Pelvic Floor Encore

Well, well, well.

By the look of my stat counter it appears I've struck a hot topic with Monday's post: Pelvic Floor Party: Kegels are NOT invited. The comments have been flying and Katy Bowman has been along with us to answer questions. Katy even posted on the topic on her own blog, Katy Says (and the post has cool graphics, so you must check it out). As the conversation ensued in the comment section I had one more question for her--one I thought deserved its own post. Here--thanks to your standing ovation--is an encore question and answer.

And here's another question for Katy on the Kegels. I don't think you're saying we write Kegels completely out of the books, are you? Would Kegels be useful, say during pregnancy and, especially immediately after childbirth when the PF has been directly traumatized? But the difference is we should not go overboard and we still have to build up the other muscles surrounding the PF. Post birth we can go from the Kegel being something we do as an exercise (a few times throughout the day versus 200 times like people have been saying) to something we do in "real time" situations (to hold back urine when we sneeze/laugh/cough/etc.)

Katy, what say you?

I can’t believe how popular this blog has become. Do you know I have friends from elementary school emailing me saying they read this posted on Facebook by people I don’t even know? And I think it is striking such a cord because 80 percent of women are facing this problem, many times silently, and are now really confused. That isn’t what we want either, is it Kara?!

So now you may be wondering “who to trust.” Why would you listen to me? Why am I saying something soooo different than other “experts”? These are all good questions, and questions you should be asking. First off, let me fill you in on the Kegel exercise. Dr. Kegel, an OBGYN, had a device that he invented that he thought would help many of his (caucasian) patients recover from the birthing process.

Before I go any further: It is well documented that Western, modern-living women have much more difficult births than their less-modernized counterparts. During these times (mid 1800’s to the 1930’s) pelvic floor damage and baby-head smashing was a problem for “civilized women,” but not the “Tinkers” (Irish gypsies) or tribal-living women. The only differences in these groups turned out to be the size of their birthing space. The size of the birthing space (the obstetrical conjugate) is created by the bony surfaces of the pelvis. The sacrum (the base of the tailbone) makes up the back side of this birthing space. The cool thing is, the sacrum is not attached to the pelvis, but floating against it. Less-civilized women (like their male counterparts) have squatted to “bathroom” their entire lives. This squatting increased their birthing space by activating the glutes (pulling the sacrum back to open the birthing space). This extra space meant less pressure on their PFs during birth (less tearing of the muscles and tendons) and required less damage to the ligaments in between the bones.

Another way to say this is the life-long habit of squatting is what prevented the PF from being damaged in the first place. The balance between the perfect amount of glute contraction and the perfect amount of PF tone give you what you want. Good pelvic (and abdominal) organ support. [Kara's Note: read Katy's post about the Hunter Gathering Mama for more about squatting for birth preparation.]

Back to Dr. Kegel. Now he had all these women who were noticing weakness and invented the Kegelizer, or something like that. It was equivalent to the Kegel-exercisers you see now. Just insert and squeeze. The squeeze improved the lost mental connection between a damaged PF and one that was firing correctly. Firing correctly meant that when the PF was done contracting, the muscles could restore to their optimal length. This part of Dr. Kegel’s research protocol has been left out and the only part that has been passed on is the contracting part.

Science Note: The muscle tissue in your PF is the same as the muscle tissue in your biceps. When you’re done realllly working your biceps, you’d like your arm to go back to its original length, right? What if, when you were done doing your curls, your elbows stayed as bent as they were when your muscles were the TIGHTEST? If you equate strong with tight, then you’d have “strong,” contracted arms with bent elbows all the time. Tight muscles. Unusable arms.

That’s not what TONE is. Tone is having the MOST strength and the MOST length.

Doing Kegels all the time will get you a TIGHT, unusable pelvic floor. This is why people’s ORGANS ARE FALLING OUT OF THEIR BODY.

Probably the worst time to be doing Kegels in the way we think “Kegels” is during pregnancy. If you looked at the research for birthing mechanics it is clear that women (especially Western women) are allowing their pelvic girdle to collapse based on our lack of glute (and calf and hamstring tension). The research shows that PFD isn’t a problem in other parts of the world.

So, all you Hot Mamas-To-Be out there HAVE TO SQUAT THREE TIMES A DAY until these joint motions come naturally. That’s how you tend to your PF before delivery. To all of you Hot Mamas out there with your birthing days behind you: Don’t let your PF gripping become stronger than your glutes.

