Getting to (Another) Point about the Pelvic Floor

As often happens when I interview someone for an article, sometimes we get off topic. I am notorious for starting a conversation about one thing and leading soon to something entirely different, but eventually circling back (because I'm convinced background is incredibly important) and returning to the topic. My husband has cut me off more than once: "What is your point?"

What IS my point? My point is, I learned something in this interview that would be superfluous background for the article but fascinating for me nonetheless and so worthy of sharing with my blog readers.

But first I have to tell you about the woman I interviewed (see, more background!). Her name is Elizabeth Noble, a physical therapist and author of a book I read 8+ years ago after picking it up from the bookstore on the way home from that 20-week sonogram appointment, which revealed not one but two babies. Her book, "Having Twins," is still on my bookshelf. I especially enjoyed the passage where I learned that my love of sweet potatoes might have had as much to do with my twin pregnancy as my family history and age. My twins were conceived between Thanksgiving and Christmas--the height of yam eating season.

Oh grief, I'm really off the point now.

Sort of. I was speaking to Elizabeth Noble, who also wrote the book "Essential Exercises for the Childbearing Year," for an article about positions that can help relieve discomforts of pregnancy. And in that conversation she shared this revelation with me:

"What pregnancy does is reveal to a woman her strengths and weaknesses in her muskuloskeletal system. She would have those problems eventually."

Wowza, huh?

So here we are going around blaming our pregnancies for this or for that (ahem pelvic floor disorder, anyone?) when we actually have our pregnancies to thank for getting us to, and addressing, our future body sooner. Of course, ideally we should prevent those problems in the first place, but we have so much working against us... like chairs and cars and computers and televisions...

Anyhow, "those problems" almost always have everything to do with a weak pelvic floor. I believe increased athletic activity can also illuminate pelvic floor weakness in the same way a pregnancy can. When you're demanding a lot from your body and you have muscle imbalances and pelvic floor weakness--where, begins the genesis of our movement--the low back, knees, hips, even feet, will eventually feel the effects of those weaknesses.

Noble, who also is an anthropologist and founder of the Section on Womens Health at the American Physical Therapy Association, echoed a strategy heard here before by Katy Bowman: Start squatting.

She said, "The pelvic floor attaches to the external rotators of the hips; when you come out of a squat, you tighten the pelvic floor." The problem, she added, is that few people in the western world squat anymore. Even when she travels to Asian countries even the younger people aren't squatting like their grannies.

I found this passage in her book interesting:

The comforts of modern life have more and more removed us from the routine physical work that compensates for these structural weaknesses by muscular development. We sit too much. We use laundry dryers instead of bending and stretching at the line. If you ever drive a car without power steering, or use a manual typewriter after an electronic keyboard, you have felt how labor-saving devices make us weak. Worst of all the "modern improvements" is the water commode--the porcelain throne on which people sit to perform functions that should happen only in squatting. Alas, around the world squat toilets are disappearing and pelvic problems for both men and women are increasing in proportion.

She told me she squats on her toilet seat. "I climb on to them," she said. "I put my feet on the rim of the toilet. It can be a dangerous position; one day my foot slid in." She also said there are platforms people can buy or make to modify their toilets so they can squat on them.

Naturally, I had to try.

Fail.

It was high time I cleaned my bathroom floor anyway. Part of the failure was that I was trying to watch (wouldn't you, I mean, to make sure you hit the target?) but in bending my neck down, I also tilted my pelvis forward. That meant missing the bowl. Another obstacle: this can't be done with panties around your ankles.

While the Bill & Melinda Gates foundation is in the process of reinventing the toilet for the developing world, we might ask to include a new design for industrial countries so we can take back our pelvic floor.

Meanwhile, I harken back to Katy Bowman's advice: just use your shower to squat and pee.

