At Long Last…The Pelvic Floor Article

June 14, 2013 at 1:44 pm 36 comments

iSC pelvic floor

The Pelvic Floor musculature (illustration credits unknown)

Though I’ve researched the heck out of it, taught workshops about it, referred to it in previous articles/posts and commented about on other peoples’ blogs and/or social media posts…I even have one of my own (a pelvic floor that is….and I’m absolutely certain that you have one, too)…until now, I haven’t written a full article here on it. At long last…The Pelvic Floor Article.

There has been a lot of talk of the Pelvic Floor in recent years. An obsession. It’s faded away a bit as the new obsession has been fascia. The next obsession…? It’s probably happening already and I am not even aware…because I don’t care. I care about the body as a whole. I encourage you to do the same. Please know the seeming individual aspects of the body and then recognize that everything…everything workds together. Nothing is separate in your body. nothing. Even the darling obsession of fascia as an interwoven mesh of connective tissue is a misunderstanding. A little quickie: all soft tissue is collagen based, even fascia, and all related. There is no one or the other…they are all one. It’s so honest that people can’t really wrap their heads around it and like to separate as though muscle and fascia could live without each other. Muscle is fascia is tendon is ligament is bone…clearly a topic for another day.

So…The Pelvic Floor. The current or passing obsession is that we must teach people how to use their pelvic floor by doing a “Kegel” a purposeful and strong engagement of the muscles of the sphincter of the urethra that leads to the bladder and the vagina that leads to the cervix and uterus. And to some to also do an anal squeeze engaging the anal sphincter that ends the colon.

What’s so odd about cueing this and utterly inappropriate is that these muscles work just fine…unless you actually have some sort of pelvic floor dysfunction where either you or your client is losing urine from the bladder, feces from the anus or air from the vagina or organs from any of these openings (don’t be that concerned with anal air/farting).

Before I move, might I note that I referred to these natural parts of the body in their natural names. I did not reduce our human bodies to childlike silliness. Please call a vagina a vagina. You are adults. Speak as adults in the teacher forum. To our clients, you can call a vagina a vagina or a penis a penis, too. If you are uncomfortable, then there are issues to be dealt with there. Teaching Pilates may very well be your hobby and not your profession, that is all good! Yet, when you are teaching or writing, I encourage you to be professional and help our very young business actually be a business of professionals (even when darling hobbyists).

Moving on…

So…as long as all is going relatively well, the sphincters of the pelvic floor work just great!
However…these days it does seem that a lot of people develop issues there. Mostly the loss of urine when under physical strain, a lot of air coming into and then out of a vagina and, in later years, for women, the prolapse of the uterus. That can be with our without any natural or unnatural trauma to the pelvic floor. Why are so many people having issues?

You see, the health of the pelvic floor is utterly reliant on the balance of muscles in the torso. Utterly. You see, there is a balance and coordination of the muscles that create and maintain intra-abdominal pressure. They include: the pelvic floor muscles (PF), transversus abdominis (TA), multifidi (M) and the diaphragm (D). If these 4 muscle groups work in good coordination with each other, barring any surgeries or traumas to the PF (including the natural trauma of the labor of childbirth and unnatural episiotomy {cutting of the perineum}) then there is no problem. However, if there is imbalance…and then misfiring…problems occur.

No single muscle or muscle group works on its own. We are organisms…not mechanisms. Every part of your body is working all of the time. Literally. You are absolutely not ever in zero-work in any muscle group or system ever. So…the PF is not on its own and must not be treated as such.

If you sneeze with a moderately full bladder, do you lose some urine? I should hope not. If you do…then there is a weakness and lack of coordination of muscles…not just of your PF muscles…of PF, TA, M and D.

Now, how could a PF dysfunction occur if you didn’t bear a child? How is it even possible? What about excessive air entering and leaving the vagina? What is going on?

Imbalance.

TA and M have to be strong.
D has to be strong.
All have to coordinate.
Then PF will work well.

20130614-131254.jpg

(illustrator credit unknown)

Intra-abdominal Pressure Coordination

Intra-abdominal Pressure Coordination from Rehabilitation of pelvic floor muscles utilizing trunk stabilization by Ruth Sapsford – See article link below for higher resolution image.


This is not supposition. This becomes intuitive…but only through education. Here is a great paper on the subject:

Pelvic Floor – Rehabilitation of Pelvic Floor Muscles…Trunk Stabilization

So, you teach all clients and practice for yourself to lift your abdominals in and up and and and “lift” your lower back bones. Eventually, all back bones. (I put “lift” in quotes because we recall that no muscles actually separate bones. Muscles and all soft tissue manipulate bones through a continuous webbing of tension. We work to manipulate into the most optimal positions…in the spine that means maintaining space whilst moving.) A deep exhale works your deepest abdominals…Transverse Abdominis (TA)! That maintains intra-abdominal pressure while air is leaving allowing the Multifidi (M) to remain efficiently active. Not to mention, then TA pulls on the Thoracolumbar Fascia…also adding the appropriate tension for M to work efficiently.

