Thursday, November 6, 2014

The Ultimate Core

At long last, the route of all postpartum and even pregnancy problems when it comes to maintaining fitness and health- pelvic floor syndrome/dysfunction! All the fellas out there, read no further if you can't stomach it, but wouldn't it be nice to know what your mom went through for you and what your wife or sister or friend is going through, so you can be more supportive when she is a little cranky postpartum (or any other time in life, for that matter!)?

What is the pelvic floor?

Pelvic floor is the term for the muscles, ligaments, and connective tissue that support the female abdominal contents like the uterus, bladder, vagina, and bowel. My favorite thing about the pelvic floor (as if I have so many things that I like about it) is that people describe the muscles themselves by saying, "the muscles you use to Kegel," and they describe Kegel-ing by saying, "You know, contract your pelvic floor muscles, the muscles you use to stop and start your flow of urine." Well, now that that is all perfectly clear to those who haven't done an anatomy class or who aren't OBGYN's. Honestly, I have seen and dissected the muscles in anatomy class and also done my fare share of pelvic exams during medical school and residency, and you still need to train yourself how to use them and Kegel properly, especially after pregnancy when everything is a wee bit different down there.

What is pelvic floor dysfunction?

Pelvic floor dysfunction encompasses a wide range of issues that result from weakened pelvic floor muscles that ranges from urinary or fecal incontinence to uterine or other pelvic organ prolapse. There can be impairment of the sacroiliac joint, lumbar spine, coccyx, or hip joints. The surrounding tissues can have increased or decreased neurosensitivity leading to pelvic pain. Pelvic floor syndrome is more of a pain syndrome that could mean that you have pain with intercourse or experience pelvic pain even after 6 months postpartum. This is all so uplifting, isn't it? Don't worry, I am writing this blog to help!

What causes it?

The major known causes of pelvic floor dysfunction are obesity, menopause, pregnancy, and childbirth. There may be an inherited deficiency in collagen in some women that makes them more prone to developing these problems. They have researched whether pelvic floor syndrome results more from traumatic births or methods of delivery, but the percentages are the same if women had vaginal births vs. C-section, so it's really about all that time your body and your collagen adapted to carry your baby in your uterus during pregnancy. At least 1/3 of women will have one of the conditions that make up pelvic floor syndrome during their lifetime.

Why core training is important
Photo credit:

Everyone thinks that "core" is just your abdominal muscles, but the pelvis (sacrum and ileum) has to stabilize itself during gait to absorb the forces that are distributed from the trunk and upper extremities to the lower extremities. The SI joint is at a pivotal place on the pelvis, where the hips and spine intersect. There is increased joint laxity during pregnancy, particularly in the SI joint, which causes a lot of women to have SI joint pain or even neurological symptoms in their legs. Unfortunately, the increased joint laxity experienced during pregnancy can continue postpartum, and the entire pelvic floor can remain weak and lax. Moreover, the positioning that occurs during pregnancy, the increased lordosis (sway back) and anterior tilt of the pelvis that occurs during pregnancy takes time to undo with neuromuscular re-training. All of this means that the muscles that help stabilize your CORE, your whole skeletal system, and allow you to absorb the increased forces that occur when you are walking, running, and jumping, need extra training. These muscles include muscles in the hip, pelvis, and trunk. It's not just about abs anymore, ladies.

Tips for Kegel-ing

1. Find the right muscles.
You can find those elusive muscles used for Kegel exercises by stopping your flow of urine. The muscles you contracted to do this are the same muscles you will need to contract for a Kegel. If you are still having trouble, if you aren't sure if you are Kegel-ing properly, or if you think  you are Kegel-ing properly but you still have urinary incontinence, ask your OBGYN for pelvic floor physical therapy (Yes, it exists).

2. Find the time.
Some women do them at traffic lights!

3. Use Type I and Type II muscle fibers…
Contrary to popular belief, doing 10-second contractions for multiple repetitions isn’t always the way to go. Your pelvic floor needs strengthening of both Type I and Type II muscle fibers; you need endurance to hold urine at all times, and you need fast-twitch fibers to make a forceful contraction during Valsalva (sneezing, coughing, laughing, and other actions that increase intraabdominal pressure) to prevent sudden leakage of urine.