What else did Elizabeth Noble leave me with? She says if you have to sit, sit on an exercise ball. I sat on one when I worked while pregnant but had since gone back to the chair. Now I'm back on the ball (as I type this on Sunday afternoon my 2-year old is sitting on it behind me and bouncing mightily).

Which brings me to something else she said (a side story? more background? information to support my point? Hell, I don't know anymore) that's worth repeating: The exercises that are good for you to do in pregnancy are good for you to do for the rest of your life.

Keep up those post-partum exercises. F-O-R-E-V-E-R.

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

Second Annual Pelvic Floor Party: Kegels ARE Invited!

Yes, Kegels are invited, you can bring them along like a date for your super strong booty, but only if you do them right! That means if you're following the advice of such notable experts as Dr. Oz and Dr. Laura Berman (love ya both, but ya'll need to brush up on your pelvic floor advice) then you won't get through the door.

So who decides if you get in? The Kegel Queen. She is the perfect party guest (because she wears a crown, after all). And don't even try to sneak in the back door (ha!) because she will find you and give you a royal talking to.

I know because it happened to me. Not kidding. There's video to prove it. What would you think if you saw someone wielding a skeletal pelvis at you? (The pelvic floor anatomy lesson is absolutely worth the time it takes to watch the video.)

There were a lot of people talking after that Pelvic Floor Party: Kegels NOT Invited post and the follow up post, Pelvic Floor Encore, and the Kegel Queen was one of them. After she posted the You Tube videos (the one above is part two of two), Katy Bowman interviewed the Kegel Queen on her blog. It. Is. Hilarious.

I can't help but like her. So, of course, I checked out The Kegel Queen (a.k.a. Alyce Adams, RN) and liked that her Kegel lessons did not involve the mainstream approach that Katy Bowman shuns in "Pelvic Floor Encore," where she explains her problem with Kegels which, incidentally, is also a problem for the Kegel Queen. It's nice to know that the Squat Queen and Kegel Queen are not at war over the same territory.

Loaded with all this new information, I realized I had spread that mainstream, useless approach myself in an old post I had written about Kegels in April 2009. At first I didn't concern myself with it, after all, that post was buried in the archive of my blog. Who would see it? Then, to make sure, I Googled "Kegel," and saw that my post  appears on the first page of results. Crap! Rather than delete the post, I think it needs a makeover. Who better to lead the makeover than the Kegel Queen herself?

We started with this sorry paragraph:

So how do you do Kegel exercises? The easiest explanation is to squeeze those muscles "down there" that would stop the flow of urine and those that would keep you "puckered up" in a tense situation. The pelvic floor muscles are like a hammock between your tail bone and your pubic bone. The idea is to contract or tighten up that hammock. Ideally we should all be doing 200 a day. There are two main ways to Kegel: Flicks are quick contractions and you should aim to do them in sets of 10. The other option is to hold a Kegel, ideally for 10 seconds or more.

The Kegel Queen would like to send me to the dungeon for that. For starters, I include three of the biggest Kegel mistakes in that short paragraph. Here are the Kegel Queen's list of five biggest mistakes:

Kegel Mistake #1: Moving the Wrong Muscles
Kegel Queen says that the pelvic floor and only the pelvic floor--not your butt, your abs, your hip flexors--should contract during a Kegel.

Kegel Mistake #2: Making the Wrong Movement
A Kegel, says the Queen, is a contraction that lifts the pelvic floor up and forward.

Kegel Mistake #3: Doing Hundreds of Kegels a Day
Not so, says Her Majesty. A few will do, so you don't overwork the muscle.

Kegel Mistake #4: Doing Fast, Light Squeezes
Just like any other strength training, Kegels should consist of several strong and sustained reps.

Kegel Mistake #5: Making Kegels Complicated
Devices that require you to take off your pants will eventually collect dust in the back of your underwear drawer, says The Queen.

