Here are some practical suggestions to accompany our recently published article in OT Practice
Exercises/Lessons for Sally’s Incontinence Related Intervention
The following exercises/lessons are not limited to treating incontine nce, but are appropriate for almost any type of pelvic floor related disorder .
Pelvic Breath Lesson
Position the client in sitting or supine with knees bent and feet flat on the floor. Provide the following cues:
1. Sense the body and breath. Where do you notice the movement?
2. Guide the breath into the lower trunk. Feel it in the belly, low back and pelvis.
3. Bring your attention to the inside of the pelvis.
a. The pelvis is shaped like a boney bowl with a hole in the bottom.
b. The bowl has a muscular bottom going from the front of the pelvis (pubis) to the tailbone. This muscle is shaped like a hammock. When you feel the urge to urinate or defecate, you lift the hammock to “hold” and when you reach the toilet, you release these muscles to evacuate.
c. As you breathe, see if you can feel a subtle movement in the pelvic floor muscles.
(Repeat each of the following sequences 4-6 times)
4. Accentuate the movement with the breath.
a. Inhale and release the pelvic floor down, then exhale and VERY gently draw the pelvic floor toward your head.
b. Imagining that the lungs are nestled in the “hammock” where the bowel and bladder really are may simplify this action.
5. Quadrants of the pelvic floor: left, right, front and back
a. Inhale and release down as you relax the left quadrant (area between the pubis, tail
bone and left sit bone) and gently lift it as you exhale. Using the “pelvic lung” imagery, breath in and out of the left “lobe”.
b. Inhale and release down as you relax the right quadrant (area between the pubis,
tail bone and right sit bone) and gently lift as you exhale. Using the “pelvic lung” imagery, breath in and out of the right “lobe”.
c. Release down on the inhalation into the front quadrant (area near genitals/pubis)
and draw up as you exhale. Using the “pelvic lung” imagery, breath in and out of the front “lobe”.
d. Release down as you inhale into the back quadrant (portion near anus and tailbone)
and gently lift as you exhale. Using the “pelvic lung” imagery, breath in and out of the back “lobe”.
e. Inhale and relax the whole pelvic floor (right/left, back/front), exhale and gently lift as you exhale.
f. During the exhalation, use pursed lips or engage the throat muscles (ujaii breath) as if fogging a pair of glasses. Do you feel the engagement of the pelvic floor and the abdominals?
g. Rest. As you breath, can you feel the movement of the pelvic floor? Has your perception of the breath changed?
The pelvic breath was taught in the last 15 minutes of Sally’s first session. She found the breath work very relaxing and “thrilled” that she could feel the pelvic floor move. Sally also noticed how the front quadrant of the pelvic floor was weaker and harder to sense that the back portion. This is a common experience as the deeper, more powerful muscles are in the back and the superficial, weaker muscles are in the front (urogenital muscles). She also commented on how the abdominal (and pelvic floor) muscles engaged when exhaling through pursed lips. Sally was given a CD, recorded by the therapist, for her home exercise program.
Coordination of the Obturator Internus and Adductor Muscles with the Core
As previously mentioned, the pelvic floor muscles are the “floor of the core.” However, focusing primarily on the “floor”, does not take into account the “floors” synergistic relationship with the obturator internus and the adductor muscles. The obturator internus is a lateral rotator of the hip that attaches to the pelvic floor and forms a conduit for the pudendal nerve. Dysfunction of this muscle, which can sometimes result from hip replacement surgery, contributes to a host of pelvic floor disorders. The hip adductor muscles attach to the pelvis at the pubic rami and strongly influence the urogenital muscles of the pelvic floor. Muscles do not work in isolation; therefore improving the strength and coordination between these muscles, facilitates a stronger, suppler pelvic floor.
Coordination of the Obturator Internus and Adductor Muscles with the Core
These lesson s can be done in supine or sitting.
Version 1: Tie a piece of elastic band above the knees. Place the knees and feet together. With the feet stationary, gently roll the knees outward. Hold for 10 seconds. Do not strain or restrict the breath. Sense how the back of pelvic floor engages. Release the knees and relax for 10 seconds. Repeat 10 times.