Great!

So…cue abdominals and and and back muscles. Start with lower back/lumbar.  You must work your back muscles, no matter what lovely teacher has told you not to.  Without actively engaging your back muscles…you have a weak back.  You just have to have good coordination and order-of-operations:  abdominals first (lower fibers of all abdominals), back muscles second (multifidi and erectors).  Efficient.

And this means…not just during spinal extension.  Your back muscles work all of the time.  They do whether you cue them or don’t cue them…as all muscles work all of the time (get used to that notion…it’s not only The Truth…it’s vital to your understanding).  And cue them when you and your clients are in forward or lateral flexion, spinal rotation, lifting tall and in spinal extension.  Back muscles must work efficiently to angle the vertebrae into optimal positions.  Optimal positions make the shape that you desire with the most space possible on all sides of the joints (vertebra to disc to vertebra) so that there is appropriate space for nerves to leave the spinal column.

Now…the use of the Diaphragm is essential. So…let’s make sure that you’re teaching and using the diaphragm. Did you know that the diaphragm contract on an inhale dropping down in the abdomen. That way air can come rushing into the lungs. The intercostals work to lightly stiffen the ribcage so that the air does actually go down…

Wait a minute. Did I just say that the air has to go down? That would mean belly-breathing. Don’t we back breathe and rib breathe in Pilates? And hold our abdominals tightly so that we don’t belly-breathe?
Don’t we “knit our ribs”, “close our ribs”…?
No.  No we don’t.
Indeed, you have been taught that, but it is not what your body is meant to do.  I say this very often: Well-meaning teachers who didn’t/don’t understand how the human body really works taught you to do this.  They were not trying to hurt you, but their lack of knowledge will ultimately hurt you.

You must belly and back breathe.  You must allow space in your thorax/torso for air to enter.  Your diaphragm (D) drops down when air comes in.  That is the engagement…effort of your D.  That is how it gets strong.  That “dropping down” is lower than the level of your ribs…that is into your abdomen.  That means you have to let go of the “death grip” on your abdominals and allow yourself to breathe…take in air…allow your D to work.  A weak D is bad news.
(P.S. – Stay tuned for the next article/post…it will be on releasing the death grip of abdominals.  You must!!!  For this reason and more…)

So…what happens with a weak D?
1 – You don’t take in enough Oxygen.  Oxygen is the food of your body.  So…you starve yourself.
2 – Your nervous system goes into crisis mode.  You breathe from  your upper chest, can’t get good enough breathe and this is the signal of distress.  You exist in crisis.
3 – Your intra-abdominal pressure is off…which is bad for your back…and…your PF!

And then you have to allow your D to “relax”.  That is what a strong exhale is for.  And what aides in the exhalation?  TA!  D and TA interdigitate.  They literally weave into each other where they insert in the thorax.  They are responsive to each other…as long as we exercise them both!

Barring any trauma to the PF…D + TA + M helps PF remain healthy.

DYSFUNCTION:

Now…when does dysfunction come into play?

Again…barring any trauma, if D, TA or M are not functioning well…are not fit, then PF can suffer.  As you can see from the earlier information, the intra-abdominal pressure is going to be “off”.

Pelvic Misalignment and Loss of Urine

However, the real issue from this is that especially if TA and M are weak…then the pelvis can tip in all sorts of interesting directions…and that causes major problems for the PF.

The PF muscles ought to work quite well no matter what the gravitational situation.  However, they are called upon to work most efficiently when gravity pulls the contents of the abdomen firmly down against the PF.  If you’ve got gravity pulling and the floor is tipped at an awkward position and then challenged say by running or jumping, then the PF muscles are going to be challenged beyond their means/abilities.  The typical first sign is the inability to hold your urine during these activities.  Feces, air or organs releasing?  Not likely.  Urine.

I know a woman in the fitness world.  She came to me with concern over her inability to contain her urine while running.  When we met and I saw her walking pattern and pelvis…I could see right away that the issue is likely the strength of the muscles that help moderate her pelvis.  Or the lack of strengthening.  Not that she is not strong or good looking. She is.  But not strong in the right places and not in balance.  Focusing on the correct actions in a proper order of operations is vital.

What is the order of operations?  Always….Always lower abdominal fibers first to assist in effective lower back muscle engagement.  Eventually, all back muscles.  Breath will eventually be an inhale before engaging these lower abdominals, exhale adding the abdominal connection into deeper abdominals (TA) and maintaining back engagement.

So, you can do all the exercise in the world (including Pilates) and it might not help you be healthy and functional.  It’s about what you’re doing and how.