In the next paragraph of that doomed post, I launch into another Kegel Queen No-No:

The nice part about Kegel exercises is that they don't require workout clothes. They don't require a gym. In fact, you don't have to make time to Kegel, you can do it almost anywhere, anytime and no one is the wiser. The guy taking your order at Starbucks might wonder what's up with the strange look on your face, but still, he'll never know.

To do Kegels correctly, the Kegel Queen wants her subjects to please, please not do them anytime, anywhere, especially not while driving. Why?

1. To do a strong and sustained contraction requires focus. Could you dead lift your max weight while driving? Impossible, of course, but even if you could do this move in a car, you wouldn't because it requires too much concentration.
2. Having a routine is what makes any exercise program succeed. Saying you can do Kegels anytime doesn't mean you will. 
3. A proper Kegel includes fully relaxing; letting the muscles go completely soft, and letting your mind go with it. Not something you want to do behind the wheel.

Now that I am wiser about Kegels, I thought I should get more insight from Her Royal Highness.

Kara: I was intrigued by the notion that relaxing the pelvic floor is as important a step as contracting it. I understand it from the perspective of lengthening the muscles, but love incorporating the relaxation piece as described by a commenter in one of the earlier Pelvic Floor Party posts. Here's what she said:

As a counseling student, I've become aware of valuable information about pelvic floor relaxation in trauma work and in bodily health (the idea being that if we live in a constantly stressed state, in the "fight or flight" sympathetic nervous system, our bodies will burn out, hence the need for an effective way to relax). The pelvic floor is the only part of the body completely surrounded by muscle, so by relaxing the PF for 20-30 seconds, the rest of the body is triggered to relax and switch into the parasympathetic nervous system. 

You said that by incorporating this relaxing piece into a routine that it will help you enjoy it more, which of course, will help you want to keep doing it. How should we fully relax after a Kegel?

Kegel Queen: In our culture--literally starting with diapers--we’re taught to cut ourselves off from being aware of what’s going on “down there.” We’re taught that sex, pee and poo, our periods, and birth are shameful or dirty, that they should be hidden. The word “pudendum,” the medical term for women’s external genitals, comes from a Latin root that means “shame.” Seriously! Couldn’t they have named it something just the teensiest bit more positive? 

Since we’ve all grown up surrounded by attitudes like this, it’s no wonder that for most women, just consciously connecting with the pelvic floor and starting to contract and release it can be a big learning experience.

So simply becoming more aware of your pelvic floor, and giving the contraction and relaxation your full attention, is a great first step. 

Once you have a grip (oops, no pun intended) on contracting and releasing the pelvic floor, you can start intensifying the contractions and relaxing more completely. There’s a lot you can do to relax fully, and we talk about it in detail in the Kegel Queen Program. Keeping the rest of your body, and your mind, relaxed is part of it. Another piece is deep breathing in a particular way so that your breathing helps the pelvic floor relax and expand.

One thing you should never, ever, ever, ever do is push out or bear down on the pelvic floor to help it relax and expand out. Some people (yes, even professionals) will tell you to push out as part of your kegel workout, but pushing out like that can actually cause prolapse, or make prolapse worse. So you want to allow the pelvic floor to relax, but never push.

Kara: While a routine is important should you change up your position? Since the pelvic floor will be called to duty while standing, sitting, and lying down (wink, wink) should you rotate?

Kegel Queen: Yes and no. First, let me say that I’m absolutely in favor of experimenting with different positions for kegels and whatever else you might like to do (nudge, nudge). Yes, practicing kegels in different positions is a great way to prepare for those times when you’ll need to consciously engage your pelvic floor in real life. Using different positions is also a great way to understand your pelvic floor better. You’ll increase your awareness and control with those muscles.

Also, different positions affect your other muscles in different ways. Remember Kegel Mistake #1, Moving the Wrong Muscles.

What you want is to contract only your pelvic floor and no other muscles. Often there’s a certain muscle group that really wants to contract along with your pelvic floor, or instead of it.

