Introduction by Chris Lavelle, PAA Vice President
This month, we have another great article on the pelvic floor from one of our own members, Sophie Jeffries. In this article, Sophie points out the importance of training the pelvic floor to work eccentrically as well as concentrically and some creative ways to integrate Pelvic Floor awareness into Pilates workouts.
Enjoy the article and remember to always screen your clients for Pelvic Floor Dysfunction and refer them on to a Pelvic floor specialist when needed.
Thank you Sophie for your contribution!
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Eccentric Pelvic Floor Training
Why your pregnant clients may benefit from it, and how you can integrate it into a Pilates class.
Most women have heard of the pelvic floor exercise called “Kegels.” For clarity, a Kegel is when you close and lift the pelvic floor muscle group in a shortening, concentric type of muscle contraction. The other part of a Kegel that is sometimes neglected is the letting go, the release and lengthening of the pelvic floor, which is an eccentric type of muscle contraction.
This article is specifically about why and how to recognise and build the eccentric phase of pelvic floor muscle contraction into a Pilates program for women who are pregnant.
I want to preface this article with the clear understanding that pelvic floor health is an essential part of our overall health, especially for women who are pregnant or have recently given birth.
Statistics show that after having a baby;
1 in 3 women develops incontinence. (1)
1 in 4 women develops prolapse. (2)
1 in 7 women develops postnatal depression. (10)
Research also shows that there is ‘a significant association between depression and pelvic floor dysfunction’ (9) and that ‘women with pelvic floor dysfunction are twice as likely to develop postnatal depression as those without.’ (8)
As Pilates instructors, our scope of practice is, of course, in movement instruction. If a woman describes symptoms of leaking, pain, discomfort in her pelvic floor, or mental health concerns such as anxiety and depression then best practice is to refer on to her GP for further referral to a continence professional such as a women’s health physiotherapist or a mental health professional for essential assessment, diagnosis and treatment.
However, as Pilates instructors, we often see pregnant women weekly, sometimes more often, and are in an ideal position to positively impact how these women prepare for birth.
One aspect of preparing a body to birth is how the pelvic floor may relax, release and lengthen, or not.
Midwife and childbirth educator Jenny Blyth says ‘emphasis is usually placed on strengthening the holding ability of the pelvic floor muscles… However, a woman who can already contract and hold her muscles needs to know how to relax them when she births.’ (10)
In my experience, there can be a lot of focus on strengthening a woman’s pelvic floor, but like any other muscle group in the body, the pelvic floor responds well to moving through its full range of both the concentric and eccentric phases of contraction.
I’m very interested in how sometimes women are under the impression that they must do pelvic floor contractions hundreds of times a day. ‘Do your pelvic floor exercises’ is a throwaway line heard by many pregnant women without further explanation or consideration that the pelvic floor is a complex muscle group performing many functions and holding much emotional charge for many people.
I did my initial Pilates teacher training in 2004 in the UK. When we did the module on the pelvic floor, the teacher found it so awkward she had to leave the room. She left the physiotherapist who was co-teaching to explain the anatomy and function of this mysterious and for some people, embarrassing muscle group.
That was nearly 15 years ago, and I’ve had two babies since then. I’ve also taught hundreds of pregnant women in studio settings, general group classes, and also in prenatal specific mat classes which I teach at Armature Pilates in Melbourne.
Over that time, I’ve become genuinely interested in pelvic floor health. I’ve also become a shiatsu therapist, postpartum doula, and have attended many trainings around supporting a woman’s body to birth and postnatal recovery.
Do you know what the elephant in the room always seems to be when teaching Pilates to 18 pregnant women all at one time?
A baby has to come out.
A baby has to come out of each of these incredible, adaptable, and resilient bodies.
And, hardly anyone ever says anything about it!
However, what does birth have to do with us as Pilates teachers?
- It matters to your client, the mother, how she gives birth.
- Many women (not all!) want a vaginal birth.
- Having a ‘too tight’ pelvic floor that can’t relax and release (6) can influence how a baby positions for delivery and can impact how a baby is born.
- Large numbers of women who have had babies have ongoing pelvic floor injuries with symptoms like leaking and prolapse.
