How To Support Your Pelvic Floor While Sitting

I recently received a request to review optimal sitting posture, as one of our subscribers noted she sits quite a bit throughout her day. So let’s review…

To give your pelvic floor optimal support while sitting you want to sit on chairs that position your hips slightly higher than your knees. This takes the hamstring tension off your pelvis, allowing it to rock forward to a more neutral position with ease. In many chairs you can achieve this by sliding forward. Getting your buns to the front edge of the chair will help drop your knees down slightly below the level of your hips (this happens automatically on a Swiss ball!).

Then, you want to position your feet shoulder width apart or you can choose to stagger your feet with one foot forward and one foot back. You want to avoid crossing your legs because this will again increase hamstring tension that can roll your pelvis back. Once you have addressed chair height and we have positioned your feet appropriately, then simply roll forward on your pelvis until you feel pressure on your pubic bone. When you feel this pubic bone support, you are sitting on your sitting “tripod” which means you have achieved your natural balance point or neutral spine.

Our sitting tripod is composed of our two sit-bones on either side and our pubic bone up front. Note that when you have rolled forward onto your tripod, you actually alleviate all pressure from your tailbone or coccyx, and it is no longer in contact with the chair. Remember our tailbone is the back attachment site of our pelvic floor, so this slight lift puts our pelvic floor muscles at the perfect length/tension ratio for a stronger contraction and a more efficient reaction time.

When you are sitting on your “tripod,” you will also notice that you don’t have to work as hard to sit up straight. With your pelvis in this stable position, you have a natural concave curve to your lower back, which sets the table for our natural thoracic and cervical curves up the chain. You don’t have to work to “sit up straight” as you do when you are rolled back on your buns and your tail bone. To finish with optimal posture up the chain, work on resting you hands such that the are up while sitting. This engages the external rotators of your shoulders, rolling them back to a more open position. I always say, “where your shoulders go, your head will follow”.

Sitting posture…it all starts with the “tripod.”

Questions from You to Me: Breathing

How does breathing and the diaphragm affect the pelvic floor?

Our abdominal cavity has only so much room, so as our diaphragm draws down to take in a breath, we need to learn to breathe by expanding our lower rib cage and upper chest to displace the volume that the diaphragm is taking up. If we cannot do this, then the descending diaphragm will cause an increase in abdominal pressure that will displace the pelvic floor down (although this downward displacement is natural to a certain degree). If you aren’t able to expand your lower rib cage and chest then you are a belly breather which places more downward force on your pelvic floor.

When I brace, I puff my belly out, is this wrong?

I strongly discourage you to puff your belly out. When you do that, it means you are using your rectus and your obliques to stabilize, which is the muscle recruitment pattern that is the basis for most back pain. It significantly increases intra abdominal pressure while providing minimal stability to our individual vertebrae – it is just a pressurized air pocket. Whereas drawing in your transversus abdominis (TA) is like a shrink wrap – it acts as a vacuum to pull the air pressure upwards, allowing our muscles to draw in and stabilize each individual segment of our lower spine and pelvis. This assists the work of our pelvic floor. You can feel this vacuum effect and displacement and see this effect standing or sitting in front of a mirror: as you draw in your TA, watch your ribs expand, your chest lift, you actually gain a little height 🙂 as the pressure or air is displaced upward. Try it, see it, and believe it!

Pelvic Floor in “Inside Triathlete” Magazine

I can hardly contain my excitement. I just sat down with the latest issue of Inside Triathlon (March/April 2010) magazine and came across an article by Torbjorn Sindballe. He was writing about body balance and alignment, and how that can affect race results. I was intrigued because this follows along with my beliefs, as I have written about, how posture can affect the efficiency of our musculosketletal system, our lung expansion, our bone health, our pelvic floor function, and more.

As I continued to read, he addressed something that had completely changed his training: a focus on his deepest core muscles, including his transversus abdominus (TA), his multifidi, and his pelvic floor muscles. I couldn’t believe it. Did I just read that a male, pro, triathalete is stressing pelvic floor strength in his training? As a matter of fact he described two exercises you can find on our Hab-It: Pelvic Floor DVD!

