Pelvic Floor Mythbusters: Is kegeling the one true way to a healthy pelvic floor?

Pelvis Drawing

Fiona McMahon PT, DPT.

Is kegeling the one true way to a healthy pelvic floor? Not always. We can end the blog here. Just kidding, of course there is nuance to be considered here. But as pelvic floor physical therapists, nothing is more cringe inducing than hearing the phrase “just do your kegels” thrown around for myriads of ailments from low libido, to pain, incontinence, and erectile dysfunction. While it is true the pelvic floor muscles can be involved in all of these conditions and in some cases kegels may help, there are many cases where kegels are the EXACT opposite of how you should be treating these muscles.

Physiology

To understand kegels we must first understand the pelvic floor. To understand the pelvic floor we must also explain the muscles at a very basic level. Bare with me readers, this will help us as we bust through this myth. Muscles, all muscles do what they do, by contracting and getting shorter to produce force. This is easy to see on a bodybuilder doing a bicep curl. As she curls her hand up you can see these muscles shortening into a little ball. Not only is this a great way to show off your gains in the gym, the shortening of these muscles are providing the strength to perform this task. We call this shortening a concentric contraction. Kegels are concentric contractions too! A good kegel will cause the pelvic floor to shorten and provide strength. Let’s go back to our body builder for a second. She has done her lift now she needs to lower her dumbbell back to the floor. In order to lower that dumbbell back to the floor in a controlled way, she needs what’s called an eccentric contraction, which is the controlled lengthening of the muscle. If she did not have a good eccentric contraction she may not be able to lower that weight effectively after she curled it. What if she couldn’t lower her bicep at all or just very slowly after her bicep curl? Maybe her weightlifting wouldn’t be as effective, she’d tire more easily, or she could develop pain. Would you tell this woman that more bicep curls would help? Or might you suggest a program of stretching first? Telling someone to do kegels, when you don’t know the status of their pelvic floor and how well it can relax is similar to telling the bodybuilder with the non relaxing bicep to just do more bicep curls. At best it certainly won’t help the situation and at worst it could cause more pain and dysfunction.

“But Fiona, I have incontinence, so that definitely means I have weaknesses, so it’s good for me to do kegels, right?”. Maybe… but in my experience, probably not. Let’s agree on one thing, it’s completely intuitive that people would think that kegels would help incontinence. The muscles of the pelvic floor are responsible for continence… so they must be weak if one is experiencing incontinence. You are right! When we think weak with muscles, we often think weak and loose, which is one form of weakness, but we rarely think weak and tight. Let’s go back to our body builder lady. She deserves a name at this point. Let’s call her Kendra. If Kendra has a tough time moving her lifting her arm from fully straight to a full bicep curl, we could guess she is weak and loose. But if Kendra could not fully straighten her arm out she would be considered weak and tight. Both of these versions of Kendra would have trouble curling heavy weight. One Kendra due to frank weakness another Kendra because she simply does not have enough room or range of motion to generate enough force to curl that dumbell.

Tight and weak pelvic floors are a lot like second Kendra with the poor ability to lengthen her arm. Tight pelvic floors have less range of motion to generate force. You need a good amount of force from the pelvic floor to counteract the pressure of activities like lifting, coughing, laughing and sneezing and stay continent. Over loose and over tight pelvic floors can’t really do that.

If you have pain in your pelvis not from a medical condition, (although tight pelvic floors present with many medical conditions), your pelvic floor is probably tight. A tight pelvic floor may also have trigger points which can send pain to various locations in your genitals, back, legs, and abdomen. Continuing to tighten can cause this pain to get worse.