Loss of Feces

If you or your client is not able to contain feces…it is not a muscular issue.  You can work your external anal sphincter all that you want and it won’t help you hold in your feces if you have an issue.  (Please keep reading even if you’re uncomfortable or think you don’t need to know this stuff…)  You have an external and internal anal sphincter.  Your external one is limited in its ability to hold in your bowels.  It is not in high activity most of the time.  If it is…issues.  Emotional issues.  So, just like gripping your diaphragm…gripping your anal sphincter gives your nervous system signals of flight or flight…danger…distress.  “Anal retentive” is not a good label.  Please don’t encourage your clients to “hold your fart”, squeeze your anus”, squeeze your sit bones”, etc.  (I’ll do a full article on why you must not teach or do: squeezing sit bones, narrowing pelvis, squeeze your seat/butt/buttocks, etc.)

It’s your internal anal sphincter that is key to keeping your bowels inside.  And do you know how they work?  By a chemical reaction.  So…if you or your client can’t hold your bowels/feces…go to the doctor.  A major bit of chemistry is off in your body.  Time for the doctor..not for squeezing your external anus.

Anal Air

Alright adults.  Your client farts.  It’s not a big deal.  Ignore it or together share a moment’s comment.  Then…move on, adults.  If you can’t get past a fart…you’ve got some maturing to do.

If your clients anal expulsion of air is fetid (horrid smelling) and consistently so…then your client has a digestive issue that is worth sending your client to a qualified nutritionist or gastroenterologist. If it’s just air…then know that your client bears down more than lifts up…is pushing and gripping.  Teach your client to only use the amount of abdominal engagement as necessary for the exercises’ choice of stability or mobility of the pelvis and spine.  As stated earlier…lock down is no good.

Vaginal Air

Barring any trauma to the PF…if there is a considerable expulsion of air from your or your client’s vagina, then too much air is getting in and this is a PF dysfunction likely from the imbalances stated above in intra-abdominal pressure and the coordination of muscles and strength that assists in PF’s health.

Prolapsed Organs – Organs exiting the PF

OK, now…if you’ve got some organs exiting the PF…we’re talking major PF malfunction.  Barring any trauma…it’s years upon years of imbalance.  However…this is too far gone to consider just TA and M.  If it’s a woman, encourage your client to seek a doctor and Pelvic Floor Specialist.  Once trained, there are ways she can assist by putting her uterus back into her vagina, then “kegel”, maintain the kegel whilst engaging lower abdominals, TA, M and back extensors.  However…let’s not mess with anything like that until she’s seen doctors to make sure that she isn’t beyond that and needing any sort of surgical procedure to restabilize her organs.  And you must be educated in this sort of exercise.  If it is a man or woman who is losing some of his/her colon out the anus.  Also…not work for you.  Work for a doctor.  Please have your client seek a specialist.  No amount of squeezing the external anal sphincter is going to help your client.

Trauma 

Now, let’s get to the trauma.

Childbirth – Vaginal Delivery

The most common sort of trauma to the PF we see in Pilates is vaginal deliveries.

Is this “trauma”.  Yes.  While it’s as natural as natural can be…it’s still a trauma.  It takes a while for the uterus, vagina and PF to heal after childbirth.  How long?  Different for different people.  Some women find they have trouble holding their urine for a few hours or days and then it’s no problem.  Systems return to normal.  However, the stretching of the connective tissues does cause a weakening.  And especially if there is a genetic collagen weakness, then this is even more of an issue.  The actions of TA + M + D for healthy PF activity are even more essential.

Now, there can be nerve damage that causes PF dysfunction.  A prolonged  second stage of labour (over an hour in second stage) or extremely heavy babies can cause the nerves to stretch well past their typical abilities.  You see, the muscles and other soft tissue can stretch a lot, but nerves can only stretch a little.  When the other soft tissue stretches, nerve are forced to follow, but this over-stretching can cause nerve damage.

Episiotomies can factor into PF dysfunction.  An incision from the vagina along the perineum to help widen the end of the canal is very common.  There is healing time from this as the incision is then stitched up and the soft tissue takes time to heal.  However, sometimes the depth of the incision is such that it takes longer; sometimes the muscles don’t heal well…this is the PF…and it is being cut.  Sometimes there is nerve damage.  Sometimes the incision is so long from the vagina all the way the the anus that there complications from this as well.  A challenging episiotomy can cause PF dysfunction.

Other contributors to PF dysfunction include (but there are more): the use of forceps, shoulder dystocia, posterior presentation (when the babies back is to the mother’s back), induced labour…

What do these women do?  Well, they need to see a PF specialist.  Their OB/GYN should be able to recommend one or several.  Unless you’re trained in this and understand all of the implications, then you are not qualified to do this.  Just teach Pilates, please.  Help your client strengthen her abdominals, back muscles and diaphragm…along with the rest of her body!