- Women often mistakenly think symptoms of pelvic floor dysfunction are typical after giving birth, and these can have a devastating impact on a woman’s life.
- Many women feel ashamed about pelvic floor issues and most likely will not tell anyone. Not their GP, partner, friends, or even their Pilates teacher. (3)
- During vaginal birth, the pelvic floor must stretch enormously. Up to 200% (4) of its usual length. If women do too much strengthening of their pelvic floor during pregnancy and don’t learn to relax and release, this may make a vaginal birth longer (5), more difficult or even impossible.
Many factors unrelated to Pilates go into how a birth eventuates.
However, as Pilates teachers, we are well placed to support women in fostering healthy awareness of how the pelvic floor contracts and relaxes in relation to how this may impact birth and future pelvic floor health. I tend to think of this as injury prevention for the pelvic floor!
Consequently, one of the main things I focus on when teaching pregnant women is eccentric conditioning of the pelvic floor.
‘How on earth do you do that?’ I wondered back before I’d had children. I remember being flummoxed by an osteopath who suggested training the eccentric phase of pelvic floor contraction for a client. The client was male and absolutely not pregnant!
At the time, I thought I knew how to teach the concentric phase of pelvic floor activation, but the idea of teaching an eccentric phase had me confused.
It turns out it’s pretty easy and totally within the scope of a Pilates instructor role.
Firstly, what goes up must come down. Think of the close and lift action of the pelvic floor as the concentric contraction. Which then makes the release and lowering action of the pelvic floor the eccentric contraction.
After closing and lifting your pelvic floor, can you control the return? Can you smoothly and slowly, lower, release, and widen your pelvic floor muscles? Rather than just totally letting them go without any control?
Also, in a relaxed and supported position like side lying, can you release residual tension from the pelvic floor, allowing it to soften and relax completely?
Secondly, It’s important to understand that pelvic floor movement is very much influenced and impacted by the movement of the respiratory diaphragm.
Like most Pilates teachers, in my initial training, I learned about the ‘deep cylinder,’ inclusive of the pelvic floor at the base, the diaphragm at the top, the transverse abdominals wrapping around the waist and of course the multifidus at the back. However, I didn’t understand the significance of the ‘deep cylinder’ in relation to intra-abdominal pressure, and also the relationship between the diaphragm and pelvic floor health, until much later.
Regarding the lift and squeeze of the pelvic floor and contraction of the deep abdominals, I thought more was better. I thought stronger, meant better.
However, like any other muscle group, the pelvic floor needs to be able to access its full range of movement, which includes being able to lengthen and release, and also being able to respond, by contracting appropriately to the load it’s under, in any given moment.
If your bicep is at full contraction, then it’ll be pretty awkward to pick up a cup of tea without lengthening it first. Similarly, if your pelvic floor is at full contraction and you need to sneeze, it needs to release a little first, so it can adequately react to the increase of pressure from the sneeze, by contracting in and up.
If you can imagine the ‘deep cylinder’ as being a cylindrical shaped water balloon, it might help you understand the pressure system in our abdomens. Ideally in a healthy body, every breath we take moves the diaphragm downwards, which in turn applies pressure onto the abdominal cavity and consequently onto the pelvic floor, which responds by releasing a little. Imagine pressing down on the top of the water balloon and consider how the base of the water balloon might react by expanding out and lengthening down, just a bit.
Alternatively, think of how a trampoline will stretch down as someone jumps on it, and then rebounds up as the person bounces up.
Alternatively, imagine a coffee plunger, as the top is pressed down, the filter also moves down. As the top is moved back up, the filter returns up too.
This is how a healthy pelvic floor moves in response to the diaphragm, expanding down as you inhale and shortening up as you exhale. Julie Wiebe PT (sports medicine and women’s health physiotherapist) calls this action the ‘pelvic floor piston.’ (7)
Please be clear that this is not pushing down or bearing down, rather an appropriate response of the pelvic floor to the increase of pressure from above, from the diaphragm. Every breath you take is an opportunity for the pelvic floor to release and then rebound again as you exhale. This is normal, healthy, functional pelvic floor movement.