Treatments

So how do you know what to do? This is where a skilled pelvic floor physical therapist can come in handy. They can assess the muscles by touching them either externally or internally to determine what course of action is right for you. If you are loose and weak, HAPPY DAYS! Strengthening can help them get better. If you have tight and weak muscles, HAPPY DAYS again! Gentle lengthening, stretching and down training of the muscles can help them get better. Did you know, because a tight pelvic floor can cause weakness itself, returning the proper length to the muscles can restore strength, without actually needing to kegel?! Wild! Regardless of the situation happy days can be ahead.

Skilled PT

Really knowing the pelvic floor is a skill and requires advanced expertise.  Kegels should not be initiated, unless the physical therapist has carefully examined your pelvic floor. Not all therapists are trained to do that technique so it is important to inquire about their background before starting pelvic floor PT. There are a lot of different ways to treat the pelvic floor, to read more What is Pelvic Floor Physical Therapy . If you are interested in learning more give us a call at 212- 354-2622 for a free consult if you live in the greater NY/NJ/CT area.

Body, Baby, and Breastfeeding: the effects of exercise on milk supply

Joanna Hess PT, DPT, PRC, WCS

tilt shift lens photo of infant s hand holding index finger of adult
Photo by Dominika Roseclay on Pexels.com

Breastfeeding, for all its two-way benefits, requires the mother to share her body and she often ends up feeling like the health of the baby comes at the cost of her well-being—physical, mental, and social. Physical activity improves all three realms for the mother but activity may be postponed because of the assumption that it will negatively affect the baby’s growth. Can a mother have it all–breastfeed a growing baby and get return to pre-baby weight? Multiple studies and reviews show that moderate physical activity and weight loss does not negatively impact milk supply or infant growth.

Should intentional weight loss be considered during the postpartum period?

Yes, for most mothers. At one year postpartum, about one in six women retains 10 pounds or more of weight gained during pregnancy. The weight gain during and after pregnancy often stays with the mother into post-childbearing years setting up for metabolic diseases and orthopedic complications (10). While moderate physical activity itself is not sufficient for postpartum weight loss (6), physical activity remains an integral part of restoring the body’s set point in conjunction with dietary modifications. Moderate physical activity influences maternal health not only through weight control but also mental wellbeing, bone health (9), functional tolerance, sleep quality, and establishing family patterns of recreation. Breastfeeding itself requires high levels of energy, 300-600 kcal/day (5), and is associated with improved postpartum weight management long-term over 24 months (2), but not short term within 3 months (4).

Does exercise for intentional weight loss affect milk supply?

No, for most mothers. However, when breastmilk is the sole source of nutrition, a fussy baby protesting or rejecting a feed can be worrisome. Multiple studies have shown that exercise is not related to decreased milk supply, milk quality, or infant growth (1, 3, 6). Some studies show that over time, moderate exercise is related to increased milk supply (7). Some babies show a distaste for post-exercise breast milk. Lactic acid produced in vigorous levels of exercise may be associated with a decreased acceptance of breastmilk (8), but it resolves within 30-60 minutes of exercise (1, 13). Weight loss in most situations, but particularly while breastfeeding, should not exceed 0.75-1 pound/week (6, 9, 12). Wait until milk supply is established for more aggressive caloric restriction.

  • Intensity: Most studies evaluate moderate exercise intensity, roughly measured as the ability to talk, but not sing during the activity. Depending on the mother’s fitness level, the activity varies from walking to jogging. Vigorous activity is cautioned mainly because of the lactic acid buildup that is associated with poorer baby nursing.
  • Duration and frequency: 45 minutes, 5 days/week for cardiovascular. 30 minutes, 3-4 day/s week for resistance training (6).

If not exercise, what else affects milk supply?

Despite the normalcy and frequency of breastfeeding, we have yet to fully understand the complexity of the mechanism to regulate calories and nutrition, to replenish based on need, and what can increase or decrease milk supply. While baby’s quantity and quality of nursing most directly affects supply, more subtle influences like maternal food and liquid intake, exercise, sleep quantity and quality, cortisol slopes (11) also contribute to short term milk supply fluctuations.