Let’s say that for you, it’s your glutes. You can make kegels easier by choosing kegel positions that help the glutes relax. Or you can challenge yourself by choosing a position that invites your glutes to tense up, then focus on relaxing your glutes while you do kegels in that position.

All that said, the bottom line (whoops, another pun) is that kegels have to be DO-ABLE. All the different kegel positions in the world won’t help you if it makes doing kegels too complicated and you don’t end up actually doing them.

Remember Kegel Mistake #5: Making Kegels Complicated.

Anything that makes kegels complicated, whether it’s some device or worrying about your position too much, is not your friend. DOING kegels in one easy position is approximately one million times more effective than NOT doing kegels in a variety of positions. Know what I mean?

Kara: When should you "let go" of the contraction? And should you time them, to try to build on the time (like you might for holding a plank?) Or, is there a certain time to work up to?

Kegel Queen: All this is a huge part of my kegel course, and I could never do it justice in this short post.

One of the main reasons most kegel instructions don’t work is that there’s not enough detail there to show women exactly what to do. A lot of women think that if they know how many kegels to do and how long to hold them, they’re all set. But actually, if that’s all you know, odds are you’re not going to see the kegel results you want, like dry undies, relief from prolapse symptoms, and mind-blowing sex.

Women need a lot more detail about working up to the full kegel workout as well as breathing, positions, how to stick with kegels over time, and more--all covered in depth in the Kegel Queen Program. Once you learn how to do kegels right, it takes just a few minutes a day. But it’s critical to get the right information, ALL the right information, so you have the best foundation for success with kegels.

Women can look up the kegel instructions on the Mayo Clinic web site to start getting an answer to the question you ask. The information there is basically accurate. But it’s only two short web pages. In my experience with hundreds of women, you need a lot more detail to make kegels really work, like what you’ll find in my two-hour kegel course. When you do have complete information and you consistently do kegels right, the results can be spectacular.

Kara: I recently caught a few minutes of the Dr. Laura Berman show and dang if she wasn't spewing the old 200 Kegels a day advice. I remember it took (and still is a problem) a long time for OB/Gyns to come around on exercising while pregnant and letting go of that 140 heart rate--is this sort of the same thing, where the research hasn't caught up with the professionals? Where's the disconnect? Why does this bad information prevail?

Kegel Queen: That 200 kegels a day thing just keeps on coming back, doesn’t it? It’s everywhere! Here’s why we don’t do 200 kegels a day. Kegels work by increasing your control of the pelvic floor muscles, and by building mass and tone in the pelvic floor. How would you build mass and tone in any other muscle in your body? As anyone who does weight training knows, you’d do a small number of strong, sustained reps. Not 200 “quick flicks,” or 200 anything! Your pelvic floor is no different. We have decades of research to tell us what types of kegel programs work. Why aren’t more people using it?

Why does bad kegel information continue to prevail? I have spent years asking this question and in all honesty, I am still looking for a decent answer. Kegels aren’t the only situation in health care where the research and clinical practice don’t match up. For example, I have a book on my shelf called Obstetric Myths versus Research Realities, and it’s almost four hundred pages describing the ways conventional maternity care is not supported by research. 

One problem is that kegels don’t make money for the health care industry, so there’s no incentive for them to get good kegel information out there. Surgery is an expensive, dangerous treatment for incontinence and prolapse that often fails. But this type of surgery is a multi-billion-dollar industry. 

Here’s another problem with the way the health care business is set up. Imagine that Doctor Jane Doe wants desperately to teach women how to do kegels right to help them with incontinence and prolapse (and better sex!). Since all her HMO employer allows her is a seven-minute office visit with each patient, she just can’t teach kegels effectively no matter how much she wants to.

Unfortunately, the market drives a lot of what happens in health care, and there’s no big market force making sure women know how to do kegels right so we can care for ourselves at home.

