While structured breathing work may seem simple-even silly- to some, we know that it is a powerful tool for the pregnant and postpartum woman. Deep breaths have the ability to calm the nervous system which can affect muscle tension, heart rate, and blood pressure. Additionally, the respiratory diaphragm can mobilize muscles in the pelvis and back due to anatomical connections. Muscles, including those shown in the photo below, are big players in midline stabilization and support. A great place to start is the 90/90 breathing drill (seen below). Try this out for 10-15 breaths at the end of your day.
Many postpartum women do not know all of the details after birthing their baby. Some have told me they were not aware they had stitches down below until the 6-week check-up when the doctor wanted to make sure they were healing well! The check-up at 6 weeks can be quick so arrive with questions. It is helpful to know about any tearing, episiotomies, tools used during the birth, etc. These factors are all great to bear in mind as you return to exercise and daily functioning.
Another question to ask-- “Is there a pelvic health PT that you would recommend?” They may know someone in the area or have worked with them prior. However, do not become discouraged if they don’t have a name to offer. A Google search for “women’s health PT” or “pelvic PT” should show professionals in the area. Compare websites and reviews to see if the PT would be a good fit for you and your goals!
Pelvic Health Physical Therapy
Once you have been cleared by the doctor for “usual exercise” and intercourse, I highly suggest visiting a pelvic health or women’s health PT. They will be able to further answer any questions about symptoms you may experience immediately postpartum and later.
A pelvic PT is specialized on evaluation and treatment of the pelvic floor musculature. They can perform internal evaluations to test the strength and endurance of your pelvic floor, check for prolapse, address any soft tissue issues, etc.
For the evaluation, the therapist will use a gloved finger to palpate muscles internally. While a great deal of information can be gathered from an internal evaluation, it is not necessary for visiting a pelvic PT. The therapist can then prescribe exercises to help relieve the symptoms and provide hands-on work to hips, back, sacrum and other involved areas. Your PT should be a huge help in getting you back to fitness postpartum! Other areas they can treat and improve are bowel/bladder issues, painful sex, and pelvic pain.
Focus on healing and strength rather than weight loss
Social media and advertising may be all about “getting your body back” and fixing “mummy tummy,” but that is not the focus when you are postpartum. The first step in returning to fitness is addressing foundational strength and continuing to heal from the pregnancy and birth. Your body will go through so many changes in the months following your pregnancy and the timeline is different for every single woman.
Steer clear of programs that say at week 8 you do blank. It should all be self-paced and based on symptoms, your birth story, and prior activity level. Do you need help starting out? This was the number one question I received from women in the clinic. “What can I do? Where do I start?” So I developed programming to recover and rebuild your core after having a baby. Check out the THRIVE: Rebuild Bundle programming HERE.
Find a community for support
Returning to group classes or running groups can be challenging because you will not be jumping right back into the level you were previously exercising. Having a group of women who understand your needs and have been or are currently at the same stage as you is tremendously beneficial. If this sounds like something you would be interested in, please join my Back to Fitness Postpartum Facebook page. We have posts nearly every day and a lot of great discussions- some serious and some silly!
Once you return to group classes, be sure that the trainer knows you are postpartum and if there are any symptoms with movements. If they offer other movement suggestions that still do not feel great, then modify further! Symptoms (leaking, pain, heaviness in the vagina) are a signal to decrease the workload by resting or modifying or both!
Getting back to fitness postpartum can be challenging but it is not impossible! With a holistic plan and support you will be able to recover and rebuild to get back to your favorite activities. If you are looking for help with learning more about postpartum fitness, the pelvic floor and how to reach your goals, then please reach out at Athletes’ Potential.
Thanks for reading,
Dr. Jackie, DPT
Although your pelvic floor and your feet may seem as though they are different and non-related structures, this is not the case. The connections are fascial, neural and biomechanical. Your feet are your foundation; how they contact the ground dictates all movements at your ankle, knee and hip. Soft tissues and fascia in your feet have vast connections to the legs, hip and back. The feet and pelvic floor, despite the distance from each other, also share neural input!