This is so exciting to me because just two years ago as we were working to title our DVD, we were concerned with the lack of recognition of the term “pelvic floor” among women. Were we giving our DVD a name that wouldn’t be easily recognized? But now, look where the exercise world is going – to an awareness of these often forgotten muscles that provide the deepest stability to our spine and pelvis. Sinballe went on to stress that unless we slow down and stress these deepest layers, our larger muscles will take over and operate less effectively and with less efficiency!

So, pat yourself on the back ladies. Your awareness of your body and your pelvic floor is ahead of the curve. I will echo Sinballe’s sentiments that, although it may feel as though we are accomplishing more with bigger, more aggressive exercises, it is the focus on the deepest layers, including our pelvic floor, our transversus abdominus, and our multifidi, that can make a big difference. This difference can keep us continent AND this difference can improve athletic performance!

The What and Why of a Women’s Health Physical Therapy Evaluation

by guest blogger, Michelle Herbst, MPT, DPT

Physical Therapists are skilled allied health care providers who evaluate and treat illnesses and injuries specific to the musculoskeletal system.  A Women’s Health physical therapist has received additional specialized training to evaluate and treat the musculoskeletal components of uro-gynecological diagnoses such as incontinence, pelvic organ prolapse, and pelvic pain.  When evaluating musculoskeletal disorders, the physical therapist gathers information about the patient’s past and current medical history, onset of her symptoms and activities that affect her condition.  The physical therapist also collects objective information by observing the patient move, administers outcome tools, and palpates the surrounding and affected tissues.  The information collected assists in the formation of a physical therapy prognosis and plan of care.

The process of a women’s health physical therapy evaluation is similar to a physical therapy evaluation of a shoulder, knee, or spinal disorder except that there are additional and specific questions asked of the patient’s obstetrical and uro-gynecological history.  Yes, the women’s health physical therapist will ask personal questions.  Yes, with your permission, the PT may ask to observe the pelvic basket and floor.  Please keep in mind it is normal to feel some apprehension and nervousness.  And, the quality and quantity of information provided to the women’s health PT will affect the quality and accuracy of the physical therapy prognosis and plan of care.  Lastly, the evaluation completed by a women’s health physical therapist is similar yet very different from that of a medical evaluation for uro-gynecological diagnoses.  The main difference is that the focus of a women’s health PT evaluation is muscular-based whereas the physician is looking primarily at placement and overall condition of the pelvic organs.

So, what is a women’s health physical therapy evaluation?  It involves collecting information about the patient’s health history including their obstetrical and gynecological history while further defining her current complaints in relation to musculoskeletal presentation.  In simple terms, the women’s health PT, in a comfortable and professional manner, will gather information and examine how your body in functioning.  However, prior to meeting the PT you will complete forms or outcome tools describing your condition.  These forms are meant to identify your condition on a particular date and are designed to be re-administered periodically to monitor your progress after PT has been initiated.  Examples of outcome tools specific to pelvic floor dysfunctions are the Pelvic Floor Distress Inventory and Incontinence QOL Survey.  If you have incontinence symptoms you may be asked to complete a Bladder Diary prior to your first appointment.  The information gathered will greatly assist the women’s health PT in developing the most effective and efficient plan to evaluate and treat your condition.

Upon meeting your women’s health physical therapist you will likely be shown to a comfortable, private exam room.  The PT will begin with the subjective portion or open-ended question segment of the evaluation.  You will be expected to describe your problem and why you are seeking the help of a physical therapist.  Here is a list of possible questions the PT may ask, but please keep in mind the questions will be tailored to your specific problem.:   When did your problem first start?  Has your problem been getting worse, better or staying the same?  What makes your condition better or worse?  How does your problem bother you and affect your daily activities?   How do your symptoms vary with position changes, prolonged standing and walking or sudden motions and involuntary processes such as sneezing?   Have you had treatment before?  If so, did your previous treatment(s) help?