I know I did my readers a disservice by oversimplifying the Kegel. Knowing how to properly contract our pelvic floor is essential for a host of reasons, beyond that, a real Kegel can be a risk-free solution to incontinence or prolapse. She might be the Kegel Queen but she also makes a great Kegel Coach. More about her program can be found on her site, www.kegelqueen.com. And she offers a special deal on her program for those who watch the webinar available on her website. Party favor! Thanks for coming to the party Alyce!

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

How's Your Pelvic Floor?

Not everyone looks this good with a pelvis on her head:
Katy Bowman rocks the look and the pelvic floor advice.

It's been more than a year since I interviewed Katy Bowman, biomechanical scientist extraordinaire and founder of the Restorative Exercise Institute. In that post, "Pelvic Floor Party: Kegels are NOT Invited," you might remember, I asked her about Kegels, expecting to hear something insightful about alignment. Instead she informed me that too many Kegels can actually cause pelvic floor dysfunction, and she said that deep, regular squats were the answer to pelvic floor strength. From that day forward this blog (hello to any of the 70,000 visitors who discovered Mama Sweat by reading that post) and my pelvic floor hasn't been the same. To be clear, both are better for that discussion.

Katy and I wanted to check in with each other via our blogs (you can read her interview with me here). A lot has happened in a year. Katy's biggest news is that she became a mom herself. Her site should be required reading for anyone thinking about thinking about becoming pregnant. She is also gestating a few books. But I'll let her explain...

KARA: OK, smarty pants big-brain biomechanical scientist... Now that you've been pregnant and birthed a super-adorable human does the real-life experience change the text-book experience? That is to say, were there any surprises about pregnancy and postpartum? You have fantastic info for pregnancy and postpartum moms on your site, does it change at all now? (And how many different ways can I phrase that question?)

KATY: I'm glad you called me smarty pants big-brain as opposed to big-pants smarty brain. I DID have a wonderful birth, at home. (In fact, he's looking at me now, all nestled in his very own bean bag chair, wondering why I am typing on the computer instead of cooing at him all the time which is what I am usually doing.) I am also super-happy to say that I gave birth au naturel. Well, I wasn't super-happy at the time because MAN that was some intense sensations (WTF!) 

KARA: I know, huh? A little like hanging over the crater of a volcano and just when you think you might fall in you heave yourself back over the top. And while as unbearable as it could possibly be the exhilaration prevails. It's some kind of awesome. A reward in itself, along with the baby, of course. And from what I can tell, you got yourself a cute one. I hope he got your brains, too. But what I really want to know is what did that big-brain cutie pie baby do to your pelvic floor?

KATY: In regards to my pelvic floor (hey, thanks for asking about my perineum) I didn't have a tear or a rip or nada. So, no, I wouldn't change anything about my pregnancy prep, which, of course, includes alignment throughout my pregnancy and lots of correct pelvic floor use via my glutes.

KARA: And all that pregnancy pre-birth prep will soon be found in a great prenatal package through the Restorative Exercise Institute, and I might add is much more useful than knowing how the size of your embryo at different weeks compares to various types of fruit. Like a good scientist you tested all that great information out on yourself. Thanks for that scientific contribution. Any observations to share?

KATY: Well, I'll have to admit that, I WAS NOT PREPARED for how birthing felt afterward. I truly believed I would feel up to going to go hiking the next day. Turns out that a cough or a sneeze was causing panic--my body was that out of whack. It is amazing to think that, in a few hours, you can totally lose touch with a part of your body. I guess that's what happens to the pelvic floor and the core muscles after delivery. And I was glad that my pelvic floor wasn’t super-tight, fighting against me during deliver. That would have caused actual damage to the muscle, instead of just weakness due to stretching.

And, fun fact: It took me about four weeks to be able to Kegel and find these muscles.  Even then, it felt like my pelvic floor was in the other room. That’s a cool feeling...not.

So, professionally--while my pelvic floor info remains the same--everything else has changed. Like sleep. And my hair (chop). And other important things that I can't remember right now. Oh yah, memory. That's different, now isn't it.

