Questions from You to Me: What You Recommend vs. What Whole Woman Recommends

I have performed Kegel exercises off and on in the past then I read on “WholeWoman.com“, Christine Kent wrote that Kegel exercises can actually worsen a prolapse and cause further prolapse.  I know you and her both prescribe the same posture, but why do you think she says that about Kegels?

I want to make a very strong point.  Christine Kent of Whole Woman and I DO NOT agree on posture, Kegels, breathing, muscle activation, and more.  The path she prescribes is very specific, which simply does not work for a physical therapist who is always evaluating various treatment paths, depending on the patient’s symptoms, lifestyle, activity level, etc.  In other words, I believe it’s important to recognize that there are a lot of different paths available to get to the same point.  

To address my approach to Kegel exercises:  I believe it is naive to think that Kegels are all one has to do to control incontinence or prolapse symptoms.  But, Kegel exercises are certainly a very important piece of the puzzle.  An appropriate Kegel sequence, as I teach and as Brianne Grogan at www.pelvichealthplus.com teaches, includes both squeezing the muscles and elevating the muscles.  This 2-step process is necessary to activate all of the fibers of the pelvic floor.  It is this pelvic floor that is the soft tissue barrier closing off our pelvic outlet.  Our pelvic floor lends support to our rectum, vaginal canal, our bladder, our uterus, and urethra.  These are not passive muscles…they actively contract in a healthy body and when we lose the ability to contract these muscles efficiently and effectively, we begin to see symptoms of incontinence and/or prolapse. So Kegel exercises are one of the main components of an effective rehabilitation program.

To address my approach to posture:  Christine Kent and I strongly disagree on posture.  I teach a neutral spine which is a natural, subtle lumbar curve that requires activation of both the multifidi muscles of the low back and the transversus abdominus (lower abdominals).  Co-contraction of these two muscles will automatically turn your pelvic floor “on” so that you naturally hold a healthy tone in your pelvic floor throughout your daily activities.  This neutral spine position gives a slight lift to your tail bone, putting your pelvic floor muscles at the perfect length/tension to contract efficiently and effectively.  I teach posture that requires muscle activation to hold and support our body in its optimal position.  This same posture has a positive impact on bone health, breathing, and muscle function throughout our bodies.  Christine’s posture instruction puts clients in an extreme position of extension in their low back and asks women to simply let their belly hang out and fall forward.  I don’t think there is a physical therapist that would support this instruction and I would be willing to say that every woman adapting this posture will suffer from mechanical low back pain, if not immediately, then down the road at some point. 

I hope I have not spoken too strongly, but I definitely wanted to draw a clear line between programs I would refer you to such as www.pelvichealthplus.com and www.prolapsehealth.com, versus others that I would avoid.  Let me know of any other questions you have.

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21 Responses

09.24.10

Hi Tasha

Re “Christine’s posture instruction puts clients in an extreme position of extension in their low back and asks women to simply let their belly hang out and fall forward”.

I think you need to go back and revisit Wholewoman posture again. Your description is not accurate at all, and would indeed lead to the results you describe if it was done the way you describe it.

Properly done, Wholewoman posture engages the muscles that you recommend be engaged. No muscles are left slack and floppy in Wholewoman posture. It think that you and Christine may be closer together than you realise when defining posture that supports the body most effectively, even though each of you has a different emphasis. You are simply coming at it from two different origins. Two people coming to a very similar point simply illustrates to me that you are both on the right track.

I can see that a woman who has under-used pelvic floor muscles could benefit from Kegels, but once the woman’s posture is optimised, and her pelvic floor and other muscles are actively engaged, these muscles will exercise themselves with everyday movement, as the two halves of the pelvis move forward and back with our gait, one foot then the other. I cannot see the point of working them out every day if the posture is kept on track, other than as a ‘body consciousness’ exercise, or to learn to use them at will, eg when the body is in a position where they don’t automatically engage. Brisk walking in good posture would probably be just as effective, and has multiple other health benefits.

09.24.10

Louise, I believe Tasha is quite correct that the differences between WW posture and the type of posture much of PT is promoting are real and critically important.

Tasha, would you be willing to describe exactly how co-contraction of the TrA and MF turns the pelvic floor “on”. We need a good anatomical explanation of this.

