This article was written by Dr. Sarah Duvall of Core Exercise Solutions, a Doctor of Physical Therapy who specializes in women's health and pelvic floor function.
The current treatment for the pelvic floor looks at managing pressure. Surprise! It’s no longer kegels. That was 1990. What research is showing us now is that pelvic floor issues are caused more by inappropriate pressure in our core and the pelvic floor overworking to stabilize the pelvis.
So, what happens when you want to lift heavy and, I dare say, use a valsalva, but you leak during exercise? On one hand, doctors are telling patients that leaking is normal, but this is awful advice and not true. On the other hand, conservative pelvic dysfunction treatment wants to decrease all pressure in the core and have a woman never hold her breath during exercise.
Neither of these are good solutions for a woman that wants to lift weights, not worry about leaks, and keep her spine safe all at the same time.
Women can have it all. So, let’s take a closer look at how to make that happen.
Step 1: Coordinate the Pelvic Floor With the Diaphragm
As you inhale (breathe in), your diaphragm expands down and your pelvic floor relaxes down. As you exhale (breathe out), your diaphragm goes up and your pelvic floor tightens. This is a natural feedback loop within the body that creates a strong, dynamic pelvic complex. Ready to see if you are breathing correctly?
Place a hand on your chest and a hand on your belly. Take a big breath of air. Did the hand on your belly rise first, or the hand on your chest? The hand on your belly should rise FIRST. If it doesn’t, stay at step 1 until it’s second nature for your belly to rise first. Is this your normal breathing pattern when you aren’t thinking about it or do you slip into a shallow breathing pattern? Basically, I want this to be a part of you.
Next, can you feel your pelvic floor when you take a deep breath? It can take some focus, but most people are able to mentally feel what their pelvic muscles are doing when they take a really deep breath, but it often takes a little focus and a lot of practice. Work on being able to feel your pelvic floor respond to your diaphragm as you take a deep breath. Just remember: relax on the inhale, tighten on the exhale.
The pelvic floor contracts and relaxes all day long as the diaphragm works. If you are only able to utilize your diaphragm when you are thinking about it, that’s not good. That will often cause the pelvic floor to hold itself too tight (high muscle activation) or too loose (low muscle activation). Be mindful as you go through your daily life. Are you utilizing a deep breathing pattern or is your chest rising with each breath?
So, step 1, get your diaphragm working 24-7 for awesome deep breathing that turns on the pelvic floor. This will be automatic, so when you cough or sneeze (forced exhale), your pelvic floor will naturally go up. No leaks!! (We probably just helped or fixed your pelvic floor issue significantly.)
Step 2: Incorporate Deep Breathing with Movement.
Now that you are deep breathing, let’s test your system with something simple, like a squat and a side plank. the squat tests movement and a side plank generates intra-abdominal pressure.
Recap: You are now deep breathing with pelvic floor coordination and you can maintain this system under the stress of exercise. Awesome! Now, let’s take it to the next level.
What About Holding Your Breath?
A 2012 study showed that holding a Valsalva did NOT harm the pelvic floor, but a bearing down or straining maneuver did.
What does this tell us? Women who leak when they utilize a Valsalva during heavy lifting might not be performing a Valsalva correctly. They may be bearing down instead.
If you have a pelvic muscle dysfunction, it’s important to be able to feel and understand the difference between a proper Valsalva and bearing down when you hold your breath. The safest way for women who leak to hold their breath during lifting for spinal support is to hold it on the exhale because you get that natural recoil up of your pelvic floor. You may eventually be able to hold your breath on the inhale, but starting with an exhale is a bit safer and easier.
If you still find yourself leaking even after you know your diaphragm is coordinating with your pelvic floor and you are not bearing down, here are a few things to take a closer look at:
Perfect Form: Are you tucking your butt under on the bottom of the squat? Little technique issues like this one in every exercise can have a drastic effect on your pelvic muscles.
Hip Rotation Strength: You need a dynamic system from both the top and bottom. The pelvic complex needs the stimulation from the diaphragm, but it also needs the deep hip rotations and adductors as well. Having hip pain during squats, check out this article instead.
Ability to Load Eccentrically. Do not underestimate the power of being able to lengthen and open your glutes, adductors and pelvic floor to create a strong contraction and proper leak free muscle firing! Deep squatting is awesome.
Perfect Your Diaphragm: Utilize a 360 breath, not just a belly breath to really get your diaphragm to turn on your pelvic floor.
(1) Park H, Han D. The effect of the correlation between the contraction of the pelvic floor muscles and diaphragmatic motion during breathing. J Phys Ther Sci. 2015 Jul;27(7)
(2) Talasz H. et al. Proof of concept: differential effects of Valsalva and straining maneuvers on the pelvic floor. Eur J Obstet Gynecol Reprod Biol. 2012 Oct;164(2):227-33.
Sarah Ellis Duvall, PT, DPT, CPT
Sarah is a PT with passion. She has owned an out of pocket pay practice for a decade and enjoys treating both ortho and women's health issues. Her passion lies in bringing together the big picture and treating the body as a whole. She is also a mom and adventure sports athlete.
Find out more at www.CoreExerciseSolutions.com