KARA: What was the question again? I can't remember much anymore, either. I lose things all the time, too. But sometimes that's the kids' fault. Just wait till your adorable son starts taking off with your keys, cell phone and favorite lip gloss. But I'm getting ahead of myself. You're not chasing him around the house yet, but you ARE a Hot (Sweaty) Mama now and I'm quite certain you're finding ways to get your body moving. How have you been able to sneak in fitness so far?

KATY: Well, I made the mistake of opening my big hunter-gatherin' lovin' mouth and started quoting research about the peoples waaaay back and how women used to walk over 900 miles a year, carrying their babies, and that strollers were anti-alignment and natural strength (which is true, but...) 

So now in my quest to use my human body in the way it was designed to be used, I carry this kid all of the time. That is a huge workout. That, and I haven't driven my car in two months, which means you can find me walking 3-5 miles a day running my errands while working out my arms. Which are buff now. (Hunter-gatherin' Bonus!)

Because I am walking tons, my glutes and legs are super-strong. My arms and abs are super strong carrying the little man. The one piece of fitness that was totally lacking was the stretching part though. And I am a stretching freak (strength is all about those muscles being the right length, after all.) So, after reading your book I realized that I was not going to be given a magical Why-Don't-You-Go-Take-A-Yoga-Class while I sit here quietly sleeping, not pooping or crying or needing you (and that's just my husband) moment. And I started stretching in one or two minute increments. And doing my exercises when and where I could--a squat here and there, a pull up when I pass by the bars. I even stretch my chest and shoulders (great for that breastfeeding neck tension) when I'm done changing the little man, he coos on the table and I stretch like this: 

Or, I lay him on my mat and do downward dogs over him, taking breaks from one-minute holds to give him kisses. And, P.S. I mean the kid, not the hubby.

KARA: Quick though--can I make an appeal here for the best way to carry your baby? I didn't figure out till the fourth kid that I needed a baby-carrying device that distributed the weight on my hips as well as back. There are certain carriers (like Ergo and Moby) that are so much more comfortable and functional. The carriers that just drape over your shoulder seem to cause more problems, at least they did for me. I'm sure you're right about the stroller, but there is a time, there is a place (says the woman who once had three children under 2). So, how can a stroller-pushing-mum save her spine/strength?

KATY: Well for starters, use the stroller to push the kids and not as a crutch. Remember when people used to hang themselves over the stairmaster? That’s what I see a lot of. Running with the torso leaning forward of the legs...really bad for the back and, funny enough, is minimizing caloric expenditure cuz you’re using gravity to help you fall instead of your muscles to push you forward. And there’s no BUTT muscles working in a woman fallin’ forward. You catch my drift?

KARA: You got into with a lot of Kegel lovers last year. Bottom line, what's your Kegel policy? 

KATY: My kegel policy is unchanged from last year as referenced in your post because it wasn’t my "opinion" as in "Hey! I like orange cats because they're pretty..." as it is a theory based on, you, know, the physics and physiology of muscle.  


KARA: Readers can learn all about that policy, by the way, in Katy's online course, "No. More. Kegels." 

KATY: In order for the pelvic floor muscles to function properly, long term, you have to (HAVE TO) have strong and supple gluteals and deep hip rotators (like your piriformis). When you are having a pelvic floor issue, yes, the pelvic floor muscles are weak, but most likely due to the fact that the opposing muscle group is affecting their ability to contract correctly, i.e. shorten and release.

So, I don't have a Kegel policy as much as I have a butt policy. It's called, Get One for optimal pelvic floor function. Now contracting your pelvic floor is something you need to be able to do. If you can't "find it", then you need to increase this motor skill, but any good physical therapist will be able to tell you that the research shows that people who can't contract their pelvic floor (a Kegel) is more often associated with OVER TENSE muscles, not under used ones. Unfortunately we've got people getting their health information from fitness magazines or reading the abstracts of research articles they don't thoroughly understand.