What’s not always healthy is if the pelvic floor gets stuck on being ‘too tight.’ Of course, as Pilates instructors, we can not diagnose someone as having a hypertonic pelvic floor (6), that’s the domain of a continence professional. However, we can teach healthy breathing and movement patterns. Which in turn supports the healthy movement of the pelvic floor, for everyone, including women who are pregnant.
Thirdly, it’s important to remember that the pelvic floor does not live in splendid isolation at the base of the pelvis. It is attached fascially to (among others) the glutes, adductors, hamstrings, calves, feet, abdominals, diaphragm, upper traps, mouth, tongue, and jaw.
As I’m sure you know, the fascial network is impressive and is why you can help relax the pelvic floor by massaging your feet with a spiky ball, releasing your diaphragm or relaxing your mouth and jaw.
The fascial network is also why, whole body movement – like what we do in a well-delivered Pilates class – may help to condition the pelvic floor through its full range without overly tightening into dysfunction and without even really thinking about it as long as there’s a healthy breathing pattern.
Exercises like reformer legs in straps; frogs and openings, and Wunda chair; standing leg press both front and side are fantastic for this. Although not necessarily the ideal choice for a pregnant woman, of course, it depends on your client!
To condition full range of motion in the pelvic floor, it needs to be trained in its eccentric range. To do this with healthy bodies, all you need is a neutral pelvis and some hip flexion. For conditions related to dysfunction of the pelvic floor, support from a continence professional is essential.
The following exercises are great, as long as there’s no sneaky tail tucking which is way more common than you’d think! (These are examples only, not a complete list!)
- Reformer footwork – the return of the carriage.
- Wunda Chair Footwork – the return of the pedal.
- Knee Stretch in neutral pelvis – the return of the carriage.
- Scooter in neutral pelvis – the return of the carriage.
- Squats – the downward movement.
- Lunges – the downward movement.
- 4 point rock backs in neutral pelvis.
- Supine Bridging – controlled lowering of the neutral pelvis.
For eccentric pelvic floor training, you need to broaden the base of the pelvis, wherein the sitz bones widen, and the coccyx lengthens backward.
By adding hip flexion of the thigh bones to a neutral pelvis, you can get contraction of the pelvic floor in the eccentric range. In the book ‘Pelvic Power,’ Eric Franklin describes this very clearly, ‘the tuberosities stretch away from each other when we bend our legs’ and ‘when we bend forward to get up (from sitting in a chair) the pelvic floor widens.’
Ideally, you want the base of the pelvis broadening and the pelvic floor releasing in coordination with the inhale. So as you breathe in and the diaphragm descends, this is the moment to allow the pelvic floor to lengthen and widen.
For example, Wunda Chair footwork is a comfortable place for the client to focus on expanding the pelvic floor in a healthy range, as the pedals return on the in breath.
You could ask the client to slow down the return of the pedals to help focus on broadening the diamond shape of the pelvic floor as they inhale. It’s not bearing down or pushing out but allowing the pelvic floor to release, lengthen and widen as the pedals return.
Considering so many women find their way to a pilates class precisely because they are pregnant, I think it’s worth addressing the embarrassment, silence, and discomfort sometimes surrounding the pelvic floor.
We can tailor the way we teach pelvic floor activation to the needs of the individual. In this instance, to the pregnant woman who hopes to have an intact pelvic floor after giving birth. Let’s help her understand that to release and lengthen her pelvic floor is an integral part of pelvic floor health and is just the other side of the well known close and lift ‘Kegel.’
I realise that what we do in Pilates class seems a long way from the birth room. However, is it?
Week by week, class by class, we can promote healthy pelvic floor muscle activation by simply developing a better understanding of how the pelvic floor is influenced by breathing, movement, and specific repertoire in the Pilates method. Thereby ensuring our clients start to allow their pelvic floor to move through the eccentric range as well as the concentric. So perhaps going some small way to positively impacting the birth experience, and postpartum pelvic floor health.
The pelvic floor is just another muscle group like any other, needing both concentric and eccentric contractions for healthy function.
As movement professionals who teach the Pilates method, we can support our pregnant clients to become educated and empowered in how to care for their pelvic floor as they grow, birth, and nurture tiny humans.
by Sophie Jeffries, PAA member.