The Wrap Up:

No Trauma:
-Strengthen abdominals (lower abdominal fibers and TA)
-Strengthen back extensors…not just by doing spinal extension…but by engaging back muscles at all time to organize bones in their most spacious positions (space for nerves to leave the spinal column
-Strengthen the diaphragm…breathe!!!  Allow the ribcage to move and the abdominals to allow the diaphragm to work!
If they are strong enough and you allow…they will all work in beautiful coordination.

Trauma:
Do all of the above…and…
strongly encourage client to seek a specialist.

Work on this all…with everyone.  A healthy pelvic floor comes from a healthy body.  Order of operations is important.  (Don’t forget great nutrition, great sleep and great mental health, too!)

****Thank you for taking the time to continue your education in this way!  I really value you who do this!  It is a small population that really wants to know The Truth of the human body and apply it to Pilates.  We can make up answers with our intuition and suppositions…but that’s not good enough.  We’re in a service industry.  Serve with truth.  If you’re just guessing, you’re doing a disservice.  There’s plenty of information “out there”.  Go get it!  If you need assistance…get it, too.  Email me at info@TheVerticalWorkshop.  I will always attempt to help you by giving you information or leading you to discovering it for yourself.

****Thank you for taking the time to read and continue your education in this way!
Here are upcoming workshops and session information:
Full details are on my website under “Workshop Calendar”:
http://www.TheVerticalWorkshop.com
Denver, CO, USA: July 12-14, 2013 (Pilates on Tour)
New York, NY, USA: July 16, 2013
New York, NY, USA: August 4, 2013
Austin, TX, USA:  August 24 & 25, 2013
New York, NY, USA: September 17, 2013
Warren, Vermont, USA:  September 28 & 29, 2013
Fair Haven, NJ, USA: October 20, 2013
Birkerod (Near Copenhagen), DENMARK:  November 8-10, 2013
Again, full information on all of these workshops is on my website: http://www.TheVerticalWorkshop.com
Would you like to host a workshop at your studio or suggest a host studio?  Email me at info@TheVerticalWorkshop.com or comment below and we’ll discuss.
Please keep your eyes peeled for upcoming products I will be introducing to continuing your education from your own home with the aural rhythm manuals, webinars, videos, manuals and more!
Thanks for taking the time to read!
– Shari Berkowitz
The Vertical Workshop
Pilates Teacher Blog:
http://www.TheVerticalWorkshop.wordpress.com

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More Workshops June – Dec 2013…as of June 12, 2013… The Vertical Workshop Pilates Teacher Intensive Program (TVWPTI)

36 Comments Add your own

  • 1. Amy Wagner  |  June 25, 2013 at 10:46 pm

    Great pelvic floor article. The “4” really do work together as a unit.

    Reply
    • 2. theverticalworkshop  |  June 25, 2013 at 10:52 pm

      Amy,

      Thank you for reading it so quickly! I hope you’ll take time on the article by Ruth Sapsford. (It’s not a quick or easy read, but is a really good one!)

      All the best,
      – Shari

      Reply
  • 3. Cathleen Murakami  |  June 25, 2013 at 11:18 pm

    Wonderful~ hope any instructors who are still cueing “close the ribs, etc get a chance to consider this….P.S. we’ve been calling the vaginal farts – “varts”…..feel free to share that one;-)
    Cheers!

    Reply
    • 4. theverticalworkshop  |  June 28, 2013 at 3:30 pm

      Cathleen,

      Thank you for reading this!

      All the best to you!
      – Shari

      Reply
  • 5. Sunni Almond  |  June 26, 2013 at 12:22 am

    Wow, what a great read. I was taught wrong,
    and I in turn taught wrong. I took as gospel
    the information that I had been given and spent so much to learn. I feel terrible
    about perpetuating the untruths. Never again will I take for granted without doing my own research too. I also feel relieved, because this
    all makes so much more sense.
    Thanks Shari, for putting it out there and clearing the fog.

    Reply
    • 6. theverticalworkshop  |  June 28, 2013 at 3:30 pm

      Sunni,

      Fear not! And you’re on the right pat! Your own research will always give you the confidence you need! I’m glad I’m a part of the process!

      All the best,
      – Shari

      Reply
  • 7. jba400  |  June 26, 2013 at 8:20 am

    thanks for this article. i’m training to teach pilates through polestar and at the same time doing physical therapy for my own pelvic floor issues, so i find this article fascinating and informative. interestingly, i’ve had hip flexor (over-recruitment) issues for 2+ years, had seen a few physical therapists without being able to completely resolve the situation, but now with the women’s health PT we’re finally making progress! with her internal exam, we quickly realized that my left obturator was in spasm and therefore not working. now that it’s firing, we’ve moved on to co-contraction of the pelvic floor w/ other muscles and trying to build endurance. just recently my PT assessed my multifidus and of course it’s not firing as well as it should — i found that interesting b/c no other PT had ever looked at my M. and yet here too in your article you emphasize that M is a critical piece of the puzzle. great article! looking forward to the next one on letting go of the ‘death grip’

    Reply
    • 8. theverticalworkshop  |  June 28, 2013 at 3:29 pm

      Jennifer,

      Thank you for reading!