KARA: I think a lot of people (and I used to be one of them) believe the Kegel is something as easy as swallowing. We oversimplified it, and in doing so took some short cuts (the relaxing/stretching part) that rendered the exercise useless or even in some cases problematic. It's our sound bite culture. I also think a lot of women kinda resented being told to do them all the time. When the Pelvic Party Post happened last year, we (all females, everywhere) were in the process of a collective eye roll over being told to keep Kegeling when we intuitively knew that something wasn't right. Now we (all females, everywhere) are thumping our heads with the heel of our hand and saying, "of course!"

KATY: I agree--pelvic floor function has been oversimplified to “do your kegels” and really, you are talking about an area of the human body that you can study at the university level for YEARS. I was actually surprised by the number of people saying stuff like they didn’t believe that kegels could cause Pelvic Floor Disorder or that needing to squat was not research-proven. I don’t think people really understand what gets researched, what that research means, and how things not yet researched are not false. But, if your kegels work for you, then keep doing them. For those who are doing their kegels and still having problems, being open to new science-based theories are a good idea. And from the volumes of positive feedback, I am so glad you ran the post Kara.

KARA: Those Kegel posts got the attention of a lot of people for sure and I hear a book deal for you. How did that come about?

KATY: Well, the phone rang and a publishing fairy said "can I pay you to write down a bunch of stuff you love to write about?" It was amazing. And then the fairy gave me one million dollars, which was exciting, because I got into pelvic floor science to make money and not because women's health was my passion.

Just kidding.

I actually just finished writing "Every Woman's Guide to Foot Pain Relief: The NEW Science of Healthy Feet," in which I allude to the fact that your Pelvis is attached to your thighs and your thighs to your knees and feet, so you should start down at the bottom. The next book on Pelvic Health via da Butt and correct gait patterns (not via Kegels) will actually be a self-publish on Amazon. 

The publishers I talked to said that they thought people weren’t really interested in the pelvis. And then I said, “you mean the 80 percent of the population who will eventually have a pelvic floor disorder aren’t interested?” and then they hung up the phone. No, really, I just decided that women need this info NOW and not in a couple of years by the time a book gets published. Soon you can just download it. Bam. Isn't technology amazing?

And, by the way, if any of you readers would like to submit "your story" of how your switch from Kegels to squats, or doing the "Down There" exercises from my DVD helped you with PF or hip issues, I would love to include it in the book. And, if I use your story, you get a free copy! Does that motivate you? How about if I sign it. How about if Kara signs it too?

KARA: You're getting my squat story. Where should we submit them and what's our deadline?

KATY: You can share your story on the "Pelvic Floor Party Anniversary Special" post on my blog and I will be taking your stories through the end of August.

KARA: While there has been a lot of pelvic floor talk on my blog this last year, Katy has been super busy answering questions and addressing issues. Here are links to a few of the follow up posts she did:

The Hunting and Gathering Mama

You Don't Know Squat

1234 We Like Our Pelvic Floor

And the conversation continues between Kara and Katy over at Katy Says! How have those squats worked for you?

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

Pelvic Floor Party Trick

Many of you have read the recent and popular posts, Pelvic Floor Party and Pelvic Floor Encore, but you may no longer be following along in the comments where the discussion lives (rages?) on. I'm thrilled Mama Sweat is the forum for such an important discussion, but mostly all I can do is nod and smile.

This week, we got a comment that made me laugh out loud and I knew that there was no way I could leave it buried and unnoticed. From Matthew J Taylor, PT, PhD (trust him, he's a doctor) we get:

Not to confuse the issue, but to introduce some fun, I presume everyone is familiar with the concept of the connection between the pelvic floor and your tongue (careful, it's a family site)?

Seriously...sit feet flat on the floor, pelvis square on a chair, spine softly erect. Now, sensing the space between your sitting bones (ischial tuberosities), gently begin to press your tongue against the back of your teeth and watch what happens to your PF as you increase the pressure, and then watch as you slowly release (old Feldenkrais lesson).