Once sufficient information has been gathered in the question and answer portion of the evaluation, the physical therapist will transition to making detailed observations of motion. The PT will observe your normal posture and may ask you to perform basic tasks such as moving from sitting to standing, bending and lifting objects and walking.  If your women’s health PT suspects that current or past spinal, pelvis or hip conditions may be aggravating your pelvic floor condition she may ask to evaluate those areas as well.  The anatomy of the pelvic basket and floor can be greatly affected by spinal, pelvis and hip pathologies due to their common and complex anatomical arrangements.  In considering the common anatomical attachments of the pelvic basket to the spine, hip and pelvis the women’s health PT is providing a comprehensive evaluation.

Only with your permission may the physical therapist begin observation of the pelvic basket and floor musculature.   The pelvic basket incorporates muscles in the abdomen as well as the musculature sling between the pubic bone and tail bone.  Examination of the abdomen typically occurs with the patient lying on her back.  Pillows or a foam roll may be placed underneath her knees to assist in relaxation.  Examination of the perineum involves the patient removing their clothing from their waist to just upon their knees.  The physical therapist ensures safety, comfort and privacy of the patient by wearing examination gloves, providing extra pillows for comfort and draping the patient with a sheet.  At all times, the PT maintains patient privacy and completes palpation wearing examination gloves and palpates lightly using 1 or 2 fingers.  The patient may lie on her side or back with her knees supported during examination of the perineum and pelvic floor musculature.  The PT will observe skin integrity and the patient’s ability to contract and relax the pelvic floor.  If the patient consents to palpation of the perineum, the PT tests sensation and presence of pain, tissue tightness and will likely test muscle strength of the specific pelvic basket muscles and the overall strength and function of the pelvic basket muscles.   The examination may be ceased at any time.

Why all the effort and what is the PT looking for?  The physical therapist observes motion and the quality and nature of the affected tissues to determine a physical therapy prognosis and plan of care.  A lot of information can be obtained by completing an external pelvic floor evaluation but a more complete clinical picture is obtained with the completion of an internal pelvic floor muscle exam.   During the process the PT is observing and is making many key judgments based on the following:  Can the patient complete a Kegel?  Is the patient holding their breath while Kegeling?  How long can the patient hold the Kegel?  Can the patient fully contract and relax the pelvic floor muscles?

In conclusion, a women’s health physical therapy evaluation is complex process but a worthwhile and necessary one to optimally rehabilitate pelvic floor dysfunctions.  The evaluation process does not need to be completed in one visit but may be completed over several visits based on the patient’s comfort level.  As a women’s health PT, I hope that by presenting the What and Whys of the evaluation process, you will be able to participate with a steady and calm focus.  Remember – knowledge is power.

A Closer Look at Our Transversus Abdominus

The transversus abdominus muscle (TA) plays a very important role in pelvic floor (PF) rehabilitation and function, yet most explanations for controlling continence don’t mention any exercises other than Kegels. Why is this? Have our media outlets failed us by over-simplifying the method of PF strengthening, leaving those who are following their direction destined for failure? I believe so. Today let’s take a closer look at this postural muscle and the role it plays in core stability and pelvic floor strength.

First let’s get a good visual of our anatomy (you can find a good visual here: http://www.easyvigour.net.nz/fitness/hpilatesintro1_2.htm ). The muscle fibers of the TA, or lower abdominals, encircle our abdomen and pelvic area, reaching around to the thoracolumbar fascia of our lower back. This area that our TA muscle encircles narrows from our waistline down within our pelvic inlet (the area bordered in the back by our sacrum and on the sides by our two pelvic bones.) The transverse fibers of our lower abdominals run around our waist and within our pelvic inlet like a corset or brace that we can cinch up by drawing our belly button in. This corset of transversus muscle fibers narrows like a cone, ending at the level of our pubic bone. As our TA contracts, this cone squeezes like a shrink wrap, displacing air and pressure upwards and providing more stability to the individual segments of our lower spine. I also like to describe this TA squeeze as a vacuum, helping to pull our PF up and our lower abdominals in tight, only to displace the pressure upwards to our expanding lower rib cage and chest. It is easy to recognize someone standing or sitting with the TA muscle engaged because their chest will be lifted making them stand and sit taller.

