Hab-it Exercises Forums Ask Tasha! Diaphragmatic breathing

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    Stephanie Hope

    Hey Tasha!

    I am a pelvic PT myself. I am fairly young in my career – 3 years out. I treat primarily PFD – all the issues that entails. But I also treat some ortho to fill in gaps in my schedule.

    That being said, I have a near 2 year old. I myself have recently (last 3 months) experienced a urethrocele/cystocele. I have had my boss check me, she says grade 1 but with Valsalva comes down to grade 2. I am hyper aware of my body as most PTs are plus I treat this area all day every day so it’s on my mind a lot. I mostly feel the discomfort of the urethrocele. I have started more consistently doing exercises with my patients when I have them hooked up to biofeedback – I figure why not. I also try to walk 4-6 miles a day. I do Pilates – sidelying hip series avoiding RA exercises. I lift 10-20 lbs for UE strengthening 3x a week. I also do functional movements to work on LE such as squats, monster walks, lunges, standing hip 3 way with TB – you know, PT standard. I exhale when lifting my kiddo and contract at the same time. I watch my posture while documenting or when at home at rest. I use a squatty potty and make sure that department is smooth sailing. I do however have lax tissue, I’m that hypermobile person. Thankfully that meant no stretch marks – yay stretchy skin. But sucks for my pelvic organ support.

    I have become very very distressed and angry at my own POP. Seems like I would be prepared mentally and feel empowered but really it just has made me feel inadequate and resentful these past few months. I will also mention that I struggled with post partum depression and have that under control with the help of my psychologist, thank God. I cried last night to my husband saying I just hate feeling like I “can’t” do things like run or jump or whatever with my son for fear of it getting worse. (And I HATE running haha) It is making me scared to even do the exercises I outlined above. Which should be POP safe.

    I have started your program in addition to working out with my patients occasionally throughout the day. I am only really 1.5 weeks in. I have also experimented with vaginal weights but they just fall right out. I have a few questions or comments.

    1). For my pelvic pain patients I teach them how to belly breathe with their diaphragm and tummy excursion to get at that parasympathetic nervous system and to down regulate their stress response. As you know most of these young pain patients have some hypertonicity or spasm in the pelvic floor and I’ve found drawing attention to the breath and natural rise and fall of the PF is helpful. What are your thoughts on teaching diaphragmatic breathing as a therapeutic technique for stress and pain control – in the case of PFD, POP, PF weakness.
    2). The breathing you seem to outline is chest breathing which we are taught in PT school activates those accessory muscles and isn’t the best. Are you instead saying keeping lower abdomen engaged and allowing upper abdomen and chest to rise and fall – without rise of shoulders ? I just want clarification there.
    3). I gave you all that background on myself because I am feeling really down and disheartened and just wanted to know what you thought of my workout regimen in general. I type this as I’m on a airplane to Chicago for a 4 day bowel and pain course. I think this will prove to be a good addition to my personal experience to help encourage and guide my patients with this struggle but I haven’t reached that peace yet. I am just angry, sad, scared right now. Just words of encouragement will be greatly appreciated!

    Thank you for being a great resource for therapists and patients alike. As you know it’s a rare find.


    As far as breathing – I teach that it is fine to diaphragmatic breathe when you are lying supine and focus on relaxation/increased blood flow/etc, but when you are up and moving about, stand tall and proud and breathe with rib elevation and expansion. The only time this brings in upper trap, platysmus, etc is when our shoulders are locked in internal rotation and won’t allow the natural expansion of our rib cage. Allowing our thoracic cavity to expand allows us to fill our upper lobes and posterior lungs – actually max VO2 capacity – which we know as PTs, decreases with age as posture comes further forward and shoulders lock the upper ribs down. With hypertone, you may have to get supine several times throughout your day to encourage increased blood flow into your pelvis with diaphragmatic breathing, but then when you get up, think of standing tall positioning yourself in neutral spine – remember this is a positioning, not a squeeze of any muscle.

    So, yes, stand tall and proud, soft knees, tail bone lifted, chest up, hands open, and breathe with rib elevation and expansion. This allows you to keep your own back brace, your TA, with consistent tone (by drawing your anterior connective tissue to a tighter position) and it also draws all pressure up into your thoracic cavity and off of your pelvic cavity. Super important not only to take pressure off of pelvic floor, but for discs, hernias, hemorrhoids. Feel the strength in standing tall in neutral spine with “tone” in your TA. It is the opposite of the flexed posture we see so many Americans in.

    Per your description – I would decrease the amount of reps you are doing along with your patients. I want your focus more on your posture, your glutes, your TA, your adductors. Our pelvic floors are just a piece of the puzzle, often taking the focus off of the pelvic floor is mandatory once we have established a co-contraction of our pelvic floors with our adductors, TA, multifidi, and hip rotators. Once your firing pattern is re-established, your pelvic floor is firing with all these muscles, so the constant isolation of these muscles will contribute to hypertone, over fatigue, and poor efficiency with daily activities.

    The reps you are doing with your patients, along with your walking, and other strengthening is too much. We can continue to talk through this, but I want you to significantly reduce your isolated pelvic floor reps and work on posture. Instead, be aware of your pelvic floor with every squat, every adductor squeeze, every multifdi lift. All of these will also co-contract your TA – such a huge part of your rehab – not isolated pelvic floor reps.

    Read through the Pelvic Basket Muscles topic in the Education section to really dive in to TA, multifidi, and pelvic floor.


    Stephanie Hope

    Thank you for your response. I’ve decreased my PFC’s and been very consistent with my posture. The posture has been easier than I thought actually – at least when I’m act work. In the car and lounging on the couch is harder.

    Question – I am having a hard time getting the superficial PF to contract. I have been stimming it with a probe and feel it then a little but don’t have superficial vaginal closure when I’m doing your video or just doing a PFC in general. Any tips for that? Just trying to figure out how to wake those muscles up quicker. I feel an overwhelming contraction of the EAS – which I try to quiet and isolate.


    With this question, you are continuing to focus on the wrong thing. Your superficial muscle firing is not going to improve support of your pelvic organs. Rather your deeper levator ani co-contracting with your deep hip rotators, adductors, TA, and multifidi are the key to your rehab success.

    Stop the sim! I need glutes, TA, scap depressors, mutifidi!!!


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