As I travel around sharing “Explore Your Pelvic Floor and More” Yoga and Yoga Therapy courses, I emphasize the importance of adequate training and education of pelvic floor muscle (PFM) engagement with proper synergistic timing with other muscle groups with awareness, movement and breath.
I received a great question from a yoga therapist at the International Association of Yoga Therapists annual Symposium on Yoga Therapy and Research where I was presenting this workshop. One of the participants asked, “how does a yoga therapist know if the student is properly engaging the pelvic floor muscles?” The simple answer to this question is, unfortunately you don’t. Accurate measurement of PFM function and strength is difficult, even with the current tools of measurement we have such as direct skilled manual palpation or use of clinical observation skills with measuring devices such as ultrasound, EMG recordings, or MRI’s (Bo et al, 2005). However, these methods are not within the scope of practise of a yoga therapist or yoga teacher.
Additionally, over 30% of women do not engage their PFMs correctly even after their first consultation of one on one training (WHO, 2002). Even if you think you are providing proper PFM engagement cueing in your classes, you really have no way of knowing if every student is engaging correctly. Furthermore, some evidence-based treatment guidelines advise against teaching a PFM contraction for certain conditions. I further expand on this in my courses.
But for now, we can address this original question if we re-phrase it:
“how can a yoga therapist help a student optimize the probability of an effective PFM engagement?”
Here are 9 ways:
1) Education: a brief anatomy lesson of the PFMs explaining the difference between activating the compensatory muscles (gluteals, hip adductors, abdominals) vs. the actual PFMs can help your student understand what a PFM engagement ‘is’ and understanding what a PFM contractions is ‘not’. Part of the education process is increasing awareness of and connection to one’s own PFMs. **(Addendum added June 19, 2015: The anal and urethral sphincters are part of the superficial layer of the PFMs; they are not compensatory muscles of the PFMs. However, I feel it is important to note that when one is asked to engage their PFMs, they may potentially simply clench the gluteals and anal sphincter, or think that ‘stopping the flow of urine’ by contracting the urethral sphincter is solely what a PFM engagement is; and it is not. It is part of PFM engagement; but not in its entirety. Education about the deep layer of the PFMs, (which includes the levator ani (LA) group) and the engagement of LA as a lift of the perineum, is important to note so that the student doesn’t think that a PFM engagement is solely just sphincter action).
2) Visual Cueing: As part of the individualized home program, I highly recommend students actually ‘watch’ their pelvic diaphragmatic rhythm and the PFM engagement (via movement of the perineum), with a mirror to the perineum area (no clothes) in a variety of positions (see full article HERE). This is done in the privacy of their own home, on their own time, and as they feel safe and comfortable. This can help improve the efficacy of PFM engagement, as one can often times actually see the movement of the perineum timed with the breath pattern directly and observe whether or not other muscles are compensating upon engagement.
3) Mental Imagery: have your student notice and simply become aware of his or her own pelvic diaphragmatic rhythm followed by the visualization (mental imagery) techniques we used in the workshop that are also found in the “Creating Pelvic Floor Health PhysioYoga Videos.” This can help optimize the chance of a more accurate PFM engagement. These mental imagery exercises might be more effective if the student has an adequate understanding of anatomy and theoretically understands what a PFM engagement is, and what it is not.
4) Feedback: There are a variety of methods to help the student receive feedback as to whether or not the PFMs are engaging. Visual feedback as in #2 above can be useful as well as tactile feedback. The student can either palpate his or her own perineum area, or use the ‘belt method’, or an accordion folded blanket as tactile feedback to the perineum. Leslie Howard uses a folded belt and places it horizontally across the two ischial tuberosities while sitting. I like to also use the prone position with an accordion folded blanket lying vertically under the body and looped back around the pelvic floor (as if giving yourself a wedgie)! As the student breaths, he or she can feel the feedback of the pelvic diaphragmatic rhythm from the blanket.
This accordion folded blanket method for stimulating tactile feedback is also included in my videos HERE.
I also use the same feedback method in Virasana or in a modified supported Child’s Pose that is demonstrated in my YouTube segment HERE.
5) Watch for Compensatory Movements: as a yoga therapist, you can watch for any unfavourable compensatory movements as your student is trying to engage the PFMs on exhalation. If you notice the pelvis moving, the abdominals excessively contracting, or the gluteals clenching, there is a chance they are not engaging PFMs effectively. Please be reminded that with some of the functional movements that we perform in the courses or workshops, the pelvis IS allowed to move and the abdominals and gluteals are allowed to activate. But for the purposes of simply trying to help your student ‘find’ the PFMs and engage them adequately, start with the basic foundation poses/movements we complete in the course so that the focus can stay with the pelvic diaphragmatic breath rhythm.
6) Experiential: Practise is key! Tips such as “Less is More” and asking them to experience what a PFM is ‘not’ can also be helpful. **(Addendum, June 19, 2015: For example, to have students explore how ‘NOT’ to do a PFM engagement: first ask them to clench the gluteals and contract the abdominals. Then, compare that with a gentle lift of the perineum upon exhalation, without use of the gluteals, without excessive sphincter action (anal or urethral) or abdominal activation).
7) Offer Movements that Facilitate PFM Engagement in Timing with Breath: Research shows that the respiratory diaphragm, transversus abdominus (TA), and PFMs all engage in a sophisticated, automatic, and coordinated way. Therefore, focusing on breathing methods that enhance the respiratory diaphragm and TA activation can potentially facilitate PFM engagement. Research also suggests that activation of certain hip musculature plays a role in functional integration of PFM engagement. Therefore, you can use this information to facilitate PFM engagement by choosing poses and movements that are associated with engaging hip muscles such as adductors, gluteus maximus, and the deep hip rotators, while at the same time implementing a breath pattern that engages TA.
For further details, information and demonstrations, you can read the full article ‘Optimizing Pelvic Floor Health Through Yoga Therapy’ and download the videos ‘Creating Pelvic Floor Health’
8) Practise: yoga teachers and yoga therapists should practise on themselves! Practise the cues, self palpation, positions, visualizations/mental imagery, movements, breathing, and any other methods that help to optimize PFM relaxation, excursion and engagement that were included in the workshop and that are also included in the pelvic floor PhysioYoga videos as well as the online PhysioYoga and the Pelvic Floor Course. The more familiar you are with your own lived experience of PFM engagement, the better you will be at successfully explaining it and offering effective verbal cues to your students.
9) Referral to Pelvic Health Physical Therapist: I highly recommend that you refer your student to a licensed pelvic health physical therapist (PT). A pelvic health PT has the proper training and skills to more closely monitor and measure PFM engagement, and it is within a pelvic health PT’s scope of practise to do so. The pelvic health PT will be able to ensure the student is appropriately and correctly engaging the PFMs. The three of you can work together as a team to optimize your student’s overall success in healing and pelvic health and wellness!
The following online directories can help you find a pelvic health PT in your area:
Canada: CPA Division of Women’s Health
**I have created a series of VIDEO Practises intended to promote PFM awareness and to help relax and engage the PFMs in coordination with breath and movement. The videos are receiving very positive reviews from pelvic health physical therapists and yoga teachers/therapists globally. These videos are available to download online
To learn more about integrating Yoga into Pelvic Floor Health, Rehab and Wellness, my pre-recorded online course “PhysioYoga and the Pelvic Floor” is available for download.
**This article is not meant to act as medical advice nor meant to replace your current treatment. Please seek clearance or guidance from your licensed medical healthcare professional prior to participating in any of the mentioned tips, advice or movements.
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