Now let’s focus on the role the TA plays in PF strength. It has been shown that the lower fibers of our TA muscle that lie within our pelvic inlet work closely with our PF muscles, which span the base of our pelvis. Some preliminary studies have even shown that there may be a direct connection of some of the fibers of the PF and TA. Whether or not this is proven to be true – one thing we do know is that these two muscles work together as the deepest contraction, the first stabilizers, as the root of our core. (You can also include our multifidi muscles in this deep contraction but we will talk about those segmental stabilizers on another day).

You can feel this intimate connection between your pelvic floor and your TA as you perform pelvic floor elevations. When doing the two-step Kegel that I teach on the Hab-It: Pelvic Floor DVD, you will begin to feel how your TA is activated every time you work to draw your pelvic floor up into your pelvic outlet. Conversely, you can also feel your PF contract every time you work to draw your TA in while holding neutral posture. Studies have shown an increase in contractile force of our TA and PF muscles when activated together vs. contracting individually. This paints a clear picture that we need a strong TA firing along with our PF muscles to achieve optimal strength gains and efficient firing of our pelvic floor. Complete resolution of incontinence or better control of our prolapse symptoms can not be expected if we don’t have both these muscles firing together.

Now that we know the importance of our transversus abdominus muscle, how do we strengthen it? The easiest way to identify and begin TA strengthening is in a 4-point kneeling position (i.e., knee and then place your hands on the floor, right underneath your shoulders). Initially as you start, I recommend you be in front of a mirror, positioned so that you have a side view of your belly. To begin, in the 4 point kneeling position, drop your back down to a “flat back position” and relax your belly, allowing it to hang down with the pull of gravity. From this position, draw your belly up to a tighter position without rounding or lifting your back. The side view you have in the mirror will be great visual feedback; you should see your belly draw up as if you are cinching up your midsection, being careful to maintain your flat back position throughout. Lifting your belly and holding for a 5 count, 3 times each day is a great start to finding and “waking up” your TA.

Once you become aware of your TA you can begin to activate and draw this muscle in tight when you sit down at your computer, when you stand in the grocery line, as you drive your car, etc. I recommend you use a mirror to view the cinching up of your midsection in sitting and standing positions as well to ensure that you are working the right muscles.

Some other helpful tips:
• You should be able to continue with a regular breathing pattern while holding your belly in this drawn in position.
• You should see no movement of your back when you activate your TA. If your buns tuck under then you know you have activated your rectus abdominus instead of your TA. Remember, your belly should draw in with no movement of your low back.
• You may feel a tightness in your low back as you contract and hold your TA in. This is because of the attachment of the TA to the fascia of your low back and the co-contraction of the multifidi muscles of your lower back that also work to hold neutral spine.

To close this blog, I want to stress the complex rehabilitation of the pelvic floor. “Do your Kegels” should no longer be the very simply message going out to those suffering from incontinence or prolapse symptoms. The truth of the matter is that strengthening our pelvic floor and changing our symptoms requires knowledge of finding and holding your neutral spine in sitting and standing, strengthening of your TA and other coordinating muscles of our abdomen and pelvis, as well as a thorough, two-part, Kegel contraction. Continence will come with consistency!

Resolution to Take Control of Our Continence

Since January is the month for resolutions, let’s resolve to take back control of our continence. What will it take? As with all resolutions – it will take commitment and consistency. Here’s our plan:

Make a commitment to 8 pelvic floor lift and holds per day. This is a 2-step exercise. Elevation of your pelvic floor is the tough part of a pelvic floor contraction. The easy step is to squeeze your sphincter muscles as if to stop the flow of urine or the passing of gas. The tough part, and possibly the most important part, is to draw your pelvic floor up into your pelvic outlet as if there is a string attached from your belly button down to your pelvic floor and you are attempting to pull it up. You want to work to draw your pelvic floor up higher and higher for a full 8-count before you release. When performing a correct pelvic floor elevation, you will feel your belly button draw in as your pelvic floor elevates and you will keep breathing. It is easiest to train pelvic floor elevation lying on your back because you don’t have to work against the force of gravity, but you eventually want to challenge your body in seated and standing positions that are more functional.