      The weakness of obturators, gemelli and quadrates femoris is an issue in many people. Take care not to “squeeze your seat” or sit bones or any such thing, but externally rotate your femurs from the aforementioned! Very important! They are small muscles that are tremendous rotators of the femurs…and…stabilizers of the pelvis. This will be an important part of your healing. And TA, M, D in coordination with PF!

      Keep up the good work!
      – Shari

      Reply
  • 9. susan pollack  |  June 26, 2013 at 8:43 am

    As always you have managed to make a complex topic easily digestible and humorous! I started learning and then teaching pilates about 13 years ago-right after discovering that childbirth trauma was resulting in “delayed onset Pelvic organ prolapse”( my name for it) Not wanting surgery recommended by my OBGYN, I requested a pessary ( much to her surprise)Wearing the pessary while doing pilates allowed me to retrain the neuromuscular function of my core without the weight of the organs sitting on the pelvic floor. I was literally feeling my way to better function because I was never referred to a PF specialist. I only had to use the pessary for about 6 months. While my parts are not quite in the right place i do not have any symptoms of Pelvic Floor Dysfunction. I credit pilates! Thanks Shari!Keep on teaching us!

    Reply
    • 10. theverticalworkshop  |  June 28, 2013 at 3:27 pm

      Susan,

      Thank you for your support and supportive words!

      I’m so very glad that you were able to heal yourself! So glad! using a tool like the pessary…great! But it was a tool until you were able to restrengthen! So good!

      All the best,
      – Shari

      Reply
  • 11. Carole Hollis  |  June 26, 2013 at 9:05 am

    Great article and in a timely manner. Crossfit and HIIT’s are gaining ground in the region I live. Someone sent me this link the other day and after watching it, I was horrified! CrossFit – Do You Pee During Exercise?

    Because I work in a gym setting, I am constantly challenged to have clients work in unison with their body.
    We must diligently continue to educate the masses! Thank you for your help!

    Reply
    • 12. akismet-1d46cb1f78ad28e01ee73dcf85a60497  |  June 26, 2013 at 9:59 am

      Carole, I am horrified by this! Thank you for sharing it.

      Shari, great article. I thank my lucky stars daily that the gripping and locking down methods weren’t a part of my training. Working with vocal coaches now and will be using your article to further communicate with them. And will be reaching out to you relative to that as well. Thank you for such a specific approach to this.

      Reply
      • 13. theverticalworkshop  |  June 28, 2013 at 3:24 pm

        I’m so very glad that you didn’t experience the “gripping”/”lock down” in your training! So glad!
        I’ll be curious to know about your work with vocal coaches. Do you mean singing or speaking coaches? I’m a professional singer and have had many a great coach since I was a little girl. I’m curious about what you’re doing!

        All the best,
        – Shari

    • 14. theverticalworkshop  |  June 28, 2013 at 3:25 pm

      Carole,

      Thank you!

      Indeed…it is our responsibility to educate the masses. Share information that is healthy and positive and changes the activity in the fitness industry! I support all forms of exercise as long as no one is getting hurt. Urinating whilst exercising is a form of injury. No good. Thanks for this video link.

      All the best!
      – Shari

      Reply
  • 15. Sara Laurie  |  June 26, 2013 at 5:59 pm

    Thank you Shari, once again your articles are clear and straight to the point.

    Reply
  • 17. sgregus60  |  June 26, 2013 at 11:58 pm

    Love the article!!! Thanks for getting it out there. The breathing and “death grip” issues are so true…..I personally never could master the “no belly breathing” especially having played a musical instrument for many years, and I know why! I love no longer being a “gripper” myself and have seen outstanding changes in me and my clients since “deprogramming” them away from the grip of death. The “death grip” was having negative effects on my body that led to pain – intuitively, I knew it wasn’t Pilates itself, it was the gripping.

    Valuable, valuable quote and wholeheartedly agree with you that it is our responsibility to continue to educate ourselves – “Indeed, you have been taught that, but it is not what your body is meant to do. I say this very often: Well-meaning teachers who didn’t/don’t understand how the human body really works taught you to do this. They were not trying to hurt you, but their lack of knowledge will ultimately hurt you.” I love Pilates and teaching it to others, but early on realized I wanted ” to serve with truth”, so I am continuously researching what you called the “Truth of the Human Body” and how to specifically apply it to Pilates to better serve my clients. Thank you for your continued devotion to the method and your eye-opening research and articles!