Fascia is the thin covering of your muscles that looks like a spider web. The posterior fascial line runs from the bottom of your feet, up the back of your legs and torso and to your head. Along the path, the fascia connects to the ischial tuberosities, or the “sit bones”. Muscles from your pelvic floor also attach here! So tension along this fascial line will directly impact your pelvic floor. Essentially, any joint the fascial line crosses and soft tissue in the area can be effected. A great place to start is the feet! Use a lacrosse ball to mobilize the fascia and tissues in the bottom on your foot and around the ankles.
The nerves that are responsible for function around your pelvic floor—sphincters, PF muscles, deep hip rotators—are also responsible for the function of your intrinsic foot musculature. Signs of foot weakness may by indicative of pelvic floor weakness, and vice versa. So, strengthening the foot musculature and stimulating these nerves may help with pelvic floor function. Unfortunately, many athletes wear big, padded shoes which decreases the amount of work the foot musculature must do! Neglecting to walk around on bare feet is robbing your feet of their natural ability to stabilize and form to the surface but also decreases in amount of neural input.
We suggest barefoot walking and running to increase the input through your feet and begin to re-strengthen the small foot muscles. The best way is to find a grassy area, about 50-100m in length and run repeats barefooted. Your feet will be challenged much more than when running in squishy shoes, so ease in. You will also notice that your running form is probably different (better). Heel striking when barefoot in quite painful, so the body will automatically shift to more of a midfoot strike—which is good!
The ankles drive the movement of the whole kinetic chain- the knee, hip and pelvis and spine. Dysfunction or pain in any of these areas can be stemming from faulty foot mechanics. For example, walking with the toes pointing outwards will cause your ankle joint to perform on a slightly different axis than it was designed. This will be demanding on the ankles and all the way up the kinetic chain.
The knee tends to be stuck in the middle and pushed around. The ankle dictates the movement of the lower leg and then influences the upper leg. The knee is just where these two units connect. So you will notice, we do not focus on biomechanics of the knee.
The hip has a direction connection with the pelvic floor. One of the deep hip rotators, the obturator internus, connects to the pelvic floor. With this connection, the amount of hip rotation will change (increase or decrease) the tension of the pelvic floor.
Putting it all together: Our feet control the movements of the joints above it. If your arch collapses (flat feet), the lower leg will rotate inward and the knee will follow. Up the chain, the thigh will also rotate inwardly which changes the tone of the pelvic floor. The angle of the knee will change with all of this, but remember it is not the driver of the dysfunctional motion, rather the passenger. Living with faulty biomechanics (however slight) can perpetuate back, hip and/or pain and dysfunction. Rather than starting with an MRI for the back or kegals for the pelvic floor, why not see if changing how you move can decrease symptoms?
A simple way to put this into practice is a slight change during a body weight squat. Move your feet to a comfortable squat position. Before sending your hips back and down for a squat, screw your feet into the floor. That is, acting as though you are moving your big toes further apart but your feet are not moving. Keep the toes on the ground! This creates torque at the hip. By engaging the external rotators, you are creating tone at the pelvic floor--remember the connection? You may also notice that the arch in your foot becomes more pronounced. Hello intrinsic foot musculature! This motion is also helpful for those with hip pain, especially pinching at the front.
In the photos below, my feet are not in a squat stance, but I am showing the subtle external rotation. You can see the largest differences at my knee caps and the direction they are facing. Also, notice my arches after the external rotation (bottom photo). They are higher! You can see a greater difference on my left foot. My whole foot stays in contact with the ground.
Recap: The foot and the pelvic floor have more connections than you may realize. They share fascial connections as well as neural. Taking the time to mobilize tight tissues and allow for more input with bare feet can have positive effects on hip, back and pelvic floor issues. The ankles largely drive the entire kinetic chain from the bottom up. So, taking care of the foundation of movement will be the most beneficial!
