Just Relax: The Details of Pelvic Floor Down-Training

Sonali-Patel
Dr. Joanna Hess PT, DPT, PRC, WCS

What is pelvic floor relaxation?

“Just relax” must rank as one of the most infuriating phrases in modern life. Relaxation sounds easy and does not require money or advanced degrees. And yet, when someone kindly tells us to “just relax,” our minds and bodies often ramp up. For the achiever “not doing” can be harder than “doing.”

The pelvic floor relaxation addressed in this blog post relates to the treatment goal of overactive pelvic floor muscles. The goal of pelvic floor relaxation is better described as pelvic floor down training which can help to alleviate pain and tension. Pelvic floor relaxation allows us to use our pelvic floor properly. Practicing relaxing your pelvic floor is an integral part to having a strong pelvic floor. Just as a bicep that cannot relax is not strong, so too is a non- relaxing pelvic floor. Pelvic floor dysfunction characterized by excessive length and laxity is addressed here, and here.

Pelvic floor relaxation is the conscious or unconscious downregulation of the nerves, muscles, and surrounding structures in and about the pelvic floor. Nerves decrease their signaling and the muscles lengthen with less activity. Relaxation of pelvic floor muscles is like relaxing other muscles of the body, it won’t necessarily make them weak, it simply allows them to return to their normal resting position. Unlike the muscles of the arms, back, or legs, the pelvic floor muscles are usually less familiar, have multiple functions, and hold more emotional associations. Like other muscles, down training the pelvic floor muscles can happen locally or in conjunction with the other parts of the body or the whole person.

Why do pelvic floor muscles become overactive?

The topic of pelvic floor relaxation must also address the symptoms and reasons behind the overactivity of the pelvic floor muscles. Overactive pelvic floor muscles are also referred to as levator ani syndrome, pelvic floor tension myalgia, non-relaxing, tight or short pelvic floor muscles. Overactive pelvic floor dysfunction is caused by many factors and causes wide-ranging problems. Signs of overactive pelvic floor muscles regardless of gender include:

  • Pain with penetration (sexual, medical exam, tampon insertion)
  • Incomplete emptying – urinary and bowel
  • Difficulty and/or pain initiating urination or bowel movements
  • Urinary and bowel urgency
  • Pain and tension in the pelvic floor with activity
  • Pain and tension in the pelvic floor at rest

Overactivity in the pelvic floor muscles usually results from problems in surrounding areas. Because the
pelvic floor muscles have multiple functions, many factors contribute to overactive pelvic floor muscles
including, but not exclusively:

  • Direct injury or trauma in pelvic floor muscles: undesired sexual or medical experiences, childbirth, surgeries, hemorrhoids, urinary tract infections, catheterization, STDs, and more
  • Indirect injury or trauma surrounding pelvic floor muscles: low back pain, hernias,
    abdominal strains, lower extremity muscle tendinopathy, lack of balance, ligamentous laxity
  • Overtraining or exercise training with inefficient form
  • Nerve damage or sensitivity
  • History of GI issues including IBS, bloating, diarrhea, constipation
  • Gynecological disorders such as endo and lichens planus
  • History of urinary issues including overactive bladder syndrome, delaying voiding, voiding just in case
  • Hormonal changes through the month and lifespan
  • Pelvic floor muscle strengthening without relaxation between contractions
  • Lack of physical health foundations including sleep, regular movement, and diet with sufficient fruits and vegetables
  • Emotional or mental disruptions leading to persistent stress response

What is normal pelvic floor activity?

When the pelvic floor works efficiently, the muscles have an intricate concert of turning on and off with activities and rest. The pelvic floor muscles do not act as one large group and are not controlled by a common nerve. Pelvic floor muscles both contract and relax requiring complex coordination between the superficial and deep layers, the front and back, and the right and left sides. This complex, usually unconscious synchronization happens so we can urinate, defecate, allow penetration, enjoy sex, move, jump, balance, cough, laugh, have babies, and pump blood through the body. In walking, the pelvic floor muscles coordinate with the legs and breath to support the pelvic organs against abdominal pressure and ground forces, decrease just enough activity to swing one leg, stabilize the pelvis while standing, pump blood, develop enough tension to transfer forces between the leg through the trunk, and be prepared for unexpected jostles. Pelvic floor activity is good but needs coordination for tension and timing.

How do I relax my pelvic floor muscles?