    Reply
    • 18. theverticalworkshop  |  June 28, 2013 at 3:21 pm

      Thank you for being so supportive and taking all of this to heart! Thank you!
      – Shari

      Reply
  • 19. Kathryn Schumann  |  June 27, 2013 at 8:41 pm

    Shari
    What a great article. It is very easy to understand and I think, incorporate into my work outs and teaching. Working the whole body and not over correcting or over using specific muscles, I can’t wait till tomorrow to feel these aspects at work. Thank you!
    Kathryn

    Reply
    • 20. theverticalworkshop  |  June 28, 2013 at 3:20 pm

      Kathryn,

      Thank you for taking the time to read this article…and for letting me know that you find it effective. I do hope that you felt the aspects of it in your work as you had mentioned!

      All the best,
      – Shari

      Reply
  • 21. sgregus60  |  July 2, 2013 at 12:48 am

    Shari:

    I have read and reread the Pelvic Floor article. Your articles have always been of such interest to me and I guess because I could read it and shake my head YES in agreement and know that someone else out there was on the same page as me. I had felt for a while that I was one of the only doubters in my then current Pilates teacher circle. Forgive me for all of the details that follow, I can only imagine how busy you are, however I really wanted to perhaps share my experience and let you know that all your work and articles have really helped me. I personally have some PF issues from labor trauma, hip (scheduled for a replacement in Sept) and back arthritis (pain) along with scoliosis and have gone to a Pelvic Floor PT. I had some improvement, but believe that weak muscles and improper firing patterns were limiting me. I have felt like I was chasing my tail at times. Obviously, I have always believed that Pilates was good for me while my long time massage therapist had been strongly telling me that it was Pilates that was a contributor to my pain. Oh my goodness – how dare he tell me that when he knows I love Pilates, and so much that I teach it all with the objective of wanting to HELP people. I was so angry I stopped seeing him for body work. Through more and more of my own research, I started to figure out that……(and how could it be??!!)……Pilates was negatively effecting my body. Let me restate that…the way I was “taught and practicing” Pilates was negatively effecting my body. I stopped doing it for a while and found that my body pains would go away or be very minimized. Then I would start again, and the pain would come back. I still did not want to believe and had to get to the bottom of it. Like you, I want to teach the truth and as I was going through this, I experience such internal turmoil about my career. After a long while, I decided to confide in a friend who is also a Pilates instructor. Low and behold, she was experiencing some of the same things. So we decided to work together in our research. Between the two of us, we happily found other local instructors on the same page, have gone to many workshops, intensives, seminars – both Pilates specific and non-Pilates specific to get our answers. (Anatomy, kinetics, functional movement and assessment, neuro reeducation, trigger point, myofascial connective chain testing and rehab, Pilates for Pelvic Floor Health taught by a UroGynecologist, etc. etc. etc.) The more information we got, the more we had to discern what to use and keep in your tool bag and what to disregard and then how it all applied to Pilates specifically so that we could HELP PEOPLE – including ourselves. The two of us started teaching very differently and to our amazement our clients were responding so positively as were we. We have eliminated the “grip of death” or are still in the process of “reprogramming” people, which has gone almost hand in hand with the importance of proper breathing. I was right up there with the best of the GRIPPERS, never could get that RIB breathing without feeling like I was suffocating myself and yes, I was a TUCKER too. Being told I needed a hip replacement threw me into a full blown research about hips and Femoral Acetabulum Impingement and Femoral Glide problems and all the ugliness this “gripping” was doing to my body. Unfortunately, I was taught, like you said, by people that were taught that – they were not trying to hurt me. Unfortunately, there are still a lot of teachers instructing this way. I cringe when I occasionally hear a PT in the clinic my studio resides in giving inaccurate cues. So it is clear it is not just Pilates instructors that are guilty. Oh well, I have gone on long enough. Thank you again for what you do to get the correct information out there. I can’t wait to see the next article on “releasing the death grip”!! 

    PS – I went on so long, I almost forgot to ask….what do you consider your most successful cues for first engaging the low abs (lower fibers of all abs) and second the back muscles (M and erectors)? Do you just tell them to lift their abs in and up and “lift“ their lower back bones? That works for some, but not all. Here are a couple we have come across:
    • Imagine you are wearing a low slung belt on low rise pants and you are trying to tighten up the notches on the belt
    • Imagine you are trying to squeeze into a tight pair of hip hugger jeans (zipping them up and buttoning)
    • Imagine that you are trying to bring your ASIS’s together (yes, have to teach them what ASIS is) or flatten across ASIS
    • Imagine you are trying to cinch up the lowest part of a corset
    • Imagine someone placed a heavy object on your belly and you are trying to draw in an away from it

    If I am working with a client that was released from Pelvic Floor PT’s in our clinic, then there are a limited number of specific Pilates exercises -determined by testing by PT, including reps and sets and the kegels are done at a specific point in the exercise, in specified sequences and rhythms. Here are the cues for the kegel activation:
    • Squeeze with the muscles used to stop a stream of urine
    • Squeeze with the muscles you would use to hold in a tampon
    • Squeeze with the muscles you would use to avoid passing gas
    • Imagine trying to touch the tip of the tail bone to the pubic bone

    Thanks so much Shari for all your time and effort!