Thanks for reading,
Dr. Jackie, DPT
What is your pelvic floor and why does it matter? The pelvic floor is a sling of muscles that runs inside the pelvis. It works dynamically with the diaphragm and abdominals to dictate pressure during breaths. The pelvic floor also has intimate connections to the sphincters of your urogenital structures. These structures are important for 3 vital human functions: peeing, pooping and sex.
Yea, I said it. The stuff that no one wants to talk about.
Some men and women experience incontinence or urinary urgency but think that is “just something that happens” with age or high level activity. This simply is not true. Others may have pelvic floor dysfunction symptoms including low back/hip pain, constipation, painful sex or feelings of incomplete voiding.
Every time you breathe, your pelvic floor is moving and contracting. The way in which you stand and move has a direct effect on the ability of the pelvic floor or contract and work in synergy with the rest of the deep core. What if you could change a few daily habits and have decreased pelvic symptoms? Check out these 7 common habits and see what applies to you:
1. Ab gripping- Whether it is to make your tummy look flatter, for stabilization during everyday movements or due to overtraining abs at the gym, ab gripping is adding constant and unbalanced pressure to your pelvic floor. When you are simply moving throughout your daily activities, your belly should be relaxed! I give you permission to fight the social stigma of a less-then-flat abdomen and give your pelvic floor a break. Let the belly go!
2. Preventive peeing- Many people have the habit of trying to urinate when their body is not signaling that they need to void, usually right before leaving the house or on a scheduled break at school/work. This “peeing just in case” can also lead to pelvic floor dysfunction or worsen existing issues. Your bladder will now have a different set point of when it thinks it’s full! Now the pelvic floor muscles never have to be coordinated to control a full bladder and fight the urge for 30 minutes before you get home.
3. Hovering- Believe me, I’ve been at music festivals and used a porta-potty that was so gnarly I didn’t want to touch the handle! What I am about to say does not apply to that situation--I would not recommend that you ever sit in that. However, when using the restroom in public, many women will hover over the toilet while urinating. This is not doing your pelvic floor any favors. Remember, the hip musculature and pelvic floor have connections so while you are holding an isometric air squat, do you think your pelvic floor is relaxed? Hell no, it’s holding on for dear life. Take your time when peeing and try to sit whenever possible. Most bathrooms these days have those little paper covers for the toilet seat. Use that! And take your time, giving your pelvic floor time to relax and the bladder to completely empty.
4. Breath-holding- As I mentioned before, the diaphragm and the pelvic floor work together. So breath holding will also increase pressure on the pelvic floor and increase the likelihood of leaks. Those who use breath holding as a strategy while moving light object or bending over, usually do so to avoid a leak or feeling of urgency. However, this increased pressure increases the likelihood of a leak! I understand that there are times breath holding is essential- lifting heavy weights. There are alternate strategies to avoid leaks in these situations—outside the depth of this post!
5. Butt clenching- This goes right along with ab gripping- relax! Deep hip muscles have fascial connections with the pelvic floor, so a tight booty = a tight pelvic floor. But tight means strong, right? No, in this sense I mean tight as in over-recruited. Your pelvic floor is on high guard all day from increased pressures and over-recruitment. Then you expect it to hold on tighter with a violent sneeze or a couple dozen box jumps? It is tired! The pelvic floor function and intimate relationship is more about timing and synergy than strength. Ladies- be careful when are trying to look sassy in those heels on Saturday nights. High heels can also cause women to unconsciously hold their pelvis in a tucked position or butt clench.
6. Poor posture- So I have said a lot about pressure, particularly imbalances and increased amounts. However, posture is often the prequel to the alternate recruitment strategies discussed above. If your diaphragm and pelvic floor are not stacked on top of each other, then they are at a disadvantage for working together. In appropriate synergy = pelvic floor dysfunction. The best way to check this is to look at your posture in the mirror or have a friend take a picture. You want your rib cage and your pelvis in line. Poor posture indicators are your lower ribs poking forward, nipple trajectory pointing upward rather than straight, hip bones much further forward than your lower ribs.