Could you also give us a head-to-toe example of the type of postural instructions you give?

Thanks!

Christine

09.24.10

Christine, welcome to Hab It: Pelvic Floor! I am happy to talk with you in depth about my views here, because, as you probably are aware, I have been blocked from your site for unknown reasons.

The posture that I teach is one that requires healthy muscle activation all the way up the chain. Beginning from the ground up, I coach equal weight on both feet, soft knees (meaning this position requires muscular control vs. locking them back), and then with your hands on your hips, you can rock your pelvis like a cradle to find the extremes of your range of motion. The two extremes are the buns tucked under position, otherwise known as a posterior pelvic tilt, and the extreme gymnasts position, otherwise known as an anterior pelvic tilt. It is not healthy for our bodies to be at either of these extremes, but rather in neutral spine which promotes maximum blood flow, healthy muscle activation, and protects our vertebrae, facets and discs of our spine from significant stress and strain. To find this neutral spine, it is easiest to take your pelvis to the maximum gymnast position (Christine, this engages your multifidi muscles), and then engage your TA, by drawing your belly button “up and in”. This co-contraction of your TA will bring you bring your pelvis back ever so slightly, softening your lumbar curve to a neutral spine that has the muscular support of your deepest three stabilizers – your multifidi, your TA, and your pelvic floor.

I have several blog entries on posture and the co-contraction of our three deepest stabilizers that need to fire first before every reach, every lift, and every push/pull. It is this healthy firing pattern that must be restored to allow women to return to their prior level of activity (including running) with controll of their symptoms.

I welcome you to read through my blog entries and I will be happy to answer any other questions that you may have.

-Tasha Mulligan MPT, ATC, CSCS

09.24.10

Louise, I believe that I teach a neutral spine posture, while Christine teaches extreme extention of the spine. I also teach activation of the Transversus abdominus as being an important component of pelvic floor rehab. Studies have shown a connection of the lower fibers of the TA to the fibers of the pelvic floor and demonstrated a co-contraction of these muscles. As you work to elevate your pelvic floor, you will naturally feel your belly button pull in which is your TA co-contracting with your pelvic floor elevation. The multifidi is drawn into the mix, b/c it is an important muscle that gives our tail bone a lift and holds the lordotic curve of our spine. The activation of this muscle puts a passive tension on our pelvic floor so that it is in a better position or length/tension to fire when we need it too. These three muscles are the root of our core. They are co-dependent and enhance the strength and function of the others.

I agree with you that once you re-establish these three stabilizers and your optimal firing pattern, then your pelvic floor doesn’t necessarily have to be worked daily, but it is healthy to do so. Much like your daily workout for prevention of osteoporosis and maintenance of posture. You have to continue to engage muscles or we begin to see break down, and the rate of this break down increases with age. How do we all age well? Exercise/strength train/eat well/ and so on.

So, as much as I agree that our daily activities are supposed to stress our pelvic floors enough to maintain healthy function, often this isn’t enough as we age, experience hormone changes, deliver babies, etc. Similar to the chronic back pain patient that must continue to do strengthening exercises to prevent a reoccurence of pain – so must a women with an injured or weakened pelvic floor perform specific exercises to prevent symptoms of incontinence or prolapse from re-ocurring.

-Tasha

09.24.10

Thanks for your response, Tasha. I just checked and your account is and has always been active. We have a very short list of problematic people who have been blocked and you have never been amongst them. Likely, you have forgotten your password. If you wish to post, send me an email and I will re-set your password.

09.24.10

I would welcome the opportunity to participate on your site again.
Thank you.

09.24.10

The differences between the two postures cannot be explained any better than by the two teachers of each different posture.

However, I might add an important difference: Neutral spine does not eliminate or place cautions on post surgical people regarding the benefits of its usage. It does not place stress on the sacro-iliac joint system and no extra cautions are necessary to women who have had surgical interventions, other than the usual: don’t do anything that causes discomfort. Neutral spine, to me, could also be called ‘natural spine’ and thus it should only improve posture without any un-natural changes necessary to implement it. We all need to improve posture, prolapse or not, surgery or not, and I for one will always choose the course which is least likely to cause me discomfort.

