After years of advocating for better pelvic healthcare advice for women by passionate pelvic floor specialist PTs preaching “kegels aren’t for everyone”, we have finally seen a mass narrative shift in the larger society. We are starting to hear patients come into our offices for the first time and already mention that they heard that kegels may not be the best thing for them to solve their pelvic health issues. This is a HUGE win for pelvic health!
Are you new to this saga of “stop telling everyone and their sister to do kegels” movement? Well let me get you up to speed on this one. An OBGYN by the name of Arnold Kegel first described exercises aimed at strengthening the pelvic floor in 1948. This was the first non-surgical alternative offered to women. The advice to “do your Kegels” was given out liberally in doctors offices and among friends and families since the 1950’s.
In the early days of pelvic physical therapy as far back as the 1970’s to early 1980’s, therapists were helping women overcome issues such as urinary incontinence and pelvic organ prolapse by examining and guiding women to work on rehabbing their pelvic floor strength. They would often teach their patients to do “Kegels” as part of their treatments.
This advice became so well known, that by the end of the 20th century, most women had heard of this Dr’s name (Kegel). Unfortunately, this magic exercise did not end up being the cure-all that was so often promised. Some women would get better by “kegeling” and others would see no improvement or even get worse. There was more to the issues that concerned pelvic health and pelvic PTs were researching and finding in their clinics that the pelvic floor was never an isolated island unto itself. To help their patients, they found that they had to look way beyond the pelvis to best diagnose and treat their patients who would like nothing more than to stop leaking, suffering with pelvic prolapse, pain with intimacy, and more.
As you can imagine, treating the pelvic floor knowing that the entire body can affect the pelvic floor can seem like a complicated thing… and it IS. As well rounded orthopedic pelvic therapists, we do not even ignore the feet or the jaw when assessing our patients. But how do we take in all of this information and create a solution for our patients that doesn’t completely overwhelm them and help them actually overcome and thrive on the other side? Good question. It has taken me since 2010 to create a framework that I could easily explain to my patients and other therapists that I have mentored. This framework has helped me break down many bits of information into 4 main categories. Are there things that are missing in these 4 categories? Yes, some include the nervous system and mental health side of things, but these 4 categories cover the lion’s share of WHAT is going on and HOW can we resolve the issue?
The Four Pillars of Core and Pelvic Health
Each category is a stand alone category that is huge in the process of helping someone resolve an issue that is connected to the pelvis and pelvic floor. This includes the low back as it does attach to the pelvis.
1. Breathe- Breath is the foundation of core and pelvic floor muscle function. Through healthy and coordinated breath, our core muscle health can be restored and maintained. In the journey to restoring core and pelvic floor health, breath will always be a part of the first steps. The first steps in postpartum recovery as well.
2. Alignment- Our muscles can only work optimally when our bodies are aligned well. Poor body positioning can put muscles into excessively long or short positions which can make them extra tense or not be able to turn on at all. Factors like pregnancy or having a sitting job can result in a body that cannot easily find healthy alignment.
3. Coordination THEN Strength- Our deep core muscles need to 1st be able to coordinate together as a TEAM before we can focus on getting stronger. The muscles also need to have a healthy resting tension and not be stuck in a shortened contraction state. We must first help them to regain normal tension/length before it is appropriate to work on improving strength. Repetitively tensing pelvic floor muscles alone will usually lead to more leakage, pain, or pressure issues.
4. Hip Strength- Our hip/glute muscles are the FOUNDATION for our back, hip, knee, core, and pelvic health. Poorly activating glutes are an epidemic in chair-using societies. Regaining the ability to fully access the glute muscles both intentionally and on autopilot can help resolve low back pain, hip flexor tension, pelvic floor tension, pelvic floor dysfunction, and more. The pelvic floor muscles cannot function well if their surrounding support system is not working properly and uniformly like the supports on all sides of a trampoline.
When we see a client for the first time at Pinnacle, we do a full body assessment (head to toe). Then after we do a pelvic floor muscle assessment near the end of the visit, we have the information we need to address their issues in the 4 pillars method. We can review our findings within these 4 categories and we can focus on solutions and home program strategies that hit on each of the 4 pillars.
Newer patients will likely be asked to do more isolated exercises that focus on only one or two pillars together while a more advanced patient is beginning to do exercises that merge all 4 pillars of core and pelvic health and it should look like a cross training workout. Our patients can readily see where they are at on their pelvic health journey by using the 4 pillars as a gauge. Is their breathing great? Can they coordinate their deep core to not lose pressure with blowing up a balloon? Can they squat like a pro and feel their glutes fully activated and in charge without feeling any low back tension? I have found this framework to be valid for urinary leaks, pelvic pain, pelvic organ prolapse, low back pain, and more.
If you are struggling with core or pelvic floor issues, you may want to ignore that advice to do “Kegels” and have a skilled pelvic health therapist do a thorough assessment and help you come up with the comprehensive plan designed just for you.