Anything else before squeezing into the WunderUnders?

  • Fatigue. At 6 weeks postpartum, the majority of mothers do not yet have their normal level of energy (9) making additional activity difficult and almost incomprehensible to include into long days. Physical activity is only one part of wellness in the postpartum period.
  • Fussy baby. Full breasts contribute to uncomfortable and leaky exercise. If possible, feed your baby before heading off to exercise. Clean off the sweat after exercise, wait for 30 minutes if your baby seems fussy after exercise.
  • Good fitting bra. The balance of support for comfort and managing compression to protect milk ducts is the goal for your sports bra. Take off your bra when feeding to allow for complete emptying of the breasts and maintaining supply.
  • Hydration. Although hydration is more important for mother thirst than milk supply, increase fluid intake during and after exercise by about 1 liter (5). Attend to the thirst signal.
  • Baby and mother health. Although studies show that physical exercise does not detrimentally affect infant growth nor maternal health, consult with your healthcare practitioner if baby or mother aren’t following expected patterns.

A postpartum exercise plan should be a gradual and systematic return to previous level of activity. The physical therapists at Beyond Basics Physical Therapy safely guide women through this postpartum period to address multiple factors in recovery and return to fitness.

REFERENCES

1 Carey GB, Quinn TJ. Exercise and lactation: are they compatible?. Canadian journal of applied physiology. 2001 Feb 1;26(1):55-74.

2 da Silva MD, Oliveira Assis AM, Pinheiro SM, de Oliveira LP, da Cruz TR. Breastfeeding and maternal weight changes during 24 months post‐partum: a cohort study. Maternal & child nutrition. 2015 Oct;11(4):780-91.

3 Daley AJ, Thomas A, Cooper H, Fitzpatrick H, McDonald C, Moore H, Rooney R, Deeks JJ. Maternal exercise and growth in breastfed infants: a meta-analysis of randomized controlled trials. Pediatrics. 2012 Jul 1;130(1):108-14.

4 Elliott SA, Pereira LC, Guigard E, McCargar LJ, Prado CC, Bell RC. Association between breastfeeding, maternal weight loss and body composition at 3 months postpartum. The FASEB Journal. 2016 Apr;30(1_supplement):45-.

5 Kolasa KM, Firnhaber G, Haven K. Diet for a healthy lactating woman. Clinical obstetrics and gynecology. 2015 Dec 1;58(4):893-901.

6 Lovelady C. Balancing exercise and food intake with lactation to promote post-partum weight loss. Proceedings of the Nutrition Society. 2011 May;70(2):181-4.

7 Lovelady C, Lonnerdal B, Dewey KG. Lactation performance of exercising women. The American Journal of clinical nutrition. 1990 Jul 1;52(1):103-9.

8 Mortensen K, Kam R. Exercise and breastfeeding. Breastfeeding Review. 2012 Nov;20(3):39.

9 Mottola MF. Exercise in the postpartum period: practical applications. Current sports medicine reports. 2002 Dec 1;1(6):362-8.

10 Nascimento SL, Pudwell J, Surita FG, Adamo KB, Smith GN. The effect of physical exercise strategies on weight loss in postpartum women: a systematic review and meta-analysis. International Journal of Obesity. 2014 May;38(5):626.

11 Straub H, Simon C, Plunkett BA, Endres L, Adam EK, Mckinney C, Hobel CJ, Thorp JM, Raju T, Shalowitz M. Evidence for a complex relationship among weight retention, cortisol and breastfeeding in postpartum women. Maternal and child health journal. 2016 Jul 1;20(7):1375-83.

12 Thein-Nissenbaum J. The postpartum triathlete. Physical Therapy in Sport. 2016 Sep 1;21:95-106.

13 Wright KS, Quinn TJ, Carey GB. Infant acceptance of breast milk after maternal exercise. Pediatrics. 2002 Apr 1;109(4):585-9.