    Reply
  • […] breathing”…then you have a weak diaphragm, too.  Yes, I did discuss this briefly in “At Long Last…The Pelvic Floor Article” and I will discuss the mechanics of breath more in the future, but though you’ve been taught […]

    Reply
  • […] At Long Last…The Pelvic Floor Article | The Vertical Workshop's … […]

    Reply
  • 24. Ben Gaffney  |  December 3, 2013 at 12:22 am

    The transversus abdominis was initially understood to exert it’s beneficial effect on lumbar spinal stability via increased intra-abdominal pressure and by exerting a lateral tension on the thoracolumbar fascia. It’s effects on increasing intra-abdominal pressure may actually be harmful:

    “Intra-abdominal Hypertension is defined as an intra-abdominal pressure above 12 mm Hg” (Khan et al., 2010)

    A maxmimal pelvic floor contraction increases intra-abdominal pressure to 10 mm Hg (Neumann and Gill, 2002)

    “The liver is particularly susceptible to damage during IAH. Blood flow in the hepatic artery and veins and the portal circulation is reduced even in “small” elevations of IAP of 10 mmHg”

    “…Bowel mucosa seems to be quite sensitive to elevations of IAP and is associated with reduction of mesenteric blood flow, which can occur at IAP of only 10 mmHg (leading to a) …loss of the intestinal mucosal barrier and finally, bacterial translocation, sepsis and multiorgan failure.” (Papavramidis et al., 2011)

    Can the lateral pull on the thoracolumbar fascia be exerted without increasing intra-abdominal pressure. Yes, by activating the rectus abdominis which moves forwards away from the spine, which simultaneously increases the tension on the thoracolumbar fascia and increases the volume of the abdominal compartment, thereby, decreasing its pressure. My Yoga teacher calls this technique “Tha-Mula Bandha”. Doesn’t matter what it’s called, its a smart approach that affords spinal segmental stability while avoiding the “physiological” price of increased intra-abdominal pressure. To find out more come to class, visit yogachigungpilates.com.au or resiliencephysiotherapy.com.au or visit my facebook page “Yoga Chi Gung Pilates”

    References:

    Neumann P, Gill V. Pelvic floor and abdominal muscle interaction: EMG activity and intra-abdominal pressure. Int Urogynecol J Pelvic Floor Dysfunct. 2002;13(2):125-32.

    Shehtaj Khan, Akshay Kumar Verma, Syed Moied Ahmad,1 and Reyaz Ahmad Analyzing intra-abdominal pressures and outcomes in patients undergoing emergency laparotomy. J Emerg Trauma Shock. 2010 Oct-Dec; 3(4): 318–325.

    Theodossis S Papavramidis, Athanasios D Marinis,1 Ioannis Pliakos, Isaak Kesisoglou, and Nicki Papavramidou2 Abdominal compartment syndrome – Intra-abdominal hypertension: Defining, diagnosing, and managing J Emerg Trauma Shock. 2011 Apr-Jun; 4(2): 279–291

    Reply
  • 25. “comparison is the death of joy” |  |  January 10, 2014 at 1:35 pm

    […] to focus on strengthening the pelvic floor in isolation via kegel exercises, learn why. (And here is a fantastic place to start. Shari Berkowitz’s blog has been a treasure trove of valuable information for me in […]

    Reply
  • 26. Helen  |  November 18, 2014 at 8:41 am

    Superb article. I have searching for something detailed to further educate my practice.

    Looking forward to reading more

    Helen

    Reply
    • 27. theverticalworkshop  |  December 11, 2014 at 12:45 pm

      Hello, Helen,
      Pardon my delay in replying to your comment and thank you for having taken the time to read this article and comment on it.
      I know you’re in the UK. I’ll be in London many times over the next year teaching sessions, workshops and launching my Pilates Teacher Intensives. I hope that we’ll get to see each other in some or all or something!
      All the very best!
      – Shari

      Reply
  • 28. Katia  |  May 1, 2015 at 12:03 pm

    Hi Shari!
    Great post! Thank you!
    I’m a fairly new Pilates teacher and the more I study about the body, the more questions I have :), especially when I get contradicting information from different sources.
    I would love it if you could answer some questions that arose while reading your post :).