I came up with the perfect solution, Kara. Gently tense and fully release (shy of urinating) your PF 10 times while you are in a squatting position. That way you know you are keeping all the pelvic muscles balanced.

Thank you Katy, again, for such eye-opening and SENSIBLE information. Now, let's take a vote. The exercise Katy describes as a replacement for traditional Kegels, I'm going to hereby refer to as the Bowman Squat. Everyone raise your hand if you agree.

An hour after originally posting I'm back because I've had an hour to process this and have a few thoughts. What I'm hearing is (this sounds like I'm in a counseling session, which I almost feel like I need after such apocalyptic information) that Kegels aren't inherently bad, that Dr. Kegel meant well but our puritanic based society just got a little too anal (literally) about them. I mean, I know I for one think that if 10 push ups are good, then 20 are better. If I can do a sprint triathlon, then heck let's go for the Ironman! So it's easy to see how we heard Dr. Kegel (which became every OB on the planet) telling us to squeeze, but we ignored that bit about releasing. And now I'm going deep, folks... but who among us has an easy time "letting go." That, right there, is what childbirth is all about: letting our body open up and let go. But the majority of women can't do it without numbing drugs and interventions. Open up and let go? Huh, what? No, letting go just doesn't come natural to us in our society. We can clench and squeeze and get nice and tightly wound, but ask us to let go? I think what Katy is saying is that our pelvic floor needs balance, we can't overlook the benefits of lengthening and stretching while we're busy strengthening. The exercise of letting go is always a good one to practice in any aspect of life. And I'm telling you, to relax your pelvic floor just shy of urinating--holy cow!--it's super relaxing; like sinking into a tub of warm water... wait, that was water, right?

Everything I know about pelvic floor health is posted on my website, www.lifeasafitmom.com.

Pelvic Floor Party: Kegels are NOT invited.

You now have permission to pee in the shower.

Recently I met a woman who told me she used to be a runner. Naturally, I asked: Why don't you still run? The answer: "Because 60 hours of labor with my first child and a forceps delivery ruined my desire to run anymore."

To sum up for those who still may not infer the problem: She pees her pants when she picks up the pace.

My friends and I joke about sneeze pee, jumping jack pee, trampoline pee, and other bladder challenges. But full blown incontinence is no laughing matter. I'm a firm believer that a strong pelvic floor is the answer to incontinence (although pharmaceutical companies and surgeons often try to persuade people with other remedies). A strong pelvic floor, I've learned, not only makes the difference between wet and dry running shorts, but also keeps me running pain-free: I no longer suffer from the back and hip problems that used to plague me.

So today I bring you an interview with Katy Bowman. I have had the opportunity to interview Katy for magazine articles. Since becoming a freelance writer 13 years ago I have interviewed scores of sources. Very few I remember. Katy made an impression. She is a biomechanical scientist who applies her knowledge on the human body. Among other things, she has her own DVD program, "Aligned and Well," and is the director of the Restorative Exercise Institute. Her blog, Katy Says, is amazing (and she's as funny as she is smart). I like that combination so I asked her to chime in about the pelvic floor. I had no idea she would rock my pelvic floor world. Even if you've never peed in your running shorts even a little bit, you should still read what she has to say about pelvic floor strength.

Mama Sweat: First, a lot of women just assume it's childbirth that causes incontinence, but I've read that pregnancy itself puts a strain on the bladder (so a c-section won't necessarily save you) and that most women, as they get older--whether they've had children or not--will likely experience problems with incontinence. And even men aren't immune. All this suggests that a weak pelvic floor doesn't discriminate.

Katy Bowman: Nulliparous women (that's women who've never had a baby) and men are equally affected with PFD (pelvic floor disorder) so while child birth may accelerate PF weakening, it is not a primary cause of PFD. PFD is first caused by slack in the pelvic floor due to the fact that the sacrum is moving anterior, into the bowl of the pelvis. Because the PF muscles attach from the coccyx to the pubic bone, the closer these bony attachments get, the more slack in the PF (the PF becomes a hammock).

MS: So rather than a hammock, you'd rather your PF be more like a stretcher--more firm and able to hold up weight without buckling?

KB: I like to think of the PF like a trampoline--the material is supple, but taut...the perfect muscle length.

