Kegels - always appropriate? What's correct techique and how does being extra stretchy affect yo
Hypermobility as a high level spectrum is relatively uncommon - with the higher levels often being diagnosed with Ehlers-Danlos syndrome (EDS), which is characterized by weakness of the connective tissues of the body, over-flexibility in joints and a general instability in the body.
Whilst this level of extra mobility is still relatively uncommon there is a group of people who are at some level on the more "stretchy/bendy" spectrum than most. Those people might have seemingly flexible bodies without much training, perhaps feel tiredness more than others, poor co-ordination and clicking joints. A common trait I see in these clients is hip and back pain. Most of these clients that come to me are usually mostly unaware that their bodies are more flexible than most - only that certain types of exercise - for example yoga have seemed relatively easy in the past.
Most people on the "slightly over-bending/stretchy scale" live their lives perfectly happily without pain or joint issues until pregnancy comes along. This is for a number of reasons;
- Your body during pregnancy produces more hormones to help your muscles relax ready for birth and a growing uterus/baby. This makes you more flexible during this time
- Your body is under different growing demands from a perspective of postural changes, your centre of balance and your core stabilty.
Your core stability comes from a team work effort from the diaphragm, the pelvic floor and all of the abdominal core muscles (TVA/RA/IO/EO) and the intra-abdominal pressure you create internally along with how well these separate components of the body are playing as a "team" determine how stable your core is. For example if you have too much pressure and not enough strength to cope with this during a task you might get some leakage of that pressure (a good example of this is leakage (otherwise known as stress incontinence) when running or sneezing).
The core needs to function as team players not be over-dominant in one area for the whole thing to fire correctly and to perform at it's most stable. Lets take the example of a client with a Diastasis Recti - often (but not in all cases as each DR Client is unique in their puzzle) we find overworking obliques (side abdominal muscles) and overworking rectus abdominis (top abdominal muscles) and under-firing deep core muscles (Transverse abdominis). It's this off balance that's either created the DR in the first place (along with additional pressure from babies, bloating and other factors) or certainly that's maintaining it.
If we wanted to progress this client forwards it would give therefore little benefit to prescribe her an exercise to fire up the rectus abdominis or obliques. Instead before we start to load with exercises it would be far more appropriate to downtrain those muscles and fire on the under-working ones to create a better balanced core harmony.
Where does your pelvic floor fit in to all of this?
Studies have shown that your pelvic floor works before any other core muscle. It fires itself on in minimally, modestly or maximally to support what the rest of the core is asking it to do. If your pelvic floor is weak then the support it gives to the rest of the team would be weak - weak support and the other players can't perform at their best either.
This is a common scenario we are used to hearing about in terms of weak pelvic floors and weak cores. Most women these days during pregnancy are handed some kind of information about doing pelvic floor exercises - often though with little other information other than "do them".
What's less commonly spoken about is a situation where perhaps the pelvic floor is taking on a little too much for the team. It's overworking. This is something I often find in a more mobile client because the pelvis is more mobile and therefore usually the "roots for grounding" are found here at the base - the pelvic floor.
Symptoms of an over working pelvic floor can be misleading because they often run in line with a weak pelvic floor (that is due to overworking muscles becoming tired and therefore weak). Symptoms can include;
- Difficulty evacuating stool or straining with bowel movements
- a sense of incomplete evacuation
- Urinary frequency, hesitancy, urgency, bladder pain, and sometimes urge incontinence
- painful intercourse
- low back pain
- pelvic pain
If the pelvic floor is already working and the core is misfiring because their team isn't equally pulling their weight, then you have someone with an over stretchy body so the pelvis is having to do more work to stay stable, then you take away more team members of the core unit during pregnancy as those abdominal muscles get stretched and lengthened and the diaphragm and ribs become compressed, then the postural changes that take place in a pregnant woman's body to tuck the tailbone to create space for a baby (mum flat bum syndrome!) AND adding a growing weight on top it's very little wonder that mums with this condition often end up with hip/back pain and potentially some signs on weakness in the pelvic floor
What can you do to help if this has just described yourself?
- You need to address your core's team balance - are your ribs/diaphragm compressed? Do you need to release the obliques, downtrain the pelvic floor?
- You need to create stability for the pelvis in other areas - the glutes and deep core muscles being your first point of call. Commonly I'll actually find overworking upper glutes in these clients because they are bottom gripping (more on that topic in my pevious blog "is your butt a real pain in the back?") but under-active in the rest of the glutes, so you'll need to choose these exercises wisely to affect the balance of the glute team evenly just in the same way as your core team
- Notice your posture and movements - are you tucking your tailbone under, are you sitting too much? What's your posture like during feeding? is your head poking forwards. All of these can affect your pelvic floor workload.
Knowing the right exercise to do is KEY to any exercise prescription - so when we have a leaflet of "do your pelvic floor exercises" handed out by your midwife this is truly unhelpful especially to this population. A well functioning pelvic floor will assist you in labour, but studies have shown that (Kari Bø and her research team) looking at outcomes for a large group of women and comparing their vaginal pressure readings, women who had longer second (pushing) stage tended to have higher resting vaginal pressures at around 20 weeks of pregnancy. This suggests that tight pelvic floor muscles MAY lead to a slightly longer pushing stage of labour.
For this population kegels are not recommended - it's not a one size fits all plan. These clients need to down-train their pelvic floor and up-train their other surrounding supportive muscles to "help out their team mates".
If you suspect you may have an overworking pelvic floor your first point of call is to a women's health physiotherapist who can assess this for you. If you already know that you are having no luck with kegels and still seeing symptoms it's certainly time to visit your local WHP because that "weak" pelvic floor might not be weak after all and all of those kegels you are doing might actually be making things worse.
It's worth a final note here around technique of the pelvic floor - for those client's who have overworking pelvic floors their technique of the lift is usually quite good but then they forget to let go or have an inability to release. It is IMPORTANT never never never to force pressure down against the pelvic floor in order to release. You must train your body to allow this to happen which can take time and on occasions manual therapy from a WHP also. It is important to do this with the correct breathing technique and posture or you will not get the benefits in the same way. If you are still sat at traffic lights doing them or whilst brushing your teeth there's no way you can be doing them correctly. You must be sitting on the edge of your sit bones in a neutral spine and you must have full concentration (you can see now why slouched feeding on the sofa doesn't make for good technique). Also you can now see why a constant hold of the pelvic floor in ANY exercise situation would not be a good thing. The core must be able to work as a team and that's as much about letting go and breathing as it is lifting up.
2 Techniques I teach that are good for weak an overworking pelvic floors are;
- Drinking a milkshake through the vagina and sucking spaghetti through your back passage. Start with the lift of each front back to front and then allow both to come back out fully until totally relaxed
- Imagine lifting up a marble with the back passage and another with the vagina, lifting up to the belly button and then allowing both to roll back out