4. Build up to 80 to 100 contractions per day.
Begin as early as 1-2 weeks postpartum with five repetitions of five-second contractions, with five seconds of rest in between, while lying on your back. At 4 weeks postpartum, try these in various positions, lying on your side, sitting, standing. Do two or three sets. Then switch to doing 2-second contractions (Type II) with four seconds rest. Then gradually progress to doing Kegels while walking or lifting things. Build up to 10 repetitions of 10-second contractions. Then add multiple sets per day of both 10-second contractions and 2-second contractions. The goal is 80-100 of both types by 2 months postpartum...

5. Pace yourself, be consistent.
I was definitely not there at 2 months postpartum! Don’t feel behind; pick up where you can and do what you can do. The goal is 80-100 contractions daily, doing them during activities, even while running. Do not despair. It takes time to progress, but before you know it, you’ll be running and coughing (valsalva!) at the same time without peeing on yourself! (It could take 6 months postpartum to get there.) 

6. Seek help.
If you are having urinary incontinence at 6 weeks postpartum, you should be asking your OBGYN for a referral for pelvic floor physical therapy. Some women are still experiencing these issues 6 months to a year after childbirth, and some women experience it again during menopause or never seem to get better. There are surgeries, there are inserts, and there are a variety of over-the-counter pad options. One new option is Under There Solutions, a group that seeks to help the 1/3 of women who experience urinary incontinence. They have fashionable absorbent panties, so you don't have to wear smelly and uncomfortable liners or pads. They are also starting to work on biofeedback intriguing does that sound? I know, you'd rather your pelvic floor PT work right away...but, in the meantime, why not? You can learn more by going to their website,

Guidelines for Core Conditioning:

The more I progress through the postpartum period, the more I really wish I had (1) done more strength training during pregnancy and (2) that I had done more core strength training prior to initiating running postpartum. After going through it myself and after seeing many women returning to exercise post childbirth and presenting with injuries to Sports Medicine clinic, I have a few guidelines:

1. FMS prior to return to sport/exercise
I would really recommend that all women get a functional movement screening after pregnancy by a trainer, physical therapist, or Sports physician. This way the problem areas can be targeted before too much stress is applied to the joints and to the anatomic positioning that has taken 9 months of pregnancy and however long postpartum to develop.

2. Be patient
What? You mean being patient as a mom extends past just motherhood and relates to all of your life now? Know that it takes time to retrain all of the neuromuscular adaptations that brought you that amazing baby of yours. 

3. Be consistent and persistent
Sometimes this means that you miss some days and have some setbacks because we all know that mothers have other things to do besides exercise. BUT, remind yourself how important this is for your health, mentally and physically, as your baby grows. Your baby gets heavier and more active, and you need to have good strength and core stability so you don't injure yourself picking your baby up from a low level or running after your toddler later on. And you know that since you have become a mom, you have forfeited any right to get that extra 15 minutes of sleep that everyone else seems to get, so, just get up out of bed when that first alarm goes off and have your time to yourself to do some core strengthening exercises and clear your head before the day becomes busy. Every day makes a world of difference, but even just 4-5 days a week, if you are consistent, will show you results if you stick with it.  
Preview of the next blog - look how much fun this girl is having!

4. Have fun with your baby!
I have been doing my PT exercises (knee rehab + core strengthening) with Violet. This makes me much more likely to get it done (since I don't have 2-3 times per day to spend 30 minutes doing something without Violet), and it also makes them way more fun! I do as much as I can of my exercises with her in her bouncer, or I play with her while she's in her "gym" (Fisher Price activity gym; she LOVES it and it is a total lifesaver if you don't have one). Then when she gets bored or fussy, she gets to come with Mommy to do more exercises. Stay tuned for my next post on the Mommy-Baby Core Workout. 

Dr. Eliza Myers (A.K.A. Superwoman) fitting
in exercises with her daughter during pregnancy! She
used the DIA Method to help with diastasis recti.

5. Start early?
I can't find anything evidence-based that shows that pelvic and core strengthening during pregnancy improves postpartum outcomes, but it can't hurt, right? And, anecdotally, I have the story of one amazing lady who did do exercises to train core muscles during pregnancy, and she reports that it made a huge difference. Think you don't have the time or the energy during pregnancy? Just take a look at this amazing wonder-woman-mom who is not only a hospital attending, a mother of 2 (now 3, actually), doing her exercises with her kids while pregnant! How is that for the ultimate motivation?

References/More Info:

Geraci MC, et al. Evidence-based treatment of hip and pelvic injuries in runners. Phys Med Rehabil Clin N Am. 2005 Aug;16(3):711-47.