Relaxation of the pelvic floor muscles is marked by a passive open, drop, and stay. This is not bulging as if to have a bowel movement. Relaxation of the pelvic floor is most easily felt in the area between the genitals and anus or around the rectal and urethral sphincters. Nerves drive muscle activity. Relaxing the pelvic floor muscles requires quieting the neural system locally, systematically, or together. Keeping this in mind will facilitate the goal of pelvic floor relaxation. You cannot “work harder” or “think better” to relax. Pelvic floor relaxation means working with ease or leaning into letting the body experience something novel. Usually, the pelvic floor overactivity is in response to a systemic or whole-body driver. Even when the cause of overactivity is at the pelvic floor, whole body quieting helps the pelvic floor muscles drop and open. Here are three ways to relax pelvic floor muscles in coordination with other systems:

  1. Movement: change positions regularly or walk to allow for movement in the rib cage and arms swinging freely keeping effort level at 10-25%. Patients often ask “what kind of exercises should I do to help my pelvic floor?” My response is usually something you enjoy, can do regularly, and gives a sense of In most movements, the pelvic floor muscles are supposed to turn on and off. This can include walking in open spaces, yoga, rehabilitative Pilates, swimming, stairs, elliptical, and tai chi. Sometimes exercise can have the opposite effect of allowing the pelvic floor to relax. If that is the case, see a pelvic floor PT so we can help you move with more ease. Easy movement initiates the rhythmic on and off of the muscle activity. How you do the activity is more important than which activity you choose.
  2. Stretches with diaphragmatic breathing, (breathing that moves the belly and chest evenly decreases the demands from the overactive pelvic floor). When you breathe and change the length of pelvic muscles, the nerves have a different stimulus that can help decrease the pain signal from the brain. For stretching for pain relief, I usually recommend that patients go to stretch, but not pain, holding for 6 breaths. Inhale into the lower back ribs, exhale all the way and pause for 3-6 seconds. Then see if you can increase the stretch a little. Here are my favorite stretches:

    • Happy baby: Lie on your back and reach your hands to your feet. Gently bring the legs to the side of the
    • Hip flexor stretch: Lie on the edge of the bed and bring one knee to the Let the other leg hang towards the floor to stretch the front of the hip.
    • Hip external rotator stretch: Lie on your back and put the ankle of one foot on the opposite Hold behind the thigh and bring both legs towards the chest.
    • Cat-Camel: On hands and knees, arch your back bringing the belly up feeling the opening of the back with inhale and gentle abdominal contraction on Then let your belly hang and sit bones spread to feel the pelvic floor opening on inhale and gentle abdominal contraction on exhale.
  3. Mindfulness and other bilateral stimulation techniques are outlined in Dr Alex Milspaw’s book for pelvic pain, Hello Down There. The overactive pelvic floor often reflects an overactive nervous system. Mindfulness and bilateral techniques help to shift the nervous system which helps to relax the pelvic floor. One of my favorite techniques in the book is mindful journaling. You can read Dr. Milspaw’s book for the how and why behind this type of intervention. Here’s an example of mindful journaling from Hello Down There:Write the numbers 1-20 down on the side of a sheet of paper. On the odd number, you’re going to notice your thoughts and label them in one or a few words. Imagine you could put all of the thoughts into a file folder, what would you label the folder? That’s what you’re writing down. Short and sweet is the goal. Sometimes it takes me to number 40 to feel relief, but even so, this works every time. The bilateral stimulation comes from utilizing different hemispheres of your brain for each awareness. Your right brain is for your awareness of physical sensations, and your left brain is used for your awareness of thoughts. ON the even numbers, you’re going to notice a physical sensation and write it down. It may look like this:

    1. To-do list
    2. Tense and painful neck
    3. Anxieties
    4. Tight chest
    5. Chores
    6. Headache
    7. Judgments
    8. Deeper breath
    9. Missing my dogs
    10. Tearful
    11. Problem-solving schedules
    12. Pursed lips
    13. Possibilities
    14. Smiling
    15. Sunny days
    16. Relaxed shoulders
    17. People I love
    18. Deep breath
    19. Mindfulness rocks
    20. Peaceful

    Less commonly, pelvic floor muscles are overactive in isolation. Or sometimes the systemic quieting isn’t enough to eliminate symptoms. When this happens, here are three ways to locally relax pelvic floor muscles:

    1. Position and imagery: Pelvic floor relaxation is the lack of activity as the sphincters open and This is different than bulging for a bowel movement. As part of the core stabilization system, the pelvic floor muscles work in upright positions to maintain stability and keep pelvic organs up. When trying to quiet the pelvic floor, the easiest position is usually lying on your back or side with pillows supporting the head, neck, upper ribs, and legs. You know you’re in a well-supported position if your ribs and belly similarly expand on inhale. The environment should be relatively free of stimulus. Pay attention to the tension in the jaw, shoulders, hands, and feet, and take a couple of breaths to let these body parts hang heavy. My favorite images for pelvic floor relaxation are:

