“Beyond Basics” Exercises: When Kegels Aren’t Enough

• The Foot
• The Pelvis
• The Deep Core
• Accessory Muscles
• Mind, Heart, and Spirit

THE FOOT:

The foot needs to balance stiffness and flexibility in order to efficiently distribute forces through the body. In a presentation by Dr. Makela Spielman in 2022, she outlines the connection between the foot and pelvic floor through:

1) The Somatosensory Cortex
2) The Neurological Connections
3) Fascial Lines and
4) Biomechanical Relationships.

The foot seems a pretty far distance from the pelvic floor. In the brain, the foot and genital sensory representations map next to each other. In the pelvic floor world, dysfunctions in the foot can be perceived in the perineum and vice versa through a process called smudging. Smudging leads to difficulty with discriminating sensations from distinct parts of the body and can also present with missing or altered sensation, or dissociation. The treatment for smudging and somatosensory reorganization includes gentle movements, left/right discrimination, tactile stimulus for novel and safe sensations, mirror therapy, as well as body map training (Vandyken 2012).

From Alarmy

The neurological connection between the pelvic floor and foot highlights the continuity of the sacral nerves. Sometimes the tension along the course of the nerve can irritate structures anywhere along the path because the nerve can become more sensitive. If this is the case, the nerve is treated with gentle movement and interdisciplinary modalities to alter the causes of irritation.

From Science Photo Library

Fascia, affectionately known as the smart saran wrap that links our body foot to head. From Dr. Fiona McMahon’s previous blog about fascia:

Fascia is the covering and connection of just about everything in the body. It wraps around organs, nerves, and muscles and allows these parts to retain their shape and function well. Within fascia we have adipocytes (fat cell makers), fibroblasts, which make collagen and elastin…. AND ARE CONTRACTILE! Fascia also has mast cells (which make histamine) and histocytes (are part of the immune system).

Similar to the neural connection between the feet and pelvic floor, the feet and pelvis affect each other through a fascial association.

From Bodyworks Mobile

In the clinic, some of the ways we treat the pelvic through the foot are:

• Standing Pelvic Rotation:
  • Stand comfortably with feet about hip width apart
  • Rotate as far as you can through the spine so that the shoulders are perpendicular to the pelvis
  • One foot should roll out while the other foot rolls in. One hip should rotate back and tip while the other hip rotates forwards and tips. Pay attention to how the position of the feet and pelvic affect each other

• Sit To Stand With Foot Tripod:
  • Move to the edge of a chair and feel all corners of your feet (heel, big toe, little toe)
  • Keep even weight and grounding through your feet as if you were pressing into sand and stand up
  • As you sit down keep your sit bones reaching back and feet grounded

• Foot Ball Rolling:
  • Roll your foot on a firm ball and hold where there is tightness.
  • You can move your toes up and down for more release and tension.

• Sciatic Nerve Flossing:
  • Seated or lying on your back, straighten one leg.
  • Move your ankle up and down without holding the position to feel a stretch anywhere through the pelvis, back of the thigh, calf, or foot

Resources like toe yoga, barefoot training, and orthotics may also be appropriate for some people.

PELVIC POSITION AND STABILITY

The position, stability, and mobility in the pelvis affects pelvic floor muscle function. The description for pelvic position includes where the pelvis likes to rest in terms of its forward/back tilt and orientation towards the right or left. The preferred position usually also correlates to stability patterns and where the pelvic moves in everyday activities. For example, if the pelvis like to be tucked under in sitting and standing, then when active, the pelvis tends to stay in that tucked range of motion preferring muscles that hold this position.

While position and posture have no association to pain and dysfunction, we often see that lack of positional variability can affect pelvic floor activation problems. Going back to the previous example, the tucked pelvis can be appropriate for certain types of dances or as an emotional response which biases stabilization patterns of the lower gluts and the back of the pelvic floor. However, if this is the only activation pattern, the pelvis will predominantly use the low glutes and back pelvic floor for difficult activities and is less likely to untuck during walking and stair climbing. The decrease in movement variability can contribute to problems. Conversely, increasing movement choices often improves pelvic floor dysfunction.

The outside stabilization of the pelvis through muscular slings changes the activity level and balance of the pelvic floor muscles. When the pelvis is supported by external muscular slings, the deep stabilizers—diaphragm, transverse abdominis, multifidus, and pelvic floor muscles are more likely to be coordinate with appropriate tension levels. These external pelvic muscular slings help transfer forces through the pelvis—right to left, front and back.

