1. BE STRONG: BUILDING STRENGTH FROM THE INSIDE OUT
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BE STRONG: BUILDING STRENGTH FROM THE INSIDE OUT
Introduce yourself.
The reason you are all here today is because there are so many women who deal with pelvic floor dysfunction on a daily basis. Pelvic floor dysfunction can range from leakage, to pelvic pain, to pelvic organ prolapse. Urinary incontinence affects 1 in 3 women in the US and the number one cause is childbirth. That’s a heck of a lot of women! You are here today to focus on a more holistic way to address these dysfunctions and help to prevent them from happening. Alright, here we go!
©2015 National Association for Continence

2. Objectives Learn the anatomy of the pelvic floor
Understand the role of the pelvic floor and bladder control
Discover your core from the “inside out”
Learn how to enhance pelvic floor muscle function
Incorporate the pelvic floor muscles in your daily activities
No notes, just read off the slide.

3. Know Your Pelvic Floor First Layer (urogenital diaphragm) Second Layer
Clitoris
First Layer (urogenital diaphragm)
Bulbocavernosus, Ischiocavernosus,
Superficial Transverse Perineal
Second Layer
Comprised of fascia to support the urethra
Third Layer (levator ani)
Pubococcygeus, Iliococcygeus, Puborectalis
Coccygeus, Obturator Internus
Urethra
Vagina
Sphincter ani externus
It’s not important to memorize these muscles, but to recognize that the pelvis has three layers of muscles.
The pelvis is a musculoskeletal structure, like any other part of our body, and requires just as much attention as any other part of the body. Like any other muscle group, these muscles can be trained and exercised to increase their capacity to function.
Sources:

4. Know Your Inner Core The Pelvic Floor Works With Your Inner Core
Diaphragm: the dome shaped muscle used for breathing
Transverse Abdominus: the deepest layer of the abdominal muscles used for stabilization of the spine and pelvis
Deep Multifidus: the deepest layer of the back muscles used for stabilization of the spine and pelvis
Diaphragm
Multifidus
Transversus abdominis
Point out the pelvic floor at the bottom of the core and that these are the “Kegel muscles”.
Look at how the pelvic floor is linked with the diaphragm, TrA and multifidus and how these muscles create your core.
Muscles of pelvic floor
Source:

5. Why Are These Muscles Important?
Support for the Abdominal Organs: “Holding Things Up”
Appreciation for Sexual Intercourse: “Use It Or Lose It”
Bladder and Bowel Control: “When You Gotta Go”
Stabilize the Pelvic Girdle: “Your Inner Core”
No notes, just read off the slide.

6. When Things Go Wrong… If the pelvic floor is too tight…
Muscles have too much tension in them; they are not able to contract or relax at a normal rate, making them weak
If the pelvic floor is too loose…
Muscles lack tension and are too lax; they cannot contract and are weak
If some muscles are too loose and weak, other muscles will often overcompensate
To keep it simple, we want our muscles not to be too tight or too loose, but that they need to be just right! Like any other muscle in the body, we are looking for our muscles to be strong and flexible.

7. “Are my pelvic floor muscles too tight?”
Some symptoms of pelvic floor tension include:
Constipation
Painful intercourse
Pelvic pain
Inability to empty your bladder completely
Painful urination
If you experience these symptoms, it is recommended you see a pelvic floor physical therapist prior to starting any strengthening program
No notes, just read off the slides.

8. “Are my pelvic floor muscles too loose?”
Some symptoms of pelvic floor weakness include:
Urinary incontinence
Urinary urgency/frequency
Stool and gas incontinence
Pelvic organ prolapse or the dropping of your organs through your vagina
Sexual dysfunction
Pelvic girdle pain
No notes, just read off the slides.
This presentation will focus on pelvic floor weakness that comes from muscles that are too loose.

9. Types of Incontinence Urinary Incontinence Stress Incontinence
“Any involuntary leakage of urine that is a social or hygienic problem and is objectively demonstrable”
Affects 1 in 3 women
Impacts women typically between the ages of 15-64
Only 25% of these women seek help
Stress Incontinence
“Involuntary leakage on effort or exertion, or on sneezing or coughing”
Most common type of incontinence
No notes, just read off the slides.

10. Types of Incontinence Urge Incontinence
“Involuntary leakage accompanied by or immediately preceded by urgency”
Often referred to as an “overactive bladder”
Mixed Incontinence (both stress and urge)
No notes, just read off the slides.

11. What Causes Pelvic Floor Weakness?
Pregnancy/delivery
Trauma to the pelvis/abdominal wall
Lack of pelvic floor/inner core exercise
Abdominal/gynecological surgeries
Bearing down/straining on the pelvic floor in daily life
Obesity
Menopause
The cumulative pressure of bearing down year after year puts a great strain on the pelvic floor. Some examples include chronic constipation, chronic coughing/sneezing, incorrect lifting form.