MS: And kegels. Everyone on my blog has heard me preach about kegels. I want to make sure all my readers are doing them right. Suggestions?

KB: A kegel attempts to strengthen the PF, but it really only continues to pull the sacrum inward promoting even more weakness, and more PF gripping. The muscles that balance out the anterior pull on the sacrum are the glutes. A lack of glutes (having no butt) is what makes this group so much more susceptible to PFD. Zero lumbar curvature (missing the little curve at the small of the back) is the most telling sign that the PF is beginning to weaken. Deep, regular squats (pictured in hunter-gathering mama) create the posterior pull on the sacrum. Peeing like this in the shower is a great daily practice, as is relaxing the PF muscles to make sure that you're not squeezing the bathroom muscle closers too tight. Just close them enough...An easier way to say this is: Weak glutes + too many Kegels = PFD.

MS: OK, I had to step away from my computer a moment to fully process this. First of all, you just said it's OK to pee in the shower, but what really has my head spinning--did I catch this right?--you said: Too many Kegels can cause PFD? Did everyone hear that loud screeching noise? You realize this goes against everything I've ever heard or read; that kegels are the be all end all for pelvic floor strength.

KB: I know, I feel like I'm running around saying The Sky is Falling, The Sky is Falling. The misunderstanding of pelvic floor issues is so widely spread, I'm a Team of One right now. But, I've got all of the science backing it up and it makes sense, the kegel is just such a huge part of our inherited culture information, no one bothered to fully examine it. Anyhow, your PF is underneath the weight of your organs, and the strength your PF needs is equal to this weight (you don't need SUPER STRONG PF muscles, just enough to keep everything closed). When you run, the extra G forces (2-3) actually increase the "weight" while running, but the PF should be adapting, just like all your muscles. One of the biggest misnomers is that tight muscles are "strong" and loose muscles are "weak." In actuality, the strongest muscle is one that is the perfect length - you need Pelvic Floor Goldilocks - it's juuuuuust right. The Kegel keeps making the PF tighter and tighter (and weaker and weaker). The short term benefits are masking the long term detriments. Ditch the kegels and add two to three squat sessions throughout the day (anywhere). The glutes strengthen and as a result, they pull the sacrum back, stretching the PF from a hammock to a trampoline. Viola! You can still practice opening and closing your PF in real-time situations, but you don't have to approach it like a weight-lifting session or anything. It doesn't need to be on the To Do list :)

MS: I am ALL for scratching items off my to-do list! Before we get too carried away with our newfound freedom from Kegels, I want to get back to the role of our glutes. What you’re saying--and I love this--is that there’s a much better reason, besides aesthetics, to avoid the flat butt syndrome found in most older women (further exacerbated in "mom jeans"). Having a booty--as in strong glutes--will not only do wonders for your view from the backside but prevent you from peeing just a little (or a lot) when you sneeze. This is revolutionary. I love what I'm hearing.

KB: Ok, I'm yelling this: YOU REQUIRE YOUR BUTT MUSCLES! There aren't any extraneous parts on the body! Every muscle is really a pulley that is holding your skeleton just so. When you let your glutes go, you allow the bones of the pelvis to collpase into themselves. The squat is the most effective and natural glute strengthener--using the full range of motion and your body weight. It is entirely more effective than any gym machine or contrived exercise. The hunter-gathering folks squat multiple times a day (or at least once in the morning), so they had a nice routine down over a lifetime. Doing this four to five times a day, every day of your pregnancy will improve the delivery as well!

MS: I’ve also read that squatting during pregnancy helps prevent the posterior position during delivery (when babies emerge face up, rather than face down), which causes excruciating back labor and with it more interventions, more cesarean deliveries. In America, where we tend to sit back and put our feet up rather than squat and sit forward, the posterior position is more common than in countries where squat sitting is the norm. I was a squatter during my pregnancies, but now I will continue: when I’m playing with The Boy, picking weeds in the yard, pulling laundry out of the dryer or getting a pot from the cupboard. Lots of opportunities to squat!

I know you've brought up posture as a culprit too. How does posture play a roll and how do we keep good pelvic posture?