    1. You wrote- “A deep exhale works your deepest abdominals…Transverse Abdominis (TA)! That maintains intra-abdominal pressure while air is leaving allowing the Multifidi (M) to remain efficiently active. Not to mention, then TA pulls on the Thoracolumbar Fascia…also adding the appropriate tension for M to work efficiently”. —
    ** My new pilates teacher is teaching me that there is no need for a forced exhalation to recruit the PF, M. (Though I did understand from different sources that I should do forced exhale to recruit the PF+M well). When you say ‘deep exhale’, do you mean forced or something else?
    ** I didn’t understand the part you wrote with the multifidi.. why does it remain active during a deep/ forced exhalation?

    2. “So…cue abdominals and and and back muscles”.
    The way I cue them is by saying- “lift your lower back bones”?
    ** By ‘back bones’ you mean vertebrae?

    3. “That means you have to let go of the “death grip” on your abdominals and allow yourself to breathe..”
    ** So I shouldn’t have my abs engaged during inhalation- as in lateral breathing? (as I was taught..)

    4. “And then you have to allow your D to “relax”. That is what a strong exhale is for”.
    ** The D doesn’t relax if it’s not a strong exhalation?
    ** So should I exhale strongly as many times as possible throughout the day?

    5. “D and TA interdigitate. They literally weave into each other where they insert in the thorax. They are responsive to each other…as long as we exercise them both!”
    ** Can you actually then exercise them separately if they are woven together?

    6. “The PF muscles ought to work quite well no matter what the gravitational situation. However, they are called upon to work most efficiently when gravity pulls the contents of the abdomen firmly down against the PF”.
    ** I recently asked a physical therapist if the PF, M, TA contract most efficiently in neutral pelvic position and she asked me- “what is most efficiently? These, as do other muscles, recruit in a huge variety of timings, strength, synergies within and between the muscles and more- task specific”.
    So what do you mean by ‘most efficiently? 🙂

    7. “Breath will eventually be an inhale before engaging these lower abdominals, exhale adding the abdominal connection into deeper abdominals (TA) and maintaining back engagement”.
    My Pilates teacher told me to engage the TA / PF only at the end of the exhale..
    So now I’m confused cause I thought that most of the movements in Pilates are done on the exhale.. but if I start engaging the M+PF at the end of the exhalation and only then start moving.. then I’m actually moving on the inhale..

    8. Can you recommend books to read or courses (online also.. I don’t live in the USA) about the biomechanics of the body?

    Thanks a lot!
    Katia

    Reply
  • 29. Victoria Sommer  |  May 31, 2015 at 4:21 am

    Hi shari… I just devour your posts. ..they re so educating and challenging..thank you for sharing !

    Reply
    • 30. theverticalworkshop  |  May 31, 2015 at 9:19 am

      Thank you for reading them, Victoria! I’m glad you’re “devouring” them!!!
      Enjoy!
      – Shari

      Reply
  • 31. Vasiliki  |  July 2, 2015 at 9:37 am

    Very informative article, I loved it. Thank you very much!

    Reply
  • 32. H  |  February 21, 2017 at 2:06 pm

    Great article! I would love to learn more about PFD and interstitial cystitis or painful bladder condition. A lot of articles seem to be focused on prolapse and leaks. My problem is that things are so tight and not firing tight. A lot of referral pain into the bladder, suprapubic pain galore.

    Reply
    • 33. theverticalworkshop  |  February 22, 2017 at 11:39 am

      Hello, Helena,
      Thank you for both reading and commenting on this article.
      Indeed, what you are referring to is hyperactive pelvic floor (PF). With that, we must consider the intra-abdominal pressure, once again (as in the noted article within my article). Many people in exercise find themselves with hyperactive PF because of the popular, though sorrowfully damaging, training techniques: kegel during exercises in order to keep a healthy PF, closing ribs (or knitting ribs or melting ribs or anything to do with the lower ribs), lateral breath (believing that diaphragmatic breath is an issue…meaning that the technique is to keep breath away from the lower ribs in the front), relentless holding of abdominal connections. All of these things can lead to a hyperactive PF.

      If you would like further information or training on how to balance? Please let me know!
      – Shari

      Reply
      • 34. H  |  February 22, 2017 at 12:41 pm

        I would love to hear more about retraining! I am seeing a pelvic floor therapist. We are doing meditation, restorative and yin yoga to calm the nervous system. Stretches such as pigeon, adductor release, low squats with the breathing technique. I am finding that every time I try to do any type of exercise especially balancing it flares everything up. I am also trying to let go of the death grip I’ve had on my Tra for the past 15 years. (upon physiotherapy advice to help me deal with back pain) Im finding it very frustrating because I was moutain biking, road biking etc. I haven’t been on my bike in about 5 months and I’m losing my mind!

  • 35. Michelle  |  March 11, 2017 at 11:41 am

    Can you advice best home videos that teach proper pilates and breathing techniques to strengthen the pelvic floor? I am the trauma, you are speaking of. Long childbirth. 6 children. Currently recovering from pelvic floor (posterier) repair. In a few weeks I will be able to start working out again. Thanks.

    Reply

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