12. How To Find Your Pelvic Floor
40% of women are doing Kegel exercises incorrectly!
Cues to contract the RIGHT muscles
Tighten the muscles around your vagina like you are stopping the flow of urine
Pretend that you are sucking a marble up from your vaginal opening
Try tightening your muscles so you are bringing your pubic bones and tailbone together or trying to bring your SIT bones together
Now it’s time to get active! Try using these cues to isolate your muscles. Don’t be shy, your neighbor won’t even know you are doing them!
Note, the urine stop test is when you try stopping the flow of urine mid-stream; this should only be done once a month to see if you’ve made any progress. This should never be a way to urinate, but just a test!

13. How To Find Your Pelvic Floor
Get familiar with yourself…
Use a mirror to see the muscle lift of your pelvic floor
Self Evaluation (yup, get up close and personal)
Urine Stop Test
Note, the urine stop test is when you try stopping the flow of urine mid-stream; this should only be done once a month to see if you’ve made any progress. This should never be a way to urinate, but just a test!

14. How To Find Your Pelvic Floor
Common mistakes
Tightening the buttock muscles
Tightening the inner thigh muscles
Holding your breath
Sucking in your belly
Remember, this is a gentle contraction. If it feels like you are trying too hard, you probably are!
So many of you found yourselves doing some of these common mistakes? This is actually quite common to overuse these other muscles, but now you know which ones are the right ones when you Kegel.

15. It’s Not Just About Tightening!
Myth About Kegels
It’s Not Just About Tightening!
Your pelvic floor needs to be able to work like any other muscle in the body. It has to:
Contract
Relax
Elongate
Muscles need to be able to go through their entire range of motion in order to be strong!
Remember, the pelvic floor is like any other muscle. For instance, the biceps. When you bend your elbow, that is the contraction, and when you extend, that is the elongation. (Demonstrate with your own biceps) The pelvic floor needs to be able to work this way too to maximize it’s function. When you can’t contract the muscles, then you might experience poor sphincter control or poor support of the pelvis and organs; When you can’t relax the muscles, then you might experience pain with intercourse, pain with sitting or you may not be able to empty your bladder completely; When you can’t elongate your muscles, then you might experience constipation.

16. Taking Your Kegel To The Next Level
When activating your pelvic floor muscles, make sure you can feel yourself tighten, relax, and elongate. Note: When elongating your pelvic floor, don’t strain
Pretend that your pelvic floor is an elevator. If your pelvic floor is at rest at the ground, tighten and lift up to the 2nd or 3rd floor, then relax back down to the ground. From the ground, see if you can elongate your muscles down to the basement.
Time to exercise again! Using these cues try to feel the entire range of motion from contracting through relaxing and elongating.
Again, make sure you are not straining when you elongate. If you feel like you are holding your breath or pushing with your abs, then you are probably straining.

17. Coordinating the pelvic floor with your inner core
Now that you know how to find your pelvic floor, here comes the tricky part…

18. The Amazing Diaphragm
When you inhale deeply, your diaphragm pushes down into your abdomen, allowing your pelvic floor to relax
INHALE = pelvic floor RELAXES
When you exhale, your diaphragm returns to its resting position and your pelvic floor contracts
EXHALE = pelvic floor CONTRACTS
Diaphragm
Multifidus
Transversus abdominis
There is a dynamic relationship between the pelvic floor and the diaphragm. Now here’s another opportunity to practice the coordination of the diaphragm with the pelvic floor. The dome-like structure of the diaphragm flattens as you inhale, pushing the pelvic floor into relaxation. As you exhale, the diaphragm returns to it’s dome-like position and facilitates a pelvic floor contraction. This might sound silly to practice breathing, but in reality, most are not breathing all the way into their pelvis and are not able to coordinate these muscles as a result.
Muscles of pelvic floor
Source:

19. The Amazing Diaphragm
It is important that you are aware of your diaphragm. Observe that a big, relaxed, cleansing belly breath results in belly rising.
Place one hand on your upper chest and one hand on your belly.
Breathe in deeply- a big belly breath. If you are doing this correctly, you should feel the hand on your belly move, not the hand on your upper chest as much.
Now do this again and feel what is happening in your pelvic floor.
So let’s practice this breathing!
As you take your deep inhale, imagine your rib cage expanding out to the sides, to the front, and to the back, filling your lungs with air. If you are having trouble feeling your breath go throughout your core, that’s ok. This is tough stuff. While you are learning, try lying on your side, in a more supported position, and see if you can feel your air move down into your pelvic floor.