      • A rose blooming (open) and then wilting (letting go to drop)
      • A jellyfish floating (open) down (drop) in the ocean
      • An elevator going to the basement (drop)
    2. Pelvic wands and dilators: For some of our patients with overactive pelvic floor muscles, we instruct them how to use pelvic wands and dilators in conjunction with other techniques. These devices help the brain attend to different, non-threatening stimuli to decrease muscle In the clinic, we help patients identify symptomatic areas and how to down- train these muscles at home. Intimate Rose has good products and educational videos for dilator and pelvic wand use. These devices are best utilized when first assessed and then guided by a healthcare professional.

When do I need more help?

At Beyond Basics, we believe in the body’s ability to heal which often happens without outside intervention. Sometimes, the body does better with some help. Pelvic floor overactivity is not all equal. The reason behind your pelvic floor muscle overactivity is critical to understanding how to relax your pelvic floor muscles. Your insight and a pelvic health therapist as part of the medical team can figure out the nuances of your presentation. A pelvic health physical therapist can help you figure out the best set of techniques to down-train your pelvic floor. Our patients often have complex presentations, so we also rely upon and coordinate expertise from other disciplines. In the clinic, we use clusters of tests to clarify the cause of pelvic floor overactivity. We treat both locally and systematically.

For some vulvas, we coordinate with other specialists when we see signs of:

  • Hormonal changes: thinning labia, fragile tissues, decreased lubrication
  • Autoimmune disorders (most commonly): lichens sclerosis, lichens planus, lichens simplex
  • Keratin pearls, Bartholin, and Skene’s gland cysts
  • Vulvar infection
  • Scar adhesions
  • Vulvodynia

We also do clinical cluster tests and screening as it relates to your symptoms for:

  • Pudendal neuralgia
  • Pelvic floor dyssynergia
  • Pelvic floor hypertonicity
  • Pelvic instability
  • Lumbar instability
  • Coccyx dysfunction
  • Structural asymmetries
  • Systemic hypermobility
  • Nerve dysfunctions

Local pelvic floor muscle down training

  • Conscious relaxation: In general, we spend most of our time increasing awareness and giving appropriate feedback on how to grade tension in the pelvic floor muscles. Because you ultimately need to learn how to monitor and manage pelvic floor tension, we make sure that we modify the amount of feedback so that you can feel confident. We use the following techniques:
    • Biofeedback: with a machine, a mirror or with supportive surfaces so that you can feel the movement and muscle activity of the pelvic floor muscles
    • Imagery and diagrams: for visual learners, it’s important for the brain to see what is usually an area that is hard to We have videos, pictures, and anatomical models to help.
    • Association with other parts of the body: using what you already use for relaxation techniques and body awareness, we can build on those pathways to connect for pelvic floor tension. For example, monitoring and releasing tension from the shoulders, jaws, and feet can help teach the same on the pelvic floor.
    • Imagery: We share scripts and describe images that help you normalize pelvic floor Some of these images include a jellyfish, flower, arcade toy claw, trampoline, scarves, elevator, etc.
    • Grading muscle tension: Many patients can contract their pelvic floor muscles but have a problem grading the tension for the task. This is usually automatically regulated, but with pelvic floor overactivity, this often seems more like an all-or-nothing contraction instead of a range of tension. In general, most activities require 25-50% pelvic recruitment, and this “tension to task” can be the next step for muscle down-training after learning how to relax.
    • Paying attention to specific overactive muscles: while the pelvic floor is often imagined and described as one unit, it is fourteen different muscles with slightly different functions and orientations. Depending on the reason for the pelvic floor dysfunction, paying attention to a specific pelvic floor muscle can help with down training. In the clinic, the therapist with your consent would locate and palpate the muscle to help the brain pay attention. Then using a variety of techniques can teach you how to let go of the tension, through movement, breath, or conscious relaxation.
  • Manual therapy: Manual therapy is when the therapist uses their hands to help the muscle How manual therapy works remains unclear, but likely the introduction of a novel stimulus allows the brain and muscle behavior to have a better opportunity to learn another strategy. The therapeutic effect of touch and mindfulness also calms the nervous system allowing for an improved environment for change. Passive techniques are associated with less effective outcomes. However, if the brain is actively learning and participating in treatment even in treatment without physical movement, this activity improves carryover and results. Manual therapy techniques are usually organized into:
    • Soft tissue mobilization: moving the soft tissue with varying levels of compression and stretch either with the hands or other This is what most people associate with a massage.
    • Myofascial release: gently moving the muscle and fascia, usually in a direction of ease to allow for relaxation.
    • Trigger point release: applying deep localized pressure at parts of the muscle that are more sensitive and usually hold significant tension. Clinically, if a specific spot is more sensitive to pressure and radiates pain in a familiar pattern, this would be the “trigger point”.
    • Joint mobilization: moving between a joint with gentle oscillations or quick manipulations to improve overall active movement. This theoretically gives different inputs into the joint receptors to allow the muscles to relax.
    • Strain-counterstrain: positioning the muscle in a shortened position until the muscle goes The hypothesis is to turn off the stretch signals to the brain and give a reset.
  • Active release or mobilization with movement:
    • The patient has small movements while the therapist applies pressure on the joint or at the soft The goal is to increase active pain free range of motion.
    • For example, to improve pelvic outlet opening, the therapist can hold the front of the pelvis while the patient rolls the thigh bone. Or the therapist can hold the muscle inside the sit bone while the patient rolls the thigh bone.
  • Combination: These techniques can be combined to augment the effects of relaxation.