7. Sitting all day- Sitting is just bad for you, plain and simple. But it has particular effects on the pelvic floor from both a myofascial and alignment standpoint. The glutes and your pelvic floor are buddies, they like to work together. When you sit on your glutes all day, the fascial layers become compressed and unable to slide as easily. As far as alignment, who can actually sit with good posture for 8 hours? Not me. I don’t think I would trust someone that could- they are probably an alien. Those deeper hip muscles that have connections to the pelvic floor can become tensioned and tight which could lead to a tighter pelvic floor- remember tight doesn’t equal strong! That being said, as you sit slumped over a computer, your alignment of ribs over hips is likely disrupted. Then we are back at the beginning with an imbalance of pressure. Don’t you see, it is a never-ending cycle?!
** Allergies/coughing/sneezing- Ok, so this isn’t a habit per se but worth noting on this subject! Women and men with persistent allergies causing frequent cough and sneeze episodes may also see increased pelvic floor dysfunction due to the frequent pressure changes. If this sounds like you, be sure to find some medicine that works for you or talk to a physician about possible allergies. If the coughing is from smoking, well that is absolutely a habit that you can direct effect!
I think it’s safe to say everyone could find at least one habit that applies to them. Take some time to be more aware of your posture and how you are holding your muscles when they should be relaxing! Stress urinary incontinence and urgency is not normal but it is common. You never know, a few simple habit fixes may resolve your symptoms. If not, reach out to us at Athletes’ Potential, we would love to help!
Dr. Jackie Varnum DPT
Many active women wish to continue their lifestyle even through pregnancy. Aerobic activity and resistance training are fantastic for maintaining fitness while keeping the baby healthy. Of course, always consult your doctor after becoming pregnant to make sure that it is safe to exercise at various intensities.
The general guidelines are to accumulate at least 20 minutes of moderate intensity almost every day of the week. For those of you who look for more intense activity, 3-5 days of vigorous activity is suggested for 20-60 minutes per bout.
Baby Bumps & Barbells guidelines:
As the baby bump grows and the center of mass is moved forward, your posture will be affected. The lumbar lordosis, or curve of the low back, will increase drastically throughout the pregnancy. Often times, your thoracic spine will flatten. Although postural changes are expected and normal, it is important to continue to maintain the best posture possible. Continuing upper body strength training and focusing on proper posture are key.
Another group of muscles that is greatly affected during pregnancy is the posterior chain. I’m talking specifically about the glutes and the hamstrings. Any barbell work to strengthen these areas should be continued throughout, keeping the baby bumps and barbells guidelines in mind. Lunges and squats remain some of the best and most simple workouts to target the posterior chain with little risk.
Birddog- if achieving this position proves to be too difficult, you can keep your knees down and extended just one arm at a time. Then you can progress to extending just one leg at a time before combining for an arm and a leg simultaneously.
As mentioned earlier, pregnant women are inherently more bendy than they were pre-pregnancy so stretching may seem unwarranted. However, most of these stretches are aimed at relieving areas of pain or tension from the growing bump and new posture.
Child’s pose- as the baby bump grows, this can be modified by having your arms and hands out-stretched on a workout ball, chair, or any other elevated surface. A large ball will give you the option of small rotations right and left with your arms to feel the stretch intensified along your sides.
Seated Hamstring Stretch- as the bump grows it may be necessary to use a bed sheet wrapped across the bottom of the foot and held with the hands.
Hip flexor stretch- while standing at the bottom of a staircase, place the lead foot two or three steps up. Keeping the back leg on the bottom with a slight bend in the knee, shift the weight forward to the lead foot to the point that you feel a comfortable stretch in the front of you trailing hip.
Cat Cow- a great way to stretch the lower back and get the thoracic spine moving throughout the entire pregnancy.
Pigeon- if you are unable to achieve or maintain this position, adding a firm pillow under the upper thigh of the back leg and buttock area of the front leg may be more comfortable.