I am bi-pedal and not able to walk in any other way than the way I walk. My dogs walk differently than I, but their spine is parallel to the ground. I just can’t walk that way and swing my pelvic organs forward and I can’t twist my back in hyper extension or I’d be incapacitated. So I try to find a neutral position and improve my upper body posture as well and contract appropriate muscles when I lift and so on.

I think evolution to bi-pedal posture makes it important that we do not spend our lives sitting and slumping and exaggerating the weaknesses of bi-pedal posture. Clearly exercise and movement and good posture will compliment rather than detract from our evolutionary progress.

09.24.10

When I first discovered my stage 2 cystocele and rectocele after delivering my 2nd baby I was devastated. I sought out physiotherapy and was shocked when they asked me to do some kegels and I couldn’t even maintain them laying down!! Now after a few months of Tasha’s DVD and learning neutral spine posture, I am able to kegel sitting and standing with such strength and stamina – I can literally lift my entire pelvic floor “basket” and everything feels amazing!! As a dancer used to “tucking in” the pelvis, getting used to a different posture is certainly challenging, but the neutral spine position is so natural looking and feeling that I am not embarrassed to use it in public.

09.24.10

Hello All,

I first discovered my POP (grade two cystocele and mild uterine prolapse) at 2.5 weeks post partum with my little 6lb 3oz girl. I was devastated, alone, felt betrayed by life and simply SAD. I quickly turned to the internet for support and sought help from every medical discipline available (Urogenital Osteopathy, physical therapy, mayan abdominal message, biofeedback, muscle stim etc….). I quickly found the Whole Woman website which was a great support of women discussing and providing information on their prolapse. I found a wonderful friend from this website who I still speak with regularly. I quickly developed the WW posture and after two months of walking in this posture (I will admit I had minimal training on the posture as the only thing available to me to understand the posture was the DVD and book) I developed extreme lower back pain and shoulder pain. My physiotherapist could not understand why my sacrum was becoming more stiff and stuck in a solid position. Until I finally told her of the posture I was standing in. She explained to me how this posture was pushing my already pushed out sacrum more. I then went back to the Internet to seek more guidance and found the wonderful Tasha Mulligan. I quickly purchased Tasha’s DVD and began her workout and posture. I have been doing her DVD now for 1 month and love it. My back pain is now gone and I stand proud and confident in neutral spine. At 27 years old it was for me also extremely emotionally hard to walk with my belly out. Now I walk with it up rather than out (I of course do not suck in at all, instead, pull my belly button up). Tasha’s posture guidance is excellent and has helped me a great deal not only with my prolapse but also with my standing confidence (especially since my new POP was a significant hit to my self exteem). I have also obtained support from all my therapists in walking and standing in Tasha’s posture (Physio, Osteopath and gynecologist).

Please do not interpret this as my saying the WW posture is awful and incorrect as I am not properly educated in this discipline to provide that analysis. It simply was not good for my body and my prolapse.

THANK YOU TASHA for sharing your experience and your methods for living with and controlling your prolapse with us women in extreme need of your learnings.

MM

09.24.10

I had a pelvic organ prolapse at 4.5 months postpartum. I found the whole woman website and at first I was so happy to have a place to read others experiences and know that I was not alone. I am a physical therapist and the recommended posture on thw WW site did not ring true to me but I tried to use it anyway because I was desperate for improvement in my symptoms. I found that it hurt my back really bad and I knew that this could not possibly be right. I was so greatful to find Tasha and Hab-it.com. Really great information that was explained clearly and also helpful for my prolapse symptoms without agrivating other areas of my body.

09.24.10

Hi Tasha,
I love your “Hab It” DVD.
I have a uterine prolapse with cyctocele and rectocele.
I really want to get in shape again – I had stopped going to the gym for awhile since my mother passed away – and I really want to improve my POP so that I can take long walks again and not always be aware of “the bulge”. I am resuming my daily visits to the gym this coming week.
I’m not going to have a hyst, so I am going to improve this on my own.
I also need to take off some weight – about 30 pounds.
My question is: At the moment, I am very busy, and would like to start practicing correct posture.
I don’t have time at the moment, unfortunately, to go through the DVD in order to get all the instructions for the correct posture. I will do that later.
Please help me and give me some written simple instructions for getting and implimenting correct posture.
Please don’t use medical terminology, as I am not a specialist in medical fields.
I just want some simple instructions: How do I do it?
I was going to use the WW posture, and some of it is probably fine, but for me personally, practicing a sway back will give me lower back pain, and I don’t want that.
I can’t wait to start practicing and to get into shape!
Please give me some simple instructions for the correct posture to improve my prolapse.
Thanks very much! :-)
Marti

09.24.10

Marti – I am excited for you to return to the gym. It is a fantastic first step in improving your prolapse symptoms along with improving your cardiovascular function, your lung volume, your brain function, your bone health, and of course, your core strength and posture.