Version 2: Exhale through pursed lips while lifting the pelvic floor and rolling the knees outward. Inhale and release the pelvic floor and knees. Repeat this sequence 10 times. Pursed lip breathing promotes coordination between transverses abdominus and the pelvic and respiratory diaphragms. Another alternative is to exhale with the glottis partially closed (ujaii) which brings a third diaphragm into awareness for functional stability.
Version 1: Place an object like a ball or towel between the knees, feet hip width apart. Gently roll the legs in and squeeze the object. Do not strain or restrict the breath. Hold for 10 seconds. Sense how the front of the pelvic floor engages. Release the knees and relax for 10 seconds. Repeat 10 times.
Version 2: Exhale through pursed lips (or partially closed glottis) while lifting the pelvic floor and squeezing the ball. Inhale and release the knees and pelvic floor. Repeat 10 times.
As a general rule, give equal time to strengthening and relaxation, but make adjustments to suit a client’s needs. Throughout the exercise, guide clients to release any unnecessary tension such as hiking their shoulders or tightening their jaw.
Sally was guided though the obturator and adductor exercises on the second session. Her biggest challenge was coordinating the breath and leg movements, “I was surprised that I was holding my breath. Who would have thought breathing and moving could be so difficult.” The following session Sally commented on being surprised at how often she held her breath during the day, and how much “easier” everything was if she breathed. This is a common issue as many clients restrict their breath when learning new skills or doing challenging tasks. These exercises are often a first step in helping clients learn to coordinate breath with movement.
Pelvic Floor Functional Movements
How many clients adhere to their home exercise programs? Although most have the best intentions, compliance is often disappointingly low. Therefore, helping clients integrate the pelvic floor muscles in common movements such as squatting, lifting, standing, and bridging promotes lasting change, while maintaining the suppleness of these muscles.
There are additional benefits to this practice: energy conservation and joint protection. When the pelvic floor muscles are integrated into full body movement, tasks are easier and require less effort. Improved coordination of the core muscles stabilizes the lower back, minimizing the risk for injury while lifting, pushing or pulling objects.
Pe lvic Floor Functional Movements Lesson
Pelvic Squat and Lifting
As we squat, the following movement occurs in the pelvis: the sit bones move laterally, the iliac crests are drawn medially and the sacrum nutates (“nods forward”). The pelvic floor muscles, some of which attach to the sit bones, lengthen in an eccentric contraction. When we push out of the squat, the pattern reverses. Clients are guided to sense these subtle movements. The next step is to coordinate the pelvic squat with the breath. The following cue is given: “ Inhale as you squat and allow the pelvic floor to release down. Sense how the sits bones separate. Exhale as you stand and lift the pelvic floor while bringing the sits bones closer together. Keep the movement slow and small.” Once the client is proficient in this coordination, progress to doing the pelvic squat while cooking, waiting for a bus, or standing in line at the grocer. The last step is to coordinate the pelvic squat with pursed lip breathing, which promotes even more lumbo-pelvic stability, when lifting objects such as a box, laundry basket or even a child off the floor. In this practice, clients are learning to integrate the pelvic floor with full body movement in many context.
Sitting to Standing and Bridging
As we bend forward to stand, the sits bones move further apart and as we rise, the sits bones come closer together. Therefore, the cues are the same as the pelvic squat – inhale and relax the pelvic floor as you bend forward, exhale and lift the pelvic floor as you stand. Engaging the pelvic floor muscles in this manner, makes standing easier as the “floor of the core” helps lift the body upward. The same coordination of the pelvic floor muscles can be used to facilitate bridging in bed.
Sally enjoyed coordinating the pelvic floor with the functional movements. She noticed how standing and bridging were much easier when she consciously engaged the pelvic floor – and practiced the pelvic squat when talking on the phone, cooking or waiting in line at the bank or grocery store. In these situations she kept the movements very small stating, “No one knows what I’m doing, but they wonder why I’m smiling.”