Find your neutral spine posture and hold it. You will need a mirror for this. What you are looking for are the natural curves of your spine. These are a slight concave curve of your neck, a gentle rounding of your upper back, and again a slight concave curve of your lower back. Exaggerations or lack of any of these curves will take you out of your neutral spine positioning and compromise your pelvic floor function, among other things. When finding your neutral spine you want to stand with soft knees, meaning that your knees are not locked back but, rather, have a slight wiggle to them. Next, with your hands on your hips, rock your pelvis, tucking your buns under and then rock it back so you are standing in a gymnast’s posture. Once your have found this extreme (gymnast) position, bring your pelvis back slightly to find a neutral position. In this neutral spine position, draw your belly button in to tighten up your own inner corset around your spine. Holding neutral spine throughout your daily activities puts your pelvic floor muscles at the optimal length/tension ratio so that it is better able to react and contract when you lift, cough, or laugh. Let it be your goal to become aware of those times when your posture is the worst, i.e., working at the computer, standing in line, etc. and consciously find your neutral spine at these times. With consistency, your body will naturally hold this neutral position.

Commit to 3 exercises per day to work specific muscle groups. Rotate exercises working your low back, your inner thighs, your transversus abdominus, and your hip rotator muscles. All of these muscle groups are important because they all work to either stabilize while your pelvic floor elevates or they work in a coordinated fashion along with your pelvic floor muscles. I often refer to a pelvic or abdominal basket weave to give patients a good visual of the interdependence of these muscles. Weakness of the front, back, sides, or floor of the pelvic/abdominal basket affects the basket as a whole, so we have to strengthen all the parts. You can learn effective strengthening exercises for all of these muscle groups from a local physical therapist or personal trainer.

Drink more water! This is the exact opposite strategy of what many women do when incontinence begins, but it is exactly what a healthy body needs. The nutrition experts say eight cups or 64 oz. of water per day (and I agree) but let’s simplify – how about drinking one full glass of water before each meal and you will be giving your body what it needs. Why? Because water helps to flush your system. There are many foods we eat that can be bladder irritants. http://my.clevelandclinic.org/disorders/overactive_bladder/hic_bladder_irritating_foods.aspx The irritation of our bladder can lead to increased urge as well as increased frequency of urination. The equation is simple: the more water in our system, the more diluted these irritants will be.

Get out and move! Exercise in the form of walking, dancing, swimming, etc. is beneficial to your neuromuscular system, your cardiovascular system, your respiratory system, your digestive system, and your brain function. In a nut shell, I can’t give you a negative effect of exercise, so don’t get pulled into the downward spiral of pelvic floor muscle weakness (incontinence) limiting your activities, which leads to more pelvic floor and coordinating muscle weakness (worse incontinence). Our bodies are amazing and our muscles, our bones, and to some degree our cartilage will adapt to the stresses placed upon them. So as long as you are committed to a specific pelvic floor strengthening routine and good posture, a regular cardiovascular exercise routine will help condition your entire body and help you toward your goal of resolving incontinence.

“Bad” Abs vs. “Good” Abs

Let’s talk abs for a bit. Did you know that you have different kinds of abs that perform very different actions? There is the rectus abdominus, which are our 6-pack abs, that start just below our sternum and run down to our pubic bone. It is the rectus abdominus (RA) that people are talking about when they say, “check out his/her abs!” The true function of our RA is to curl our spine forward, bringing our ribs closer to our pelvis. Everytime we contract our RA, we compress our abdominal and pelvic cavities, increasing our intra-abdominal pressure. This increased intra-abdominal pressure can wreak havoc on our pelvic floor, on hernias, on hemmorrhoids, and on varicose veins on the lower half of our bodies. So, that rectus abdominus may be better left for looks, because the negatives of overusing this muscle definitely out weigh the positives.

We also have our internal and external oblique muscles, which run in a diagonal pattern on both sides of our midsection. I group the oblique muscles with the rectus abdominus because they also flex our spine forward (and rotate it to one side or the other). Our obliques, along with our rectus abdominus will tend to push our belly out, an obvious sign of increased pressure within our abdominal and pelvic cavities.