20. It’s Not Just About Sit-Ups and Crunches
Myth: Sit ups and crunches are all I need to do to get a flat tummy and work my abs.
Those exercises are just one-dimensional and only work the more superficial abdominals
We need to work the entire core, in all planes of motion, which means finding the deeper, inner-most muscles
External abdominal oblique
Transverse abdominis
Layer 1: Immediately below the skin - Rectus
Layer 2: External & Internal Obliques
Layer 3: (deepest) Transversus Abdominus
Source:
Rectus abdominis
Internal abdominal oblique

21. It’s Not Just About Sit-Ups and Crunches
Find your Transverse Abdominus muscles by tensing your lower, inner-most abdominal wall while continuing to breathe.
Bring your belly button back to your spine
Hug your abdominal organs with your lower abdominals
Like you are trying to get into a pair of slightly tight jeans

22. It’s Not Just About Sit-Ups and Crunches
Core Activation: “On All Fours”
Start in tabletop position (hands and knees) with the hips and knees at 90 degrees.
Press hands into the floor and engage the transverse abdominals.
Lift arm up towards the ceiling.
Hold for 5-10 slow breaths.
Option to extend the opposite leg behind you with foot on the ground, or leg in the air.
Practicing on all fours is a great way to help feel the contraction of the lower abdominals and using your core entirely.

23. It’s Not Just About Sit-Ups and Crunches
Core Activation: “Bridges”
Flatten your spine and press your pelvis up toward the ceiling, rolling up one vertebra at a time.
Keep the pelvis level.
Hold for 5-10 slow breaths.
Option to lift one heel or foot, keeping the pelvis level.

24. It’s Not Just About Sit-Ups and Crunches
Core Activation: “Clamshells”
Lay on your side with knees bent. Roll the entire trunk slightly towards the floor so you feel the abdomen engage.
Keep heels together as you lift the top knee. You want to feel the action in the rear end, not the front of the hip. (If you are feeling the action in the front of the hip, try rotating your trunk closer to the ground.)
Repeat 20 times on right and left sides.

25. Putting It All Together
If you feel some tension in your low back as you contract your transverse abdominus or even feel that you lifted your pelvic floor…you got it!
This is the ultimate coordination of transverse abdominus, deep multifidus, diaphragm and pelvic floor

26. Use Your Core Throughout The Day
Use your deep inner core with every day activities such as:
Lifting
Going from sit to stand
During other exercise
Coughing/Sneezing
Squeeze before you sneeze - “the knack”
Let’s all try this. Don’t think about anything and just sit up. Now, sit back down. Try practicing engaging your TrA and pelvic floor and then stand up. Did you notice the difference?
Same thing with coughing. Practice taking a cough. Remember how it feels. Now, try activating your core and then cough. This is called “the knack”. Now do you feel a difference?
It’s a matter of perfect practice so that this becomes more natural throughout your day.

27. Finding Balance There are 45 muscles that attach to the pelvis!
It is important to help optimize the pelvic floor function by balancing the strengthening with stretching of other muscles surrounding the pelvis
Let’s practice stretches for some of the more commonly tight muscle groups
We’ve been talking about the inner core, and now we are making our way outside!
When you practice stretching, remember this shouldn’t be painful.
It is advised to warm up prior to stretching by doing some light activity like walking, even just for 5-10 minutes.
Each stretch should be held for 30 seconds to get the biggest bang for your buck! Only stretching for 5-10 seconds doesn’t do the trick.

28. Finding Balance Piriformis Stretch Lay on your back with knees bent.
Place your right ankle on your left knee.
Reach for your left thigh and pull it towards your chest to feel a stretch in the right buttocks.
Repeat on other side
These are just examples, don’t limit your possibilities!
Note to teacher: have participants practice if your environment allows it.
Piriformis stretch:
Lay on your back with your knees bent. Place your right ankle on your left knee, like in a “figure 4”. Reach for your left thigh and pull your left thigh towards your chest to feel a stretch in the right buttocks. Make sure you repeat on the other side.

29. Finding Balance Hamstring Stretches: Downward Facing Dog
Start in Table Top (hands and knees).
Send the sit bones back to where the wall meets the ceiling, keeping the back straight.
While breathing in this posture, visualize the tailbone reaching toward the ceiling during inhalation, allowing the pelvic floor muscles to release.
These are just examples, don’t limit your possibilities!
Note to teacher: have participants practice if your environment allows it.
 Downward Facing Dog- : Start in table top. Send the sit bones back to where the wall meets the ceiling, keeping the back straight. The knees should be bent if there are restrictions in the hamstrings and lumbar spine. Feet can walk back until the first sensation of stretch is achieved. While breathing in this posture, visualize the tailbone reaching toward the ceiling during inhalation, allowing the pelvic floor muscles to release.

