Category Archives: Pelvic Floor

How you can help your pelvic floor

I was asked by someone this week about rehabbing the pelvic floor post birth, in preparation for getting back to running.  I was so pleased that she was aware of the importance of taking her time – things keep popping up in my timeline about postnatal classes where people are running with buggies, skipping and even doing jumping jacks! All of this can have a deleterious effect on the pelvic floor and continuing to overstress a weakened pelvic floor can lead to prolapse.

However taking your time, making a few lifestyle changes and building up core strength can mean that even if you’re currently experiencing pelvic floor dysfunction (any leaking, back pain, heaviness in the pelvis) you may be able to get back to your previous exercise routine.

I prolapsed after my first child and was given very little advice about it other than being told I would probably need a hysterectomy when I go through menopause.  Because of this experience I have spent my time learning more and applying it to my own life as well as in my work with others.

First thing I implemented was no impact.

As someone who wasn’t a runner, this wasn’t a big change.  But I did have to stop jumping around in my aerobics classes and also give my trampette a wide berth…!  I can now run for the bus without worrying and I played rounders in the summer where I was sprinting for quite a while with no effect.  So I could probably run now if I wanted to but I’m still choosing to stay low impact most of the time.

Second thing was no crunches

The downward pressure created by crunches/sit-ups will push on the pelvic floor.  Full planks and press-ups and exercises with both legs lifted also creates a lot of pressure and so I avoided them.  However there are alternatives – for example in press-ups performing them on an incline, plus incorporating crunchless core exercises – so there is no reason to stop exercising, just make a few changes.  Bear in mind that sitting straight up in bed is also a crunch (and how many times do you do that a night?) – I roll over to get out of bed instead.

It’s not all about what you shouldn’t do though. There are things that I needed to start doing:

  • alignment/posture

particularly the with respect to the pelvis.  Try tucking your tailbone under and bringing your hips towards your ribs.  Lift the pelvic floor now.  Then take your hips away from your ribs, allowing your lower back to arch more, then lift the pelvic floor.  Then bring yourself to a neutral pelvis where your level through the front and the back of the pelvis (think of it like a bowl) – the pelvic floor lift should feel easier in this position.  Pelvic floor works best when we are in alignment, with the head, shoulders, rib cage, pelvis and heels all stacked up in line

  • breathing

both looking at how you breathe during exercise and from day to day.  During exercises you need to breathe out on the effort and lift pelvic floor at the same time.  This also applies when you are lifting a weight – baby, shopping etc. – and also when you go from seated to standing (The knack – as you go from sit to stand but vice versa too).  The other aspect of breathing is to stop breath holding and sucking your stomach in.  When you breathe in your stomach should actually swell not suck in.  I see so many people who’s stomachs stay still when breathing and instead their shoulders lift.  Try lying on your back with your knees bent, feet flat on the floor.  Put one hand on your chest and one hand on your stomach.  As you breathe in you should feel your chest move first then your stomach.  Your stomach lowers as you breathe out and then your chest.

All these changes I’ve made have meant that my prolapse has improved and I’m hoping to avoid that hysterectomy!  I know that there’s still work to do and I’m currently learning more about another part of the puzzle:

  • relaxation

stress can affect the pelvic floor, there’s also some evidence that lower limb injuries and back injuries will impact the pelvic floor too, even years after healing or the pain has stopped. There may also be scar tissue from episiotomies or tears.  I’ve just learnt some trigger point release for that – sitting on one of the spiky balls!  It’s uncomfortable but definitely has an effect – I will let you know how that goes!  And it’s also helped to introduce deep breathing, mindfulness and relaxation practices into my daily life.

 

So when looking at rehabbing the pelvic floor, it’s not just about a list of exercises to do – we need to think of the body as a whole and the pelvis at the centre of that, and looking at improving in all these areas

Heal your diastasis with food!

I really enjoyed listening to a webinar from Jessica Drummond of the Integrative Women’s Health Institute last week.

One of the sections that I was particularly interested in was on postnatal soft tissue and wound recovery – applicable particularly for those with diastasis or a c-section and perineum wound.

My advice nutritionally has always been to use bone broth either in soups or gravies but her information will give you a few more tools to use!

Eating foods that are high in collagen can help to repair and build damaged tissues – this includes wounded and strained core and pelvic floor muscles.

Good sources of lysine and proline, the amino acids that build collagen, are meat, chicken, fish and egg whites. For vegetarians – peanuts and wheat germ.