Deep Squat- a great stretch for your hips and pelvic floor during the pregnancy. **Caution – in the third trimester, ask your doctor before trying this stretch as it may induce labor **
Remaining active will lead to a healthier and happier pregnancy. Keeping the posterior chain strong can ward off back pain for mom while exercise activity increases blood flow for the baby. Remember, it is important to always listen to your body and consult healthcare professionals when questions arise.
Thanks for reading!
-Dr. Jackie, DPT
R Artal, M O’Toole. Guidelines of the American College of Obstetricians and Gynecologists for exercise during pregnancy and the postpartum period.
Photos: FitPregnancy.com, tfwropestone.com, fusionwellness.com, themusicmommy.com, alimcwilliams.com, momjunction.com
Midline stabilization is heralded as the foundation of safe and successful weightlifting. But have we been ignoring a part of the “core”? The pelvic floor is a topic that tends to be avoided. Most people do not casually discuss urinary frequency over coffee or admit to their coach that they pee every time they perform double-unders. Men- if you think this one is just for the women, stick around!
I only realized the prevalence of leakage after CrossFit HQ posted a video following regionals. All of these women were saying “It’s ok, I pee during workouts too. It’s normal!” Please do not confuse normal and common. Urinary incontinence may be common in certain populations, especially of heavy lifters, but it is absolutely not normal.
The pelvic floor includes a group of muscles that attach from your coccyx (tail bone) and sacrum to your pelvic ring.
These muscles are important for bowel and bladder function, organ support, and stability of the pelvis. Although pelvic floor dysfunction (PFD) was thought to be largely a problem of women, it is becoming apparent that men have similar issues. The pelvic floor may seem very foreign and uncomfortable to discuss, but when it properly functions it can improve your workouts. Here’s how:
I like Mary Massery’s description of the core as a “soda-pop can”. The front of the can is the abs, the back is the multifidi, the pop top is the glottis and the bottom of the can is the pelvic floor. The core pressure is maintained by a functioning glottis and pelvic floor, with the diaphragm acting as a pressure regulator.
When you take a breath in, the diaphragm descends. This requires the pelvic floor muscles to descend and lengthen. When you exhale the diaphragm rises and the pelvic floor rises and tightens.
In fit individuals, (notice I said individuals and not just women), a common pelvic floor problem is overactive muscles. Very strong back or abdominal muscles can cause increased inward pressure. It’s been shown that when your deep abdominals contract, so does your pelvic floor.
Imagine squeezing the can from both sides with the pressure maintained. The bottom and top will have to withstand more pressure and bulge. If your abdominals are always squeezing in then your pelvic floor is always pushing up to withstand the pressure. It’s overworked! The diaphragm is pretty darn good at its job. If it does not work, we have a bigger issue on our hands.
So often, when something’s ‘gotta give’- it’s the pelvic floor. When all of these muscles work in concert, your canister and the force it can produce is maximized. Thus, your workout improves.
A conversation about breathing techniques regarding the glottis and diaphragm is essential to training the entire core. Here I am simply touching on one contribution but remember it does not work alone.
Keep in mind, PFD can also manifest in ways such as pelvic pain, painful intercourse, low back pain, urinary frequency or even the dreaded butt wink. It is not just urinary incontinence.
“ Pelvic floor pain is only caused by pregnancy, right?”
Wrong. There has been no correlation shown between PFD and post-partum women. Sure, some moms experience issues but again, it is not normal for any population. Weakness and/or tightness of the pelvic floor can be caused by poor postural habits, extended periods of sitting, over training of the abdominals and pregnancy. Excluding pregnancy of course, men are susceptible to all of the other risk factors.
“Ok, so I pee on myself at the gym and it’s not normal. What do I do to stop it?”
Thanks for reading!
-Dr. Jackie, DPT
Sapsford, Ruth R, Hodges, Paul W. Contraction of the Pelvic Floor Muscles during Abdominal Maneuvers. Physical Medicine and Rehabilitation, 2001, Vol.82(8), pp.1081-1088.
Presentation at CSM 2016 by Mary Massery: referencing Massery 2005 & 2006.
Dr. Danny and Dr. Jackie's views on performance improvement, injury prevention and sometimes other random thoughts.