The back (posterior) pelvic muscular sling stabilizes when the leg and opposite arm move back to engage the gluteus maximus and opposite latissimus dorsi muscle. This sling pattern pushes and propels us through the world. Problems with this sling stabilization are common in clinical practice and with pelvic floor dysfunction.

The front (anterior) pelvic muscular sling links the inner thigh and opposite side abdominals to engaging the adductor and opposite abdominal oblique. This sling allows us to move from side to side allowing muscles to relax after contracting. Symphysis pubic dysfunction is a manifestation of problems with this stabilization pattern.

The side (lateral) pelvic muscular sling works when one leg is moving in activating the adductor and the other leg is moving out turning on the opposite gluteus medius. One of the main purposes of this sling is to give our body boundaries to keep movement efficient. Deficiencies in this sling corresponds with typical stability problems that usually have an asymmetrical presentation.

The rotational muscular sling absorbs the forces into the pelvis as the hip rotates in and the pelvis stabilizes which activates the obturator internus and adductor of the same leg. This sling allows us to absorb and transfer forces from the ground without collapsing.

In the clinic, we usually see that multiple slings are not coordinating and with obvious asymmetries in recruitment patterns. Often, these asymmetries are not a problem. Sometimes, the asymmetry becomes exaggerated and limits the variability of movement. Physical therapists can test, recognize and prescribe appropriate exercises to address pelvic sling instability. Here are some basic exercises that correspond to these slings:

Posterior Pelvic Sling: All four hand and leg lift

• The goal of this exercise is to feel the upper glut engage, not the back and not the hamstring muscle. On your hands and knees position with pelvis in the middle range, lift one leg and opposite arm behind the hip. If you don’t feel the upper glut, lift your arm a little higher.

Anterior Pelvic Sling: Hook lying leg rotation with ball

• The goal of this exercise is to feel the inner thigh and opposite side abdominal muscle engage. Lying on your back, put your pelvis in the middle range. Gently squeeze a pillow or ball between the knees to engage the inner thighs. Then let your knee fall about 45-60 degrees to the side while keeping your trunk still. It may help to do this on the exhale initially.

Lateral pelvic sling: Side lying knee lifts

• The goal of this exercise it to feel your outer hip and opposite inner thigh. Lying on your side, lift one knee up to the ceiling keeping feet together to feel the upper outer hip. Then, lift the bottom knee towards the top knee to engage the inner thigh. You may need to move your knees closer or further from the body to engage the correct muscles.

Rotational pelvic sling: Hook lying knee kisses

• The goal of this exercise is to control thigh movement on a stable pelvis. Lying on your back with knees bent and feet wider than hip width, slowly let your knees come together. You should feel a light stretch and engagement of the outer hips.

DEEP ABDOMINAL STABILITY:

The internal stabilization of the pelvis and abdominals depends on pressure regulation and the coordination of the deep system of the transverse abdominis, multifidus, diaphragm, and pelvic floor muscles. The external pelvic slings give the the pelvic floor muscles a better foundation for stability. Clinical expert Julie Wiebe says, “When linked to the diaphragm, the pelvic floor acts as a powerful stabilizer of lumbosacral, sacroiliac, pubic symphysis, and pelvic-hip joints ensuring efficient mechanics.”

The pelvic floor muscles are part of the deep core stabilization system that also involves the diaphragm, multifidus, and transverse abdominis. One of the main mechanisms for stability is abdominal pressure management and coordination. When one muscle of the deep stabilization works, other parts are more likely to also work. In this way, breathing, back and abdominal muscle strengthening activate the pelvic floor musculature. However, with many of our patients, the expected coordination between muscles needs guidance to find the muscles and then appropriate progression to integration into everyday use. Here are some exercises to familiarize and find these subtle muscles.

Transverse Abdominis:

• Lie on your back with pelvis and ribs in mid-range. As you exhale, gently knit the bottom ribs together and bring the front hip bones together. You should feel a deep engagement develop wider than your six-pack muscles as the abdomen sinks. You can feel a trampoline tension, not bulging inside the front hip muscles. Your trunk and pelvis should not move. It can help to bring your arms above your head.

Multifidus:

• On your side or seated comfortably, position your pelvis in mid-range. Imagine the connection between the back of the pubic bone to the spinal level you want to engage. Then “grow” and float that spine 1 mm above the segment below it. It may help to add light pressure to the back of the hip and resist movement while staying elongated or to coordinate with breath. You can feel these muscles engage next to the spine without the big back muscles bulging.