I will refer you to my many posture blog entries to break down my posture instruction in many different ways. Simply put, the initial positioning requires you find the extremes of YOUR bodies range of motion. For example, I have less available lumbar extension than my sisiter, so my neutral spine will not look the same as hers. Your job is to find your available range and then position your joints in that neutral position. This is the same for your knees (don’t lock them back in full extension, bring them back slightly to where their is a good wiggle) as it is your lumbar spine.

The second step is what takes more consistent attention, practice, and understanding. That is the muscular support for this posture. Activating your pelvic basket requires lots of practice in front of a mirror until you get a strong feel for your neutral positioning. It is this action that I encourage you to read on in my blogs and to practice in front of a mirror (lots of mirrors at a gym so you are in luck).

If you can’t get it on your own, you may need to schedule an appointment with women’s health physical therapist to help coach you with a hands on approach, the contraction of the right supporting muscles.

This neutral spine positioning and appropriate muscle activation will not only help with your prolapse symptoms over time, but will also control your low back pain.

Good luck Marti. Be consistent and you will see improvement.

09.24.10

Hi Tasha,
Thanks so much for your reply and very helpful advice!
I’m so sorry that I didn’t reply sooner. I was very busy last week.

Tasha, I want very much to read your articles on your blog about correct posture. How do I find your various articles on posture?
Is there a way that I can do a search for them?
What keyword should I use, and how do I do this?
Thanks very much, Tasha!
Yours sincerely,
Marti

09.24.10

Marti,
When you go to the Hab-it blog page, you will see several topics or sections listed on the right hand side of the page. Posture is toward the bottom of that list. Simply click on posture and it will pull up any blog entry that I have written that addresses posture. Thanks for the question!

-Tasha

09.24.10

Thanks very much, Tasha! Will do! :-)
Yours sincerely,
Marti

09.24.10

Hi Tasha!
What about if you have been diagnosed with a sigmoidocele?
Will these exercises help?

09.24.10

Tamara,
I have not directly worked with a patient with a sigmoidocele, so it is hard for me to give an answer from experience. The one thing that I do know is that the exercises and the posture taught on the Hab It dvd are designed to teach you how to activate the correct muscles to lift pressure off your pelvic floor. This helps with incontinence, prolapse, varicose veins, and hemorrhoids. My gut is that lifting pressure off of your pelvic floor would help your sigmoidocele prolapse as well.

-tasha

09.24.10

Your Comments Is your video appropriate for me? I have no prolapsing. Weak Pelvic Floor muscles. Age 64 – 3 children – one foreceps delivery. Had a robotic hysterectomy at age 62 for stage 1 endometrial cancer. At age 64 (6 mos ago) started having bladder spasms. Urologist at Ohio State University prescripted ditropan and I am seeing a physical therapist for exercises, biofeedback, etc. It seems this video would help me? Looking forward to your prompt response. Thank you very much!

09.24.10

Linda,
This video will be a great compliment to the treatment you are already receiving through your physical therapy visits. Pay particular attention to your posture and use the exercises in workouts 1 through 4 as your home program. You will note a focus on many of the muscles that work with and support your pelvic floor muscles. Please feel free to continue to ask questions or give us feedback as you progress through the dvd.

Tasha Mulligan MPT, ATC, CSCS

09.24.10

Helpful information. Fortunate me I found your web site accidentally, and I am stunned why this accident didn’t happened in advance! I bookmarked it.

09.24.10

Hi Tasha,
I’ve been doing the hab-it videos for a few weeks and like them, but I’ve noticed I have some pain in my tailbone when doing some of the 8 count Kegals. Any recommendations?

Thanks,
MJ

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