But there are other nutrients necessary. Vitamin C is destroyed when collagen is made so your intake of citrus fruits, strawberries and dark leafy greens, for example, will need to increase.

Hyaluronic acid is needed to create bundles using collagen. It can be found in sweet potatoes, avocado, mango and bone soup – using bone broth or whole fish.

The final nutrient she mentioned is zinc. This can be found in sesame seeds, cashews, dates, linseed, cocoa, beef, blue cheese and eggs. The healthy treats we have after postnatal Pilates should take care of that!

Looking at the list, an all-encompassing recipe would be a Chinese style soup of bone broth, chicken pieces, kale or pak choy, sprinkled with sesame seeds or cashew nuts.

Perfect for the summer we’re having!!

When can I run again?

If you search the internet for the answer to starting running again after baby you may well be confused by the information out there.  There are some people who are back to their normal regime way before 6 weeks postpartum, others who advocate avoiding all sorts of exercise.  So what’s right for you?

First up you shouldn’t return to formal exercise until 6 weeks postnatal (8-10 if you’ve had a caesarean) and you should be getting the all clear from your doctor, although I know some doctors wait to combine your check-up with babies 8 week check.  And some doctors don’t do them at all now.

However once you’ve had your check that doesn’t mean you can just start up where you left off.  At 6 weeks only the initial healing of your body has been completed – full healing could take a year or more!

Returning to impact exercise too early can reduce pelvic floor strength and lead to incontinence or prolapse so it is worth taking things slowly and building up gradually.

So once you’ve had your check, and assuming you have no pelvic floor issues or diastasis, it is fine to introduce low impact exercise and specific postnatal classes.  Body conditioning classes are also fine but need to be lower weights and avoid direct work on your stomach muscles (i.e. no sit-ups or crunches or planks).  Over the next few weeks you can gradually increase the intensity and the weights.

And then what, what’s the magic number of when you can start running/crunching/go to hardcore classes?

Unfortunately there is no definitive answer.  Some say 4 months, others 6, still others a year.  I thought I’d been conservative waiting 5 months after a C-section before then teaching a high impact aerobics class.  I wasn’t and I prolapsed because of it, despite having no warning signs so I do tend to err on the side of caution with mums who come along to classes.

So the only real answer to “when?” has to be – listen to your body.  If you have any pelvis or lower back pain after exercise, a feeling of heaviness in the vagina, any bulging or straining or doming of the stomach or the pelvic floor or any leaking these are all a sign that that exercise is too much for you at this particular time.  As is shaking during an exercise or breath holding.  Doesn’t mean this will be for always – just at the moment your body isn’t ready and you need to modify the exercise until you are stronger.

This should apply whenever you’re exercising not just in the early postnatal period.  Your form is the most important thing to be mindful of when exercising and how your body is feeling.  There is always a way to make an exercise easier or to bring the intensity down.

Other things to bear in mind when exercising:

  • tiredness – fatigue can lead to injury as you push yourself through
  • sore breasts – if you can feed before exercise that can help.  A decent sports bra is important too.  There is such a thing as a feeding sports bra although they can be quite expensive.
  • loose joints – the effects of pregnancy hormones on your joints can last around 3 months post birth.  If you’re breastfeeding the effects are thought to last until 3 months after you finish feeding.

So bear these in mind when you want to start a particular exercise regime.  You can practice exhaling on exertion and lifting the pelvic floor before the 6 weeks (once any perineal damage is healed) – this way the core is protected and you will be rebuilding the body from inside out!

Pelvic floor first is a great website that’s worth visiting.  Their Returning to sport pdf gives a timeline of what’s recommended at various stages.

And remember, all my classes are pelvic floor and tummy safe!

Incontinence Part 2

November was national incontinence and bladder health awareness month in the U.S. As lots of the training resources I use come from there it seemed an ideal time for me to bang on about my favourite subject again!

I’ve already covered stress incontinence, which is the most prevalent

http://sarahparkerfitness.com/stress-incontinence/

But there are other types as well. And bear in mind incontinence isn’t just urine, it can also be faecal

  • Stress – leaking due to a change in pressure on the bladder eg jumping, running, sneezing, laughing
  • Urge – a sudden and overwhelming urge to go. Leaking before have chance to get to the loo
  • Overflow/dribble – bladder doesn’t empty fully so leaking occurs without necessarily having had an urge to wee

Incontinence is not an unavoidable consequence of ageing and childbirth. Things can be done to prevent it and/or improve it. It’s always worth seeing a doctor and getting a referral to a women’s health physiotherapist. Instead of masking the problem with pads etc – you need to find the reason and make a lifestyle change!