Diaphragm:

• In any comfortable position with hips and knees bent and pelvis in mid-range, inhale through the nose thinking about expanding the ribs in all directions as if there were an umbrella opening under the rib cage. Take care especially to move the back ribs. Then exhale all the way as if blowing into a balloon or blowing out 100 candles. Many variations for diaphragm breathing can facilitate different purposes from muscle inhibition to deep relaxation.

Pelvic Floor Muscles:
 

• In a recent blog by Dr. Fiona McMahon, she describes a pelvic floor contraction.

• A correctly performed kegel is a mix of two distinct movements, a squeeze or closure of the vagina/rectum and a lift. Often times when folks practice stopping the flow of urine, they omit the lift part. The lift part is so important and is vital in reducing the experience of stress incontinence, prolapse and other pelvic floor symptoms. A cue that I really like is to imagine your pelvic floor like an elevator. You must close the doors, (your vaginal or anal sphincter), before lifting the carriage. Close your anus or vagina, then lift your pelvic floor up. You can get really fancy by envisioning going up slowly floor by floor and you can also practice the allimportant relaxation portion by slowly lowering the pelvic floor back to the ground floor and then opening the doors (relaxing vagina or rectum).

• I usually use the image of a jellyfish closing and lifting to the water surface, then opening, flattening, and dropping to float down.

ACCESSORY PELVIC FLOOR MUSCLES:

Sometimes, the pelvic floor muscles are difficult to recruit even the best explanation and image due to weakness or alterations in cognition and sensation. In these times, it can be appropriate to “find” the pelvic floor muscles using some overflow recruitment. The pelvic floor itself also has neighbor friends (accessory muscles) that when engaged also recruit the pelvic floor muscles. For some patients, accessory muscles activation may not be appropriate when pelvic floor muscles need to be specifically targeted. However, for most patients with difficulty identifying or engaging pelvic floor exercises, accessory muscles may be an easier place to start connecting to the hard-to-find pelvic floor muscles. Many of these accessory muscle exercises were organized by Janet Hulme in the “Roll for Control” program.

• Seated hip external rotation with band: In a comfortable seated position with pelvis in midrange and resistance band around the knees, roll thighs and heels away from each other.
• Seated hip internal rotation with ball: In a comfortable seated position with pelvis in midrange, roll knees in and rotate through heels toes towards each other.
• Standing plies: Stand with pelvis in mid-range, heels together and feet pointed away from each other. Bend and roll your knees away from each other.
• Seated heel clicks (isometric): In a comfortable seated position with pelvis in mid-range, heels together and toes pointing away, push the heels together as if you were trying to move your toes away without actually moving your feet.
• Seated toe clicks (isometrics): In a comfortable seated position with pelvis in mid-range, toes together and heels pointing away, push the toes together as if you were trying to move your heels away without actually moving your feet.
• Supine hook lying combined hip ER/IR with band/ball: In a comfortable position lying down and pelvis in mid-range, put a ball between your knees and tie the resistance band around your knees. Roll your knees in towards the ball. Then roll your knees out into the resistance band. There should be very little visible movement.

EXERCISE PRESCRIPTION AND GUIDANCE:

The exercise(s) selected by physical therapist correspond with specific goals to address dysfunction that contribute to the overall problem. As a baseline, physical therapists can identify, utilize, and prioritize the recommendations from the American College of Sports Medicine which include:

Your pelvic health physical therapist will make sure you understand which muscle should be activating and which muscles should be quiet. We watch for details that level of ease, breath patterns, compensatory movements, starting positions, and sufficient range of motion. As therapeutic exercise become easier, your physical therapist can progress the exercise usually to make it more difficult, less conscious, and integrated with larger movement patterns.

THE REST OF THE BODY, MIND, HEART, AND SPIRIT

As physical therapists, we primarily treat the dysfunctions of the physical body. However, pelvic floor dysfunction can how have contributions from other systems in the body, mental, emotional, and relational factors. While these factors are beyond the scope of this blog, as pelvic health physical therapists, we are trained to recognize these influences and have a robust network of other providers to help your recovery.

REFERENCES:

Bayles MP. American College of Sports Medicine. Exercise testing and prescription. WoltersKulwer. 2018.

Spielman M. The pelvic floor and the foot: a review of the literature and considerations for assessment and treatment. Beyond Basics Physical Therapy. May 2022.

Vandyken C, Cred MD, Hilton S. The puzzle of pelvic pain: a rehabilitation framework for balancing tissue dysfunction and central sensitization II: a review of treatment considerations. Journal of Women’s Health Physical Therapy. 2012 Jan 1;36(1):44-54.