Now let’s talk about the good abs – our transversus abdominus (TA) or lower abs. These abs wrap around our lower abdomen like a back brace or a corset. Our transversus abdominus muscle draws our lower belly up and in acting like a compression stocking for our abdomen and pelvis. It puts a firm grip on our lower spine, providing a good anchor of stability for all of our other muscles to pull front, back, and side to side. This muscle may also increase our intra-abdominal pressure but it doesn’t press down on our pelvic floor. Rather, it displaces the pressure upward under our ribs. Our TA actually works in coordination with our pelvic floor muscles, and these two muscles naturally draw up from the bottom and draw in from the sides to give us the most stable base we can ask for with all the joints of the spine.

So, how do we work our abs properly to maximize the health of our lower back, upper back, neck, hips, and pelvic floor? Certainly, full sit-ups and crunches should be a thing of the past. A crunch is not our worst enemy if done properly, by drawing in your TA before contracting the rectus and curling up, but few people are able to perform this correctly without direct coaching, so it’s best to avoid doing them all-together if you are trying this on your own.

How do we strengthen our transversus abdominus? The easiest strengthening tool for this muscle is to use it throughout your day. This means that whenever you think of it, just draw your belly button up and in, pulling everything in like a vacuum from the bottom, up. CAUTION: This does not mean that you tuck your tail bone under to draw your belly in toward your spine. On the contrary, your back should not move from your optimal posture or neutral spine that we have talked about at length in several of my previous blog entries. Rather, use your muscle, your TA, to draw your belly button up and in. You will feel how this tightens up your lower abdomen. You will also feel the pull in your low back as the TA wraps around to attach to the thoracolumbar fascia and co-contracts with your multifidi muscles to hold that spine right where we want it. As you get more comfortable with this TA contraction, you will also feel your pelvic floor engage or “turn on,” drawing to a more flat position automatically without any effort from you.

Although the frequent activation of our TA throughout our daily activities is probably the best method to strengthen your TA, sometimes focused activation with specific exercises is the good way to start until it becomes second nature. Below, I have 4 exercises that will get you started.

1.) Hands and Knees Transversus Abdominus Lift. Position yourself on your hands and knees,relaxing your upper and lower back down until you achieve a flat back position. In this position, draw your belly button up and in as if hollowing out your mid section.

If you have access to a mirror, a side view will allow you to see the muscles activate to draw your belly up into a tighter position with no movement of your back. Again I want to emphasize that this should not involve any movement of your back, just your midsection cinching up as if being tightened by a belt or a corset. Hold your abdomen drawn up and in for a full 5 count, while continuing with a steady breathing pattern before you release.

2.) Quadriped TA Lift: In a 4-point kneeling position (meaning, on hands and knees), with elbows slightly bent, pull your belly button in toward your spine and lift your knees, ever so slightly off the ground. The subtle lift automatically activates your TA. Two keys to remember: 1. Keep breathing! 2. Just clear the ground with your knees. If you lift too far, you will flex your spine and activate your rectus abdominus.

3.) Plank holds – Posting on bent elbows and knees, keep your body straight by tightening your abdominals and glutes, pulling your bellybutton toward your spine. Hold this position for 30 seconds, being careful to not let your back sag. You want to work up to 2 minute holds, with any kind of a back ache being your cue to stop the hold. Once you can hold for 2 min.utes, progress to posting on your elbows and toes and again increase your time as you are able.

4.) Straight leg raise with hip external rotation – (3 sets of 10 repetitions) Lying on your back with one knee bent, point the toe of your straight leg and rotate your foot out. Pull your bellybutton toward your spine and place your hands on your lower belly to feel that your belly does not push out as you lift your leg. Tighten the top of your thigh, and slowly lift your straight leg up until it is even with your bent thigh. Hold for a two-count and return to starting position and repeat.

So after you have time to absorb all the information I have given above, let’s just simplify for a minute. Throughout your day, as you engage your transversus abdominus, you always want to feel things drawing in and lifting upward. If you at any time feel a pressure down on your pelvic floor or you feel your belly push outward, you need to stop and reset your abs.

Do I Have a Prolapse?

How do you know if you have a prolapse? Some urogynocologists go as far as to say that every woman will experience some degree of prolapse in their lives. A prolapse? What exactly is it, what causes it, what can I do to prevent it or resolve it? I wanted to use this blog to talk about all of these questions surrounding prolapse because so many of us have or will experience the symptoms.