Things that can affect the pressure within the pelvis:

  • Posture – try to keep your ribs stacked up over your pelvis when standing and sitting
  • Clothing – too tight clothing can compress and move your organs. High heels will make you tilt your pelvis in order to be able to stand upright
  • Diet – avoid foods/drinks that irritate the bladder or cause gas
  • Exercise – move more, sit less

Exercise needs to be functional, so that you’re using movements you need in everyday life – squats, lunges in all directions, hip hinges. Exercise can also have a negative effect if the exercise you’re doing is too much for the pelvic floor to withstand. Any exercise that makes you hold your breath, bear down, shake, really clench, lose postural cues or leak needs to be avoided for now.

Another useful part of your life to look at is your toilet habits as straining can cause huge problems.

  • Wee every 3-4 hours – try to avoid going ‘just in case’. You just need to relax to wee so don’t hover above the seat. Rocking the hips a little at the end can help if you feel like you haven’t emptied fully.
  • Poo when you feel the urge – don’t hold it in as this can cause compaction. Knees should be higher than your hips – feet up on a kids stool or just use 2 loo rolls. Don’t strain. If the pelvic floor won’t relax you can help by vocalising – try a grrr or ssss now and see which one makes you feel like your pelvic floor relaxes. Then use that sound when on the loo.

And finally – keep practising the knack

http://sarahparkerfitness.com/knack-pelvic-floor-health/

Stress Incontinence

So last week a blog was doing the rounds on some of the Facebook pages I follow.  It was talking about the incidence of urinary incontinence in exercising women.

There are various types of incontinence. Stress incontinence is the most common (1 in 3 women) and is where you leak urine when exercising but also when laughing or coughing. It’s due to the weakened pelvic floor not being able to withstand an increase in intra-abdominal pressure.

What I found particularly interesting in this write-up was the percentage who had a problem in very high impact sports – up to 80% of women. This figure included younger women and also those who hadn’t experienced childbirth.

This is the reason why I keep impact out of all my classes.  This wasn’t always the case – jumping jacks was a favourite of mine in aerobics.  But without fail there was always someone who left the studio to use the loo…

So it’s advisable if you are experiencing any symptoms that you also avoid high impact exercises. Doesn’t necessarily mean you will never be able to do the things you love, it is just a sign to cut back for now.

There are a number of other lifestyle habits you may want to adopt that can help if you are experiencing stress incontinence:

  • Drink plenty of water – cutting down may seem like a good idea but actually it will create stronger urine which will irritate the bladder more
  • Don’t go ‘ just in case’ – this can de- train the bladder. You should be able to last for 3-4 hours between toilet trips. And you shouldn’t have to go in the night.
  • Strengthen the pelvic floor – My Pilates classes can help with this. I have had marathon runners in my class who used to have to wear pads when racing that are now dry. It may be worth seeing a women’s health physiotherapist as well – 50% of women do kegels wrong, bearing down instead of lifting. And some women’s pelvic floor will be too tight, in which case kegels is completely the wrong exercise to do!
  • Try to pre-brace the pelvic floor before sneezing, coughing etc if at all possible.  Weirdly, lifting one leg when you sneeze can also help.
  • Practice the Knack!
Foods/drinks to avoid if you are experiencing urinary incontinence:
  • Spicy foods – can be irritating to a sensitive bladder
  • Cranberry juice – fights off bladder infections but it can also increase the symptoms of an overactive bladder
  • Caffeine – it’s a diuretic and bladder irritant. Bear in mind that chocolate also contains caffeine
  • Carbonated drinks – carbonation can irritate the bladder
  • Acidic food – includes fruits (especially citrus fruits), vegetables (tomatoes) and drinks such as juices
  • Sugar – real or artificial can worsen symptoms of overactive balladeer for some. Even ‘healthy’ sugars such as honey can cause problems
  • MSG – mono sodium glutamate has been found to be a trigger for some
I was also sent this picture (I know, I dread to think what my browsing history looks like!).

urogenital hiatus

The gap that you can see is unique to women. It is the urogenital hiatus – a gap in the pelvic floor muscles that allows for childbirth. It is also the reason why women suffer from prolapse more than men. If your pelvic floor is strong, the hiatus stays narrow and this keeps the pelvic organs lifted.  If you are experiencing leaks this is a sign that there is a weakness in the pelvic floor.  So it’s definitely worth being mindful of this gap and not putting undue pressure through your pelvic floor and risking prolapse

So don’t ignore leaking – it’s common but it’s not normal and can be improved.