Not only that, but what you are thinking and what you believe in the moment directly impacts your breathing pattern, which also sets tone in the PF (for the evidence crowds see O'Sullivan PB, Beales DJ. Man Ther. 2007.Aug;12 (3):209-18. Epub 2006 Aug 17.)

So feet on the floor, soften the tongue and exhale...happy PF's everyone!

Isn't that great? Although I don't know who old Feldenkrais is, I appreciate the new party trick because I can't touch my nose with my tongue.

On a more serious note, another comment came in regarding the important but forgotten step of relaxing the pelvic floor. Leah F. gives us another good reason to put it into practice and stop being so "assed up" all the time:

As a counseling student, I've become aware of valuable information about pelvic floor relaxation in trauma work and in bodily health (the idea being that if we live in a constantly stressed state, in the "fight or flight" sympathetic nervous system, our bodies will burn out, hence the need for an effective way to relax). The pelvic floor is the only part of the body completely surrounded by muscle, so by relaxing the PF for 20-30 seconds, the rest of the body is triggered to relax and switch into the parasympathetic nervous system. "Being able to live in a state of 'non anxious presence' (NAP) is key to managing future potential crises and traumas. NAP is not something that can be mastered in one session, but is something that needs to be practiced and used when life is not traumatic. It is a technique used to facilitate the PNS, so that we may stay relaxed and calm. Good gauge of a NAP is a relaxed pelvic floor. Being in this state allows one to be empathetic, compassionate and bear witness as a spectator. It is about relaxed mindfulness and comfort in ones own body." (Noel Holdsworth DNH, APRN-BC, CTS www.ejhealers.com)

And included in all this pelvic floor discussion we have had a few comments calling for the need for "scientific proof."

It's there, says Christine Kent from Whole Woman, Inc. who urges us to check out the paper, "Genital prolapse: a legacy of the West?" in the Australian and New Zealand Journal of Obstetrics and Gynaecology. But as she puts it: "The people who fund large studies generally do not want to know what reverses the very disorder that is the bread and butter of gynecology." She goes on to say:

More importantly are natural and real-time testimonials of women themselves, which were never possible before the great democratizing power of the internet. Maintaining the natural shape of the spine is the only way the pelvic organ support system properly functions.

And I liked what Michael Curran had to say in response to an "anonymous scientist":

As a health practitioner, I have followed this blog with some interest. In an intelligent discussion, Anonymous provides an odd voice, without the self-respect to identify the source of strange and illogical arguments backed only by having identified one’s self as “a scientist.” Where Bowman has presented a logical, coherent and viable solution for a pervasive health problem, your contribution has been to question the scientific validity of the approach by comparing PFD with stretch marks (ladies) and "inherited bad teeth."

It’s a sad state of affairs when a “scientist” - real or self-perceived - is so quick to dismiss an unfamiliar therapy when the “correlation” evidence is compelling, the contrary evidence is non-existent, and the cost of implementation is zero.

And that's the bottom line here. In my mind it doesn't matter whether there are studies to back this up or not. If you start squatting more (and squatting more will neither hurt you or cost you anything) and this helps you, then your study of one is successful.

Heck, with all the responses to these posts and so many woman ready to drop Kegels from their life (it's like a bra-burning rally at Mama Sweat) we've got plenty of willing study participants, don't you think?

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

Second Pelvic Floor Encore

For those of you arriving for pelvic floor enlightenment (or wish to further your enlightenment), Katy Bowman just posted a fantastic video tutorial on her blog (with a skeletal pelvic prop!) as a follow up to the frenzy we've been experiencing, and as Katy say:

"If there is anything we don't need it is more Huh? when it comes to our own equipment!"

Give yourself five minutes today for her vlog, Pelvic Floor Demystified.

Does anyone else want to be Katy's best friend?

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

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.