Pelvic Floor Physiotherapist Reveals Trade Secrets from the Front Lines of Pregnancy Care Regarding Kegels.
I recently have read some startling posts on the internet that all pregnant women should not do Kegels. This is the same as saying that all pelvic floors are the same. Where is the balance in that statement? It is dangerous advice for the community out there that needs to be debunked so that women see that what is indeed needed is a balance. This is what I have dedicated this blog post to pointing out.
As a pelvic floor physical therapist, I often find that absolute yes or no advice about Kegels is given to many of my patients. When it comes to pelvic floor exercises and therapies, generalizations are made all the time by clinicians. I always caution practitioners and doctors not to pidgeon-hole their patients or clients. Working with women and men suffering from pelvic floor dysfunction (PFD) requires a “wholistic” approach to ensure success. PFD can present in many ways and one type of therapy or exercise will not work for all men and women. When it comes to prescribing pelvic floor exercises such as Kegels or Reverse Kegels it is best to keep an open mind and to focus on balance and not absolutes.
Kegel Basics From the Pelvic Floor Physiotherapist Perspective
To make sure we are all on the same page lets review the difference between a Kegel and a Reverse Kegel. Reverse Kegels are relaxation pelvic floor exercises that help to create pelvic floor elasticity, flexibility, coordination, reduce spasms, reduce tone and promote overall pelvic floor muscle health. Kegel exercises are strengthening exercises that promote pelvic endurance, power, force and stability. Kegels also help improve lumbopelvic-hip stability, reduce leaking and improve sexual power.
For patients with pelvic floor dysfunction (PFD) to succeed and to train their pelvic floor muscles correctly and optimally, we have to see the trees and the forest and find the exercise (medicine) that works for them. To simply state, as many clinicians have, that weak glutes + too many Kegels = PFD, or to state that pregnant women should stop doing Kegels, is to limit oneself as a clinician and to limit the patient’s success. In particular there are many recommendations made to pregnant women from all different types of clinicians. Some recommend no Kegels during pregnancy others recommend 1000 Kegels during pregnancy. I’ve heard my pregnant patients say “my midwife or OB/GYN does not want me to do kegels because I will get too tight “down there” and have difficulty getting the baby out”. This advice of no Kegels is given even to pregnant women who are experiencing pelvic pressure, stress incontinence or have an organ prolapse. This advice is incorrect and needs to stop now. A more balanced approach would be most beneficial for this special population. Pregnant women are usually given absolute doctrines from their caregivers about pelvic floor exercises. I know because I hear it all the time treating patients on the front lines. What I don’t understand is why this continues to happen when it is clearly evident that a combination of different types of Kegels, including Reverse Kegels, would be better combination to achieve long-term success and prevent the pelvic floor complexities that result from pregnancy and childbirth.
Pregnant women in particular have complexities that must be taken into account when it comes to creating a balanced pelvic floor exercise program that will help to prevent PFD in the future. Although pregnancy does not cause PFD, pregnancy puts a tremendous number of stresses on the pelvic floor muscles. During pregnancy it is important that a trained pelvic floor physiotherapist take a good look at the pelvic floor muscles to help minimize PFD that is so prominent in the post-partum period. Also it is important to note that if the pelvic floor muscles are not trained in an intelligent manner during pregnancy, PFD will most likely occur in the post-partum period.
Lets investigate the doctrine of “NO KEGELS DURING PREGNANCY”. To advise an entire population not to do Kegels is counter productive and without merit. Pregnant women have unique health needs and one size does not fit all. Why do I bring this up? I bring this up because pregnant women are inundated with information from all branches of healthcare and many pregnant women that I treat tell me they are confused about information that is filtered to them. How can a pregnant woman make a good choice regarding her pelvic health if she is damned if she does and damned if she doesn’t and both sides of the story are not provided?
From my perspective the pelvic health therapy that works the best for pregnant women is one that is based on their unique symptoms, pelvic floor muscles, strengthening, stabilization, core abdominals and pain symptoms needs. Some pregnant women should be on a Kegel: Reverse Kegel Program and others would benefit mostly from a Reverse Kegel only program. Pregnant women who suffer from pelvic pressure, incontinence and lumbopelvic-hip instability and sacroiliac pain can benefit from what I call a Kegel-Reverse Kegel program performed in a certain ratio of seconds. Pregnant women who suffer from pelvic pain, sexual pain, vulvodynia, vaginimus, bladder dysfunction and pelvic floor tightness would benefit initially from a Reverse Kegel program which is a pelvic floor relaxation program. A Reverse Kegel program would provide flexibility and elongation of the pelvic floor muscles and pain relief to women who suffer from lumbopelvic-hip pain. Additionally, the needs of pregnant woman change throughout the pregnancy and many times a pregnant woman starts out with a Reverse Kegel relaxation program and their symptoms get better requiring the clinician to change the pelvic health program to a combination program of Kegel /Reverse Kegel. This is an art form and not a cookie cutter approach. Therefore the prescription of “NO KEGELS DURING PREGNANCY” just does not work for all pregnant women and women in general.