Let’s take it one question at a time. What does a prolapse feel like? For some it may feel like a soft, round bulge within your vaginal canal. This may be your bladder or bowel that have dropped out of its normal position and is pushing on the anterior or posterior vaginal wall respectively. For others, they may feel a firm structure within their vaginal canal or pressing out of their vaginal opening. This firm tissue is their cervix and is caused from their uterus dropping out of its normal position.

The most common sensation that women describe when they are experiencing a prolapse is a heaviness or, sometimes, an achinesss in their pelvis. Many women describe a feeling like “the bottom might fall out,” as if their pelvic organs are lacking support. The diagnosis becomes more difficult when the symptoms are mild. You may only feel pressure or heaviness with certain activities and not others. With a mild prolapse, the bulge that many feel may be higher up within their vaginal canal rather than at the opening, and is therefore not as easy to discover.

Another question is whether prolapse is associated with incontinence? The answer is that the symptoms of prolapse may or may not be associated with incontinence. They both have common causes which could be one or several of the following: decreased estrogen levels, the constant pull of gravity, decreased pelvic floor muscle strength, and tissue damage from pregnancy and/or childbirth. Because of the common causes, the symptoms of incontinence and prolapse are often seen together, but not always.

Many ask me if they can exercise with a prolapse or if they will make things worse. My answer is simple – you must exercise with a prolapse or your symptoms will most likely get worse. Now, the type of exercise may produce different results. For example, heavy lifting or any exercise that makes you increase your intra-abdominal pressure through a valsalva maneauver may increase your prolapse. For this reason, I don’t recommend crunches or sit-ups because quite often they are performed in a manner that increases your intra-abdominal pressure. I recommend setting a solid base strength with 4-6 weeks of focused exercise for your pelvic basket from the Hab It dvd before returning to cardiovascular activity.  It is important to know that you can return to the activities you love!  Your pelvic floor will respond by getting stronger as you slowly introduce more activity, giving your body and opportunity to adapt.

The next logical question is what can you do for prolapse symptoms? As a physical therapist, I always recommend exercise as a first line of defense. I don’t believe that there is any down side to exercise. The exercises on our Hab-It: Pelvic Floor DVD are designed to directly strengthen your pelvic floor and supporting musculature of the pelvis and abdomen. Whether your exercise guidance comes from our DVD or from a women’s health physical therapist in your area, the benefits are many. You will learn more about your muscles and muscle actions increasing your body awareness, you will learn about optimal posture, and you will be given exercises with a direct purpose. The key is being consistent with your exercise and making a life-long commitment. This commitment will be to a stronger pelvic floor, better posture, and a more toned midsection. What is the down-side to that?

I want to conclude this entry by directing you to an excellent discussion forum at www.prolapsehealth.com where all options for resolution of prolapse symptoms are discussed. They also provide a link to www.moondragon.com for more direct information about prolapse. I encourage you to explore all of these sites as well as my other entries here at www.hab-it.com to gather as much information as you can. The more you know, the more control you have!

Posture for Moms with their Babies

Directing women how to hold appropriate posture while caring for their new born is very difficult. I don’t like feeling hypocritical, so I must be honest with you – my posture was not great when my babies were spending a good portion of their day in my arms and sleeping on my chest. The tendency for a new mom to thrust her hips forward and to lean back with her upper body, allowing her baby to lie on her chest is hard to deny. We all do it. And as our babies get bigger and gain better head control, we continue to thrust one or both hips forward so our babies have a perch to sit on.

In our multi-tasking world, the reality is that we all hold our babies in whatever position that keeps them comfortable and allows us to perform all of our daily activities. The only time we slow down is when symptoms appear. These could be symptoms of low back or upper back pain, symptoms of incontinence (occasional accidental urine leakage), or symptoms of prolapse (feeling of heaviness or bulging within your vaginal canal). Changing your posture is the first step to resolving and preventing all of these symptoms.