Systematic pelvic floor muscle down training

  • Breathing: In the clinic, we can pay more attention to how you are breathing and why your breathing patterns may contribute to pelvic floor overactivity. For example, in paradoxical breathing the abdomen contracts on inhale which increases demands on the pelvic floor We also often notice decreased breath in the back of the ribs which is associated with overactivity in the back of the pelvic floor. These nuanced differences can be hard to notice by yourself, but when addressed can make an immediate difference in pelvic floor muscle activity.
  • Pelvic range of motion: When the pelvic floor muscle become overactive, the range of motion of the whole pelvic girdle usually decreases. This local lack of motion then limits the strategies available for general movement and stability. Also, decreased mobility can sensitize the nervous In the clinic, we identify your preferred range of motion, help you feel the full range of motion of the pelvis, and then learn how to access more of the range needed for everyday and recreational movement. We use manual therapy, therapeutic exercises, and neuromuscular techniques to help the carryover. This new movement can help the pelvic floor muscle activity regulate.
  • Stretches of neighboring muscles: A series of muscle tests can identify which of the surrounding pelvic floor muscles have adapted to decreased These muscles often add tension to already overactive pelvic floor muscles. Stretching muscles with a specific bias and fine-tuning can be more effective than general stretching. For example, the hip flexor muscle group can be biased for rotation to more specially address the psoas, iliacus, or tensor fascia lata. We can help you figure out how to best position yourself to appropriately address the limitations.
  • Strengthening of supporting muscles: We also test the strength and coordination of surrounding Often, the pelvic floor muscles become “too helpful” when other muscles are weak or inactive. These muscles are often subtle muscles that aren’t addressed in the usual gym exercises. These muscles usually include the transverse abdominis, multifidus, superior glutes, low traps, serratus, posterior tibialis, peroneals, and adductors. In the clinic, we can help you understand how to isolate these muscles in exercise and use these muscles in everyday life.

Treating pelvic floor overactivity is not as simple as having a glass of wine or taking some deep breaths. However, these are just some of the many options that can help retrain your pelvic floor muscles to work more efficiently. As pelvic health physical therapists, we help people understand the cause of overactive pelvic floor muscles, help set an environment for the body to learn, and teach the patient new ways of doing old patterns to improve their quality of life.

REFERENCES:

  • Faubion SS, Shuster LT, Bharucha AE. Recognition and management of nonrelaxing pelvic floor Mayo Clinic Proceedings. 2012 Feb 1 (Vol. 87, No. 2, pp. 187-193). Elsevier.
  • FitzGerald MP, Kotarinos R. Rehabilitation of the short pelvic floor. II: Treatment of the patient with the short pelvic International Urogynecology Journal. 2003 Oct;14(4):269-75.
  • Klein MC, Gauthier RJ, Robbins JM, Kaczorowski J, Jorgensen SH, Franco ED, Johnson B, Waghorn K, Gelfand MM, Guralnick MS, Luskey GW. Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation. American journal of obstetrics and 1994 Sep 1;171(3):591-8.
  • Milspaw Hello Down There. Hellertown, PA: Bright Communications. 2022.
  • Wickham, S et al. The Big Three Health Behaviors and Mental Health and Well-Being Among Young Adults: A Cross-Sectional Investigation of Sleep, Exercise, and Diet. Frontiers in 2020 Dec.

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