As a pelvic floor specialist, my primary focus is to find the proper dosage of pelvic floor exercise with the proper balance of core training, postural training, bladder re-training and pelvic alignment training with the correct dosage of strengthening and stabilizing exercises. I am in a unique position, unlike personal trainers, yoga or Pilates instructors, or exercise physiatrists in that I can perform an internal pelvic floor muscle evaluation on pregnant women with the consent of their OB/GYN and I can really determine the specific pelvic floor needs of these women. Because of my unique position at my healing center, Renew Physical Therapy, we do not prescribe a limiting one-size-fits-all pelvic rehab program; instead we listen closely to what each patient’s pelvic floor muscles are telling us, which is a more balanced approach.
Kegels Have Benefits Throughout Multiple Body Systems Including the Hips and Low Back
Many times, I believe this black and white advice of “NO KEGELS” is based on confusion and limited expertise of the clinician in the field of pelvic rehab. I believe that many believe the “down-there muscles” will become too tight for labor and delivery and the pregnant women could tear. It is important to note that many pregnant women do have pelvic floor muscles that are too tight, too short and inflexible and with poor coordination. Multiple births, scars, past orthopedic injuries and no pelvic rehabilitation after the first birth can lead to inflexible pelvic floor muscles in subsequent pregnancies. A history of sexual and pelvic pain can also lead to inflexible, tight pelvic floor muscles. For pregnant women who fall into this category, which is more than one might imagine of the population, I will prescribe and recommend a hands-on pelvic floor muscle/vaginal massage with a dilator or fingers and then Reverse Kegel program. I cover this type of vaginal massage in my book, Ending Pain In Pregnancy.
It is important to note here that pregnant women who have instability in the lumbopelvic-hip and or suffer from Symphysis Pubic Dysfunction might first benefit from a combo pelvic floor program that consists of both Kegels and Reverse Kegels. If a pregnant women has more pain and or symptoms after performing a combination program she will probably first benefit more from a Reverse Kegel only program. Many times you will not know what will benefit your pregnant patient until you try the exercises first. This is part of our artform, one in which we must be flexible with our treatments. Once the pregnant woman’s symptoms and pain has subsided the pregnant woman is then graduated to the next level of pelvic floor training which will include a Kegel/Reverse Kegel (contract/relax) program.
This next level is what I call a combo pelvic-health training program called Kegel/Reverse Kegel. These two exercises are prescribed in a certain ratio of seconds. For example I would instruct a patient to Kegel for 5 seconds and then Reverse Kegel for 15 seconds. This ratio is determined by internal evaluation or by utilizing external biofeedback technology. In Ending Female Pain, Second Edition you will find a chapter called To Kegel or Not To Kegel. This chapter will help to enlighten you and will guide you in prescribing pelvic exercise programs in a more “wholistic” and effective way. This is a must read for men, women and clinicians who want to understand the theory behind any successful PFM training program. In my book, Ending Pain In Pregnancy. I recommend you read chapter 9 Kegels That Work: Preventing Perineal Tears, Incontinence and Pelvic Pressure During Pregnancy. This chapter will help to shed light on appropriate pregnancy PFM training and will teach you three types of perineal massage that help to keep the PFMs flexible and strong. Additionally it is important to not only massage the PFM, but to also determine which area in PFM are the weakest and/or more compromised and to target the exercises and manual therapy to the weakest area first. It’s all about the yin (pelvic and stabilization exercises) and the yang (pelvic floor manual therapy).
In conclusion, I would never advise a one-size fits all approach for any pregnant patient and would never advise a “NO KEGELS DURING PREGNANCY” approach. I say this after having spent over 10 years on the front lines of pelvic floor physical therapy, having treated thousands of pregnant patients and having seen first-hand that every pelvic floor presents with its own unique needs. A balanced and targeted pelvic health exercise and therapy program that consist of Kegels, Reverse Kegels and manual therapy will ensure your pregnant patient’s or client’s success, short-term success of getting through labor and delivery and their long-term success by helping to prevent so many of the pelvic floor symptoms and complications that arise in pregnancy and in the post-partum period.
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