A Pain in the Bum – Pelvic Girdle Pain

Pelvic girdle pain (PGP), sometimes known as Symphysis Pubis Dysfunction (SPD) or SI Joint Pain – can be felt in the back, bum, legs and front of pelvis.

It’s a common problem in pregnancy – 20% of pregnant women get it, although it can be as much as 50%.  But remember common does not mean normal – so you don’t have to just put up with it!

The good news is that it does tend to clear up after pregnancy – only 7-8% women still have a problem postnatally.  But how you deal with it in pregnancy will have a bearing on your recovery

There are various risk factors for the condition including:

  • pelvic girdle pain in previous pregnancy
  • gaining excessive weight during pregnancy
  • lack of core strength
  • poor posture
  • pelvic misalignment or history of trauma to the pelvis
  • hypermobility, connective tissue disorders or laxity in the joints
  • expecting a large baby or multiples
  • baby’s position

There is also a range in the severity of pain felt and different activities can affect differently – some movements may cause no pain in some women but be excruciating for others.  For instance, the classic going up stairs was not a problem for me but turning over in bed was always painful. The general rule of thumb is – if it hurts, don’t do it!  There is no benefit in pushing through the pain and you’re more likely to make it worse.

Here are a few ideas to try which may help out with day to day activities:

  • Walking – take smaller steps and go slower.  Be aware that if you have a small child or a dog pulling on you that will also exacerbate it.  Otherwise walking is a great exercise and should be continued as much as possible
  • Sitting – don’t cross your legs – either at the ankles or the knees.  Sit upright and with both feet on the floor – an upright chair or birthing ball is helpful rather than the sofa.  Click here to go to my YouTube channel where there are videos instructions on sitting, standing up and getting up from the floor or bed.  Using the Knack on movement will also help.
  • In bed – turning over is usually the issue.  Keep a pillow between your knees then squeeze your knees, perform the Knack and try to keep your hips stacked as you roll.  This can be aided by having a duvet under the bottom sheet.  Also reducing friction to turning can help – using silk sheets, a snoozle slide sheet or if you’re desperate, a bin bag!

For more information the best website to use is
www.pelvicpartnership.org.uk – loads of information there.

take a deep breath

I wanted to talk about breathing this week. For something that should happen automatically, it’s often the hardest thing to get right! Most beginners starting off with Pilates struggle with the breathing. It’s ok not to get it, as long as you breathe! But if you do get it, it is integral to proper form, pelvic floor health, core strength and general well being.

One of the reasons people feel so relaxed in Pilates classes is because of the focus on thoracic (or rib cage) breathing. Day to day we tend to use our secondary muscles for breathing – our chest and neck muscles – which leads to shallow breathing and is linked to our fight or flight instinct so keeps us on edge. By breathing into the rib cage we can take deeper breaths which helps us de-stress and brings a sense of wellbeing.

If you’re not sure if you’re doing it right, resting your hands on the bottom of your ribs can help give you feedback, as can wrapping a scarf around and breathing into the scarf. We’ve also been using the imagery of an umbrella opening and closing – you can visualise this easier if you click the link to see this video. It is an amazing animation of rib cage movement when breathing properly. It also shows the movement of the diaphragm and the lungs and then the muscles.

The other focus I talk about is the lifting of the pelvic floor as you exhale. I filmed this video to show how the movement of the diaphragm controls the breath. The pelvic floor then mimics the movement of diaphragm – this way it keeps pressure in the abdomen constant.

By training pelvic floor with the breath out on exertion you can prevent downward pressure on the pelvic floor and so prevent continence issues and prolapse. It also aids recovery of abdominal muscles and teaches proper recruitment of the core rather than an over-reliance on the six pack muscles – this imbalance in muscular strength can lead to back pain.

So by focusing on thoracic breathing we can get so many benefits – from relaxation to reduced back/neck pain, improved core strength and less incidence of pelvic floor dysfunction and more! So, take a deep breath!

Pelvic Organ Prolapse

Pelvic Organ Prolapse (POP) is a secretive, not often talked about thing.  And yet last week every single day I ended up speaking with people about their prolapse so it just seemed destined that that is what I would write about today!

Prolapse is the descent of one or more internal organs that then push into the vaginal wall.  There are different stages – mild, moderate to extending outside the body.  There are many symptoms, many of which could be attributed to other ailments.

