The traditional and the modern approach to pelvic floor exercises
by Sarah Fishburn
All healthcare professionals tend to agree that a strong pelvic floor (PF) is important in women as these muscles are vital to good continence and to maintain sexual pleasure, as well as preventing pelvic organ prolapse (where one or more organs descends into the vagina – these organs are usually the uterus, bowel and bladder). Age, weight and childbirth can all contribute to the weakening of the PF in women.
There’s quite a lot to say on this subject because there are at least two schools of thought concerning how to do PF exercises. We will stick to the two main schools: the traditional approach and the newer techniques; a brief explanation of each is given below.
The traditional approach to PF exercises – in a nut shell
Traditionally, the idea was to strengthen the muscles around the anus and the urethra by contracting them (often described a ‘drawing in’ or ‘zipping up ‘ by increasing a tight hold in the muscles from the anus to the front of the urethra). If you have consulted a women’s health physiotherapist within the NHS over the last 20 years, the approach may be similar to this although some practitioners who were trained more recently may adopt a newer approach. The traditional technique usually involves ‘finding’ or identifying the correct muscles by seeing which can inhibit the ability to urinate (N.B. in recent years practitioners have suggested that this is necessary only once and briefly to locate the correct muscles, because halting the stream of urine can be detrimental and can cause additional problems). Depending on how weak the practitioner finds the PF muscles (by inserting a finger internally and encouraging the woman to demonstrate the strength of ‘grip’ on the fingers), a certain number of exercises will be suggested and these usually include a mix of slow and faster ‘holds’ so that the muscles increase their strength over time (roughly three months) and are sufficiently strong to keep the bladder outlet closed. This approach is similar to the example given in the ‘A problem with the waterworks’ article and certainly seems to have worked for its author.
The newer approach/modern view of PF exercises – in a nutshell
Over the last ten years (and possibly longer), the traditional approach to PF exercises has come in for criticism. This is because there is a concern that concentrating solely on doing strengthening exercises for the PF can actually make a weak PF worse. The idea is that just trying to uniformly tighten the PF can be a bit of a blunt instrument and insensitive to the complexities of the PF muscles. This approach recognises that there’s too much emphasis on tightening the muscles of the PF and that overtight, tense muscles (that are over-taut) then become out of balance and can increase weakness rather than resolve it. This modern view gives as much consideration to relaxing the muscles as to stimulating them. So the aim is to find which muscles are working hard and which are underperforming and encourage all to work equally with sufficient opportunities to relax. The end result is to ensure there’s a balance and unity to muscle stimulation to enable improved function.
The modern technique usually involves a number of treatment techniques to help reduce tension in the pelvic floor, release tight muscles and improve the performance of weaker muscles. In some instances, the manual therapist uses fingers internally to reach deep muscles and release trigger points where muscles are overworked. Practitioners of this approach often take a holistic approach to the question of PF function and see how the whole body is functioning. This is because there’s recognition that we often hold tension in our bodies and restrict our breathing and movements e.g. by shallow breathing or breath-holding, or adopting standing or sitting positions where muscles cannot function properly or reach a relaxed state. Old injuries and pains can make us compensate and this too can have a negative impact on how we carry ourselves. So the practitioner may review more than just medical history to take in current standing, sitting and walking positions, etc, in order to check that the body is able to work efficiently and freely and is given scope to relax. As a result, breathing techniques may be offered to help release overtight muscles which may be over-worked and inefficient sharing parallels with the PF muscles. The aim is to retrain and instil helpful habits where the muscles work, relax and function effectively again.
For more information
Numerous websites have been created by physiotherapists to offer more information about PF exercises that reflect the more modern approach as outlined above. Be aware that not all ‘new approaches’ might agree in every detail but most seem to advocate the importance of relaxing muscles and breathing deeply to avoid over emphasising strengthening exercises which can overwork muscles so they instead become weaker. You might find it helpful to look at these to learn more about the benefits before starting to look for a physio to treat PF dysfunction. Two websites that are worth looking at for more information include:
Maeve Whelan is a Specialist Chartered Physiotherapist in private practice in Dublin. If you visit Maeve’s website, you can see that she advocates the ‘new approach’ to pelvic floor exercises to address bladder dysfunction (and Maeve also includes bowel dysfunction). Much depends on our awareness of holding tension so that we can actively work at releasing it. Maeve outlines some of the techniques that can help and why they are useful to practice. She also offers a ‘Release to Balance DVD’ which she has produced and can be bought through the website.This DVD goes into detail and demonstrates the techniques Maeve uses to improve the PF.
Samantha or Sami is an Australian trained and registered physiotherapist who graduated with a Bachelor of Physiotherapy from the University of Queensland in 2010. Since then she has worked primarily in private practice with a focus on pelvic health and peri-natal care, providing education to pre and post-natal women, yoga teachers (including teachers in training), doctors and other health professionals. Sami also favours a ‘new approach’ to pelvic floor dysfunction. She says that in order to resolve pelvic floor dysfunction over the longer term, it’s essential to look at the whole body to raise awareness about alignment, how to stand, move or squat as naturally as possible. She has a regular blog which also outlines the benefits of relaxing the abdomen and avoiding the tendency to ‘suck’ in the stomach as this tension can cause problems for basic functions like digestion and the pelvic floor. She offers a number of blogs about how to go about managing the pelvic floor to improve its function.