KB: You can only have optimal PF function when the pelvis is in a particular position. The two bony points on the front of the pelvis (where you put your hands on your hips) should be vertically stacked over your pubic bone. Most women have become "tuckers" based on their mom or gram telling them to not stick their butt out. Athletes tend to be super-tight through the quads and psoas, which also keeps the pelvis tucked under. Wearing high heels requires women to reposition their joints to deal with the torque at the ankle, and many women will post-tilt the pelvis there as well. For optimal pelvic health, one needs to make sure the posterior muscles (glutes, hams, and calves) aren't pulling the pelvis under and keep the psoas and groin loose as well.

MS: So, this requires that we stretch out the muscles in front and strengthen the muscles in back?

KB: The muscles are weak because they are tight. More "strength" or tension-increasing exercises are going to make it worse. Instead, muscle lengthening exercises--especially stretching the calves, hamstrings, groin (adductors)--are the best prescription. Also, you need to learn how to hold your pelvis correctly to optimize strength!

MS: Which brings me to your DVD with the awesome title: "Down There."

KB: The DVD is designed to get the pelvis in the correct position so the PF can work optimally. Typical PF treatment is trying to strengthen the PF muscles with the pelvis itself is in the wrong position, which means the treatments don't work very well. That's why once you have surgery, the statistics say you will have to have a 2nd, 3rd, and even a 4th in your lifetime! It is not a permanent fix, so it's better to not even go down that road. The DVD will teach you to stretch and relax the muscles that are pulling the pelvis out of alignment--and let the correct muscle tone of the PF re-establish itself.

MS: Should we watch it in the bedroom with the shades drawn or is this something we can do with the kiddies around?

KB: Yes! You can keep the lights on and even the front door open. The exercises are mostly inner thigh and back-of-the-leg stretching, so if you don't tell anyone what it's for then they'd never know. And it's also a great program for kids to follow--especially if they are having problems wetting the bed--the muscle tension pattern is the same in the kids as they are in incontinent moms.

MS: OMG! If you were sitting here in front of me I'd kiss you right now! I am forever washing bedsheets. I can't wait to try it out.

Let's get back to peeing in the shower. Now that you've legitimized it for us (I don't advise this practice at the gym, however), let me ask this: Why do I feel the urge to pee a little (or, OK, I'll say it, sometimes a lot) when I hit a warm shower? Wasn't this covered in a Seinfeld episode? Seriously, what is it about the warm water that makes me want to let go?

KB: When the PF is weak, women start to use the glutes and adductors to keep the bladder closed (instead of the sphincter muscle of the bladder itself). When you hit the shower, those external muscles relax and HELLO! you realize that you don't have actual control of the deeper, internal muscles of the PF.

MS: OK. I thought my PF was strong, but I see I have more work to do. I suppose it’s like any muscle, strengthening must be an on-going practice. But for someone who is suffering from incontinence, or this friend of mine who is afraid to run, how soon should they expect to notice a difference once they start a "training program"? And at what point should a woman consider pharmaceutical or surgical options? Ever?

KB: I don't think a surgical option is ever a good idea, as the problem isn't coming from one time damage, but the accumulation of 1) bearing down a lot and 2) from squeezing the PF all the time. Working on relaxing the PF and keeping it closed "just enough," stretching the backs of the legs to free up the pelvis, doing regular, daily squats to strengthen the glutes, and ditching the heels (except in special occasions) are things you can do all the time for all-the-time improvement. Also, doing tons of crunches where you are bearing down on the PF will only make PF health worse. It's better to do transverse abdominal stabilizing exercises - like the plank - that will decrease any bearing down that sprains pelvic organ ligaments. Once you get yourself out of the weak and overcompensating PF tension cycle, you should feel like you have better bladder control within a few weeks. If you are already experiencing organ prolapse (it is way more common that people realize) you need to skip the run and switch to long, endurance walks (minimize G forces), and do your pelvic-aligning exercises every day--maybe even twice.

MS: Wow. This is revolutionary. And it makes sense. I can hardly believe I'm just. now. learning. this. I can't be the only one who's feeling a little cheated. Women (and men) need to know all this. Thank you, Katy, for answering my questions and sharing your knowledge. I know this information will change a lot of lives. And if I can stop buying nighttime pull-ups for my girls, the benefits are more far reaching than I thought!

****Due to the popularity of this post (where are all you people coming from?!) I did a follow up interview with Katy Bowman. This is especially important if you're a Kegel fan--we haven't written them off entirely. Check out Pelvic Floor Encore.

Everything I know about pelvic floor health is posted on my website, www.lifeasafitmom.com.