  • Urinary incontinence or urine retention – feeling of never fully emptying bladder
  • Constipation or faecal incontinence
  • Feeling of dragging, like your insides are falling out or heaviness/ache in rectum/vagina
  • Lump or bulge in vagina
  • Inability to hold a tampon in
  • Lower back or pelvis pain
  • Vaginal/rectal pain
  • Painful intercourse/lack of sensation
  • Leakage of urine/stool during sex

The earlier prolapse is discovered the better as there are preventative measures – surgery can be avoided or its severity lessened.  They will also help post-surgery.  Typically one prolapse can lead to another unless steps are taken to prevent this.  Understanding more about how it occurs can also help prevent it.

Causes of prolapse are many and varied

  • Childbirth – 50% of all women who have given birth will prolapse
  • Menopause and age related drop in oestrogen levels
  • Chronic constipation
  • Chronic coughing
  • Obesity
  • Genetics
  • Neuromuscular conditions
  • Heavy lifting
  • Diastasis recti
  • High impact aerobic activities – running, jogging, high impact aerobics

It’s worth noting though that POP doesn’t happen overnight – typically many factors over a number of years will build up to cause it.  What’s crucial is intra-abdominal pressure – the build up of this results in bearing down on the pelvic floor. It’s a necessary bodily phenomenon – without it we couldn’t poo – but if there’s a constant downward pressure it can be more than the pelvic floor can cope with.

And this is where the knack comes in.  By mindfully contracting the pelvic floor before we stand, lift, cough, sneeze etc. we prepare for the force to come.  Practicing the connection with your outbreath and your pelvic floor contraction can retrain the body and help it to do it’s job.

Other things to bear in mind

  • Weight control – particularly the amount of abdominal fat you’re carrying
  • Lifting technique – never hold your breath.  Always exhale on exertion and lift pelvic floor
  • Toilet technique – no straining.  Try to have feet on a stool (2 toilet rolls will do) to raise knees above hips.   Vocalising can also help!
  • Exercise – pelvic floor safe exercises for those with a weak pelvic floor, prolapse or have had gynaecological surgery. Gentle Pilates. Core strength and pelvic floor activation. Exercises to avoid – crunches, double leg lifts, full plank position, high impact sports. Ultimately you need to decide what to stop and what to continue with – you can get support for exercise, from supportive shorts to sea sponges and pessaries.

For more information and support see the APOPS website at www.pelvicorganprolapse.support.org.  They also have a private Facebook group – pelvic organ prolapse.  Also Pelvic Floor First at www.pelvicfloorfirst.org.au

Good books – Sherrie Palm, The Silent Epidemic and Sue Coult, Pelvic Floor Essentials.  I have copies if anyone would like to borrow them

Get a kegel app for your phone – lots of free ones but the one most recommended by women’s health physiotherapists is the NHS Squeezy app

And as they say on Channel 4 – “if you have been affected by this” please feel free to get in touch.  I would be glad to give any help and advice.

The Knack – pelvic floor health

Do you sneeze wee? You need the Knack!

Do you sneeze wee? You need the Knack!

I was listening to an interview with acclaimed women’s health physiotherapist Michelle Lyons last week and was surprised to learn that going from seated to standing puts more pressure through the pelvic floor than lifting a 20lb weight! Bearing down on the pelvic floor that many times throughout a day could lead to, or worsen, pelvic floor disorders – such as incontinence and prolapse.

I have been working on correct standing technique with my pregnancy class for a while now but changed the emphasis last week and gave ‘the Knack’ to them as homework.  Now it’s your turn to practice daily! This is not just for pre and postnatal women – 40-70% of ALL WOMEN have incontinence and 50% of women who have given birth will develop prolapses.  These are stats worth avoiding!!  The Knack is a preventative measure to be used throughout our lifetime.

How to do it

1.  Sit at the edge of your chair, up on your sit bones, heels in line with your knees.

2.  Breathe in.  As you breathe out allow your pelvic floor to relax.

3.  Breathe in.  As you breathe out think of drawing your pelvic floor in and up.

4.  Continue breathing out and lifting the pelvic floor as you stand up.

5.  Once standing, allow the pelvic floor to relax.

You can see a video of me showing the knack here

At first try to practise this standing up after every visit to the loo.  Once you get used to it start to introduce the Knack every time you stand up from a chair.  Keep practising until it becomes second nature.  I’m still practising!