30. Finding Balance Hamstring Stretches: Active Hamstring Stretch
Stand with feet wider than hip distance apart and knees bent.
Clasp hands and place elbows above the knees. Inhale.
Exhale, begin to straighten knees, keeping the back straight, and raise the pelvis toward the ceiling.
Extend the knees to feel the first sensation of stretch in the calf/posterior thigh.
These are just examples, don’t limit your possibilities!
Note to teacher: have participants practice if your environment allows it.
Hamstring stretches:
Active Hamstring Stretch (photo shown is only half of the action) - Stand with your feet wider than hip distance apart and knees bent. Clasp hands and place elbows above the knees. Inhale here. Exhale, begin to straighten the knees, keeping the back straight, and raise the pelvis towards the ceiling. The knees may or may not straighten all of the way – extend the knees to feel the first sensation of stretch in the calf/posterior thigh.
3) 

31. Finding Balance Hamstring Stretches: Standing At Step
Place heel on the step with your toes pointed up to the ceiling
Hinge forward at your hips, so you feel the stretch in the back of your leg.
Repeat on opposite side.
Option to use a strap to deepen stretch.
These are just examples, don’t limit your possibilities!
Note to teacher: have participants practice if your environment allows it.
Hamstring stretches:
 3)  Standing at step- Place heel on the step with your toes pointed up to the ceiling. Hinge forward at your hips, so you feel the stretch in the back of your leg. Option to use a strap to deepen stretch. Make sure you do on both sides.

32. Finding Balance Adductor Stretch
Sit tall, with the bottoms of your feet together, your ankles open wide.
If your knees don’t open to the ground, place pillows or blocks underneath to help support them.
For a deeper stretch, hinge forward from your hips.
This move can also be done in a lying down position to be more restorative.
Adductor stretch- Sit tall, with the bottoms of your feet together, your ankles open wide. If your knees don’t open to the ground, place pillows or blocks underneath to help support them. For a deeper stretch, hinge forward from your hips. This can also be done in a lying down position to be more restorative.

33. Finding Balance Hip Flexor Stretch
Stand with your feet hip distance apart, left leg in front.
The left knee is bent, knee aligning over the ankle and second toe.
The right knee is straight.
Press the pelvis forward and tuck your tail under to feel a stretch in the front of the right hip.
Repeat on the opposite side.
Hip flexor stretch- Stand with your feet hip distance apart, left leg in front. The left knee is bent, knee aligning over the ankle and second toe, and right knee is straight. Press the pelvis forward and tuck your tail under to feel a stretch in the front of the right hip. Make sure you repeat on the other side.

34. Finding Balance Deep squat position for pelvic floor relaxation
Standing with feet hip width apart, squat down to lower the pelvis below the knees
If this is too difficult, practice laying on your back, making a deep squat position by pulling knees toward chest, and out to the sides.
Use your hands to hold and support your legs.
Deep squat-
The most relaxed position for the pelvic floor is a deep squat, which means the pelvis is lower than the knees. If this is too difficult, practice laying on your back, making a deep squat position by pulling your knees towards your chest, but out to the sides. Use your hands to hold and support your legs.

35. Finding Balance Pelvic Floor Decompression: Legs Up The Wall
Lie on your back, and slide your bottom as close as you can to the wall.
Place your straight legs up the wall.
If this is difficult, place a pillow under your hips.
Legs up the wall- This is another great position to let gravity take the pressure off of your pelvic floor. Slide your bottom as close as you can to the wall and place your straight legs up the wall. If this is difficult, place a pillow under your hips.

36. Are You Aligned?
Alignment is key in optimizing your pelvic floor and deep inner core function.
Finding the body’s position of natural ease avoids overworking certain muscles unnecessarily.
Keep your rib cage over your pelvis
Keep your spine and pelvis in a neutral position, not tucked underneath you (Pink Panther) or tilting your pelvis forward (Donald Duck)
Alignment is important with both sitting and standing. Keeping the rib cage over the pelvis helps keep your spine in good, upright alignment, but it also optimizes your abdominal muscles to work during these positions. It has also been proven through research that alignment is important in helping to prevent pelvic organ prolapse.
In standing or during walking or exercising, it is important to think about the position of your pelvis. If you are keeping your rib cage over your pelvis, you ideally will have good, neutral pelvic alignment. However, most of us adopt two common postures that should be avoided:
Pink Panther: pelvis is tucked underneath you, making it look like you have a “flat buttock” and the lumbar spine is very flat as well. This posture often inhibits our glutes from functioning.
Donald Duck: pelvis is tilted forward, making it look like you have some “extra junk in your trunk” and the lumbar spine has an exaggerated curve. This posture often lengthens the abdominals, making them not work like they should.

37. Questions?
Questions?

38. Help Us Help You!!
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