gently puts pressure on the pelvic floor causing a harmonious movement between the diaphragm and the pelvic floor. The pelvic floor assists in lumbopelvic stability (Markwell 2001) along with the muscles of the lower back, hips and abdominals. Anatomically there are connections as well; one of the hip muscles, the obturator internus, and part of the pelvic floor, the levator ani, are connected by a common tendon, the arcuate tendon. This means that if there is restricted movement in one or both of the hips, perhaps from arthritis, tight muscles or even ankle injuries, part of the pelvic floor will also be affected.
So it’s more than just the pelvic floor muscles then? Due to the interconnected nature of the pelvic floor and the muscles of the low back, hips and abdominals we always look at the “pelvic core neuromuscular system” or PCNS for short. This term was originally coined by my friends and colleagues, Christina Christie and Rich Colossi, physiotherapists specializing in pelvic floor dysfunction. By taking this approach we can determine if the current pelvic floor problems are actually being maintained by other things like poor posture, faulty breathing patterns or even by some thing as far away as an old ankle injury! Physiotherapist Gary Gray argues that in order to get the pelvic floor functioning optimally all the structures of the PCNS should be integrated subconsciously. For example, you don’t have to think about bracing your leg muscles to stop you from falling over, it just happens, and that should be the case for the pelvic floor as well. You shouldn’t have to consciously tense your pelvic floor to prevent leakage – it should just happen.
What is pelvic floor dysfunction?
It can take many forms, including but not limited to, pelvic pain, pelvic-organ prolapse, anal incontinence and urinary incontinence. Urinary incontinence can be subdivided into three categories:
- Stress incontinence– involuntary loss of urine with an increase in intra-abdominal pressure e.g. a sneeze or a hop causes a small leak of urine.
- Urge incontinence– the urge to empty your bladder with only a small production of urine.
- Frequency incontinence –urinating more than eight times in twenty four hours.
So what is normal? Generally you should be urinating every two to four hours during the day and zero to once during the night (although pregnancy does temporarily increase the incidence of urinary incontinence).
Are there any other problems I may have due to pelvic floor dysfunction? When we are talking about urinary incontinence it is worth noting that the loss of control and coordination of the pelvic muscles puts strain on other structures in the body. Many people do not realize that their back pain, sacroiliac dysfunction, sciatica, knee pain and ankle sprains could all be coming from dysfunction of their PCNS, and visa-versa.
What is an effective way to correct these problems?
Due to the PCNS’s highly integrated nature with the rest of the body it doesn’t make sense to continually isolate it and rely on exercises like Kegals. That would be like treating a sore knee that was caused by limping due to a sprained ankle. The ankle should be treated first, otherwise the knee pain will just keep coming back. Having said that, there are circumstances where specific pelvic floor work such as Kegal’s are useful, but if you are able to, it is more beneficial to strengthen the pelvic floor in an integrated way.
So what do we recommend to strengthen it? In order to create an environment where the pelvic floor and it’s functionally related muscle groups (diaphragm, low back, hips and abdominals) are working subconsciously we need to exercise the body in all three planes of motion using both the arms and legs to ‘drive’ or move the body to create a specific load to the whole complex of functionally related muscles.
Move over Kegals! Introducing the Pelvicore Exercise Ball…This simple device was developed by physiotherapists Christie and Colossi to help their patients get faster and better results from exercises they were doing. It consists of a small inflatable ball that fits between the knees and an elastic strap that goes round the thighs holding the ball in place. Strengthening the hip muscles becomes easy when wearing the pelvicore ball because if you step out to the side all the lateral hip muscles have to work against the resistance of the elastic strap and when you step back all the medial/adductor muscles work against the pressure of the ball. Depending on your level of ability exercises with the pelvicore ball can vary from simply sitting and slowly moving your legs apart and then back together to exercises that involve squats, lunges and alternate hand drivers. These are whole body exercises that involve all aspects of the PNCS right from the ankle up to the neck.
Try this exercise suggested by Christie and Colossi:
The Pelvic-Hip Complex Pivot Shift Matrix
- See if you can balance on one leg for about 10 seconds, if you can continue, if you can’t then practice that before you try this.
- Start with the more successful side, in this example we will stand on the right leg and move the left leg through space
- Sagittal Plane:Stand on your right leg and swing your left leg forward and back, do it with control, repeat 10 times.
- Frontal Plane:Still on the right leg take your left leg as far to the left as you can and then lightly touch your toe to the floor, taking care not to put weight on it. Then return to the middle, pause and take your left leg to the right across the body in front or behind, gently toe touch a the end of range, repeat 10 times.
- Transverse Plane:Again, on your right leg rotate your whole body to the right pivoting on the right hip, once you have gone as far as you can rotate to the left gently touching your left toe to the ground if you loose balance, repeat 10 times.
- Repeat all the above on the other side.
What Next? If you thought you were resigned to doing Kegals for the rest of your life you now know there are alternatives that may work better for you. Clients often ask us what they can do at home to help prevent problems returning. The pelvicore ball provides a simple, easy to use exercise program that can be done at home to exercise the
PCNS properly. We are the only suppliers of the pelvicore ball in western Canada. We are confident that for the one in three women who suffer from pelvic floor problems this offers a chance for them to get stronger and more flexible. What a relief to not be in fear of the familiar accidental leak that can happen all too easily when the pelvic floor is not working properly!
References
Chiarelli, P. 2002. Women’s Waterworks: Curing Incontinence. Wallsend, NSW; George Parry.
Christie, C., & Colossi, R,.2010. Paving the way for a healthy pelvic floor: Turn on the Pelvic Core Neuromuscular System with triplanar movement and functional education. Idea Fitness Journal.
Gary, G., & Tiberio, D. 2010. Seminar. Chain reaction transformation. The Gray institute.
Ireland, M.L., & Ott, S.M. 2004. Special concerns of the female athlete. Clinics in Sports Medicine, 23 (2), 281-98.
Markwell, S.J. 2001. Physical therapy management of pelvic/perineal and perianal pain syndromes. World Journal of Urology, 19 (3), 194-99.