Awareness of finding neutral spine in standing as well as in sitting is so important when you are carrying your little one simply because you are carrying an additional load which increases the pressure on your pelvic floor and your lumbosacral spine. If you thrust your hips forward, you are assuming a posterior pelvic tilt posture which increases your chances of experiencing prolapse, incontinence, and/or low back pain (you can read more about posture in previous “belly pooch” blogs and view clear demonstrations on our Hab-I: Pelvic Floor DVD). Since it is so difficult to hold neutral spine as a new mom, my recommendation for any new mom is to use a sling carrier.

There are a lot of advantages with the sling carrier. First, the little one gets to be close to his/her mom or dad where they want to be; second, there is no tendency to lean back or thrust hips forward because your little one is not up on your chest; third, use of the sling frees your hands to take care of your other children and daily tasks without sacrificing your body. Not to mention the 6-8 weeks following delivery is a delicate time when our bodies are healing and doing their best to return to their previous form. This is the last time that we need to put any added stress on our pelvic floor and the use of the sling to carry your little one limits this stress. My only caution on the sling carrier is to alternate which shoulder you drape the sling over to avoid overuse.

As your little one grows and gains head control, I do like the front baby carriers. It allows your baby to face outwards and interact with his/her environment, it allows you to distribute their weight evenly through both shoulders, and lastly, it also frees your hands as the sling did.

This blog is not to say that sling carriers and front baby carriers are required, but as a physical therapist, they are the best solution I have found for both my symptomatic and asymptomatic patients.

Before I sign off, I would like to provide a quick review of the optimal posture that we should all hold throughout our days, especially as a new mom.

Standing posture review:
1. Weight evenly distributed on both legs.
2. Knees are straight but not locked.
3. Hold neutral spine (rock pelvis to a gymnast posture and then bring it back slightly).
4. Engage lower abs by drawing belly button “up and in.”
5. Open your hands.

Sitting posture review:
1. Feet placed shoulder width apart.
2. Rock forward on pelvis so you are sitting on your tripod of 2 sit bones and your pubic bone (if you feel pressure on your buns or tail bone, you are not on your tripod).
3. Draw your belly button in and engage lower abdominals.
4. Open up your hands toward the ceiling.

How Many Kegel Exercises is the “Right” Number?

I was asked a great question the other day regarding Kegel exercises and the confusion caused from some recommendations to complete 80+ repetitions per day vs. my recommendation to complete only 8-10 repetitions per day.

This is a fantastic question and it highlights the difference between the complete 2-step Kegel that is the key to resolving your incontinence and the “quick flick” Kegel that only works one action of our pelvic floor muscles. Knowing the difference between these two approaches is very important in rehabilitating pelvic floor muscles.

First, let me describe the quick flick Kegel. It is simply tightening the sphincter muscles to stop the flow of urine. These can be done in quick succession to a rhythm of “tighten, relax, tighten, relax”, and so on. This sphincter muscle is important to work since it contracts very quickly every time we cough, sneeze, laugh, etc. It is a fast twitch muscle that can contract quickly and with good strength, but it lacks endurance. So what happens when you go for a longer walk, run, or, heaven forbid, someone tells you a really, really, funny joke? Those fast twitch sphincter muscles lack the endurance to hold on for these activities.

Lucky for us, we also have slow twitch endurance muscles within our pelvic floor that CAN keep us continent during prolonged activity. We can strengthen these muscles and maximize their endurance by elevating our pelvic floor. That is why a 2-step approach to a Kegel exercise is so important. The best way to maximize the endurance of our pelvic floor elevation is to draw your pelvic floor up into your pelvic outlet, as if there were a string attached from your belly button to your pelvic floor, and you are attempting to pull it up as high as you can. The challenge is to hold this pelvic floor elevation for at least an 8-count as you continue with a regular breathing pattern.

It is the elevation and endurance hold that is often lost in Kegel instruction. You will find that if you go through the 2-step process, your pelvic floor will actually fatigue throughout your reps, giving you the feeling like you just can’t keep it elevated for the full 8-count. Patients/clients will tell me they are more symptomatic that day or even the next day if they over-do the reps (20+) on the 2-step Kegel.

This is why I include only 4 repetitions of a complete 2-step Kegel before each workout and after each workout on our Hab It: Pelvic Floor DVD. Eight quality repetitions of a 2-step Kegel including both quick flicks and endurance holds is far more beneficial than 80+ repetitions without a direct purpose.