Pelvic PT Part 2: Training the Pelvic Floor Musculature...Are Your Patients Missing Out?

August 19, 2016 by Matthew Schmidt, PT, DPT, CSCS

What you’re getting yourself into:

2100 words; 9-15 minutes reading time

Key Points:

1.      The pelvic floor muscles are like nearly every other muscle in the body: they are split between fast and slow twitch fibers. The levator ani muscles, however, are proposed to be nearly 80% slow twitch.

2.      Fast twitch fibers are typically trained with high weight and low reps, whereas slow twitch fibers are typically trained with high reps and low weights, based on the idea that you need to train differently based upon predominance of fiber types.  Difference in training style has not been conclusively shown to affect muscle fibers in such a way; evidence is very mixed, though opinions on the matter are quite impassioned.

3.      Regardless, the general recommendation is to keep training muscles with a variety of rep ranges; in other words, follow the rules of periodization and specificity.

4.      Don’t be afraid to challenge your patients; Kegel isometrics are really only the beginning. Training this muscle requires the same amount of consideration as training any other muscle group. Rules of periodization should be followed. Variation for Kegels can be achieved by simply using Kegels concurrently with virtually any other movement.

Part 1:  Pelvic Floor Health, its not just for pregnant women anymore!

Shirts showing “pride” for leakage ²

Pelvic floor musculature (PFM) is one of the most overlooked muscle groups during a physical therapy evaluation. As healthcare professionals, we pride ourselves on being able to talk about intimate topics such as urinary incontinence with our lumbar patients or the ability to obtain an erection for a patient with a recent spinal cord injury. But it is this critic’s opinion that this simply does not go far enough. Sure, some attention has been brought to the Exercise Induced Urinary Leakage epidemic (EIUL as CrossFit names it, or Stress Urinary Incontinence as the rest of the world calls it), or the idea that the majority of strength athletes “leak” during a lift; some even wear this as a badge of pride ¹.

 As has been said before in this well written piece on Pelvic Guru³,this is not a normal occurrence and it should be addressed. That all sounds well and good, but somehow I doubt that when Mattie Rogers sets a new American Record Olympic Lifting Total, or when Marisa Inda squats the equivalent of a house filled with lead, they’re thinking “Alright, knees out, stay aggressive, keep the torso upright, and squeeze the heck out of that Kegel!” No, that’s pretty doubtful.

Mattie Rogers⁴

You might be thinking to yourself, “but Matt, I don’t see athletes, why do I need to care about Kegels??” Because believe it or not, your 79 year-old Parkinson’s patient named Jim, who is seeing you for back pain and is a glaring fall risk has weak PVM. Unfortunately, Jim stopped drinking more than 16 ounces of water a day because he is afraid of falling, and since he has weak PFM, drinking water will require him to get up many times, so what better way to decrease the chances of not falling than by not drinking water so he doesn’t have to get up?

Then what is the therapist’s role in training the PFM? It starts with education. I am by no means an expert in the matter, but I can provide a quick rundown of some key points that will hopefully be of benefit to the average therapist that is interested in a brief introduction to the clinical application.

Part 2: Muscles are Muscles

The pelvic floor muscles are like nearly every other muscle in the body, they are split between fast and slow twitch fibers. The levator ani muscles, however, are proposed to be nearly 80% slow twitch⁵.

Let’s determine what we know (or should know) about fast and slow twitch muscles fibers? Fast twitch (Type II) muscle fibers are quick to fatigue and are responsible for quick contractions and typically are capable of stronger muscles contractions, whereas slow twitch (Type I) fibers are slow to fatigue and are therefore capable of sustaining contractions for a longer period of time, though they are usually not capable of as strong of a contraction as Type II fibers. The reason that I bring up fiber type in relation to PFM is NOT so that you can choose to do isometric holds for only one specific length of time or at specific intensity because you think that your patient has problems with holding a contraction for a long time but not for short bursts (like during a lift), or vice versa. The following key point explains why.

Fast twitch fibers are typically trained with high weight and low reps, whereas slow twitch fibers are typically trained with high reps and low weights, based on the idea that you need to train differently based upon predominance of fiber types.  Difference in training style has not been conclusively shown to affect muscle fibers in such a way. Evidence is very mixed, though opinions on the matter are quite impassioned.

This key point comes straight from Greg Nuckols of Strengtheory. I highly recommend reading his article Training Based On Muscle Fiber Type: Are You Missing Out?⁶, which in large part inspired me during the writing of this post. Online searches for PFM materials and personal clinic experience have shown that there seem to be two major ways that PFM exercises are taught: long holds for Type I muscle fibers and “quick flicks” for Type II fibers. Regardless of what you learned in school, or what you read in some fitness magazine, research is very mixed (and passionately so) about how to train a specific muscle fiber type more effectively.

This is seen in one of the best examples taken from the Strengtheory article as seen below:

 

Type 1 and Type 2 fiber growth after training with 30-50% of 1rm vs. 75-90% of 1rm. As you can see, the growth of both fiber types was darn near identical for both loading zones⁷

While performing PFM training in the above ways is certainly a great start, is far from where training should stop.

Part 3: Variety is the Spice of Life

Regardless, the general recommendation is to keep training muscles with a variety of rep ranges; in other words, follow the rules of periodization and specificity.

Example of a periodization model⁹

The fact remains, like nearly every other muscle in the body, the PFM is split in relation to fiber type, so a variety of methods need to be used to provide a truly effective program for your patient. Gone are the days when telling your patient to “Do a Kegel, hold and relax it for 5 seconds, relax for 5, and repeat that 10 times” is the end all be all for PFM training. I’d like to inspire you to do more. One research article suggests that working up to a minimum of 50-60 sustained Kegels per day is enough to help 88% of the patients in their study to improve their issues with incontinence⁸. That may be enough for some, but it likely is not aggressive enough for many others.

But how can you apply this to Kegels? There’s only so many ways to vary a Kegel, right? Not necessarily.

Keep in mind, though, that a football team does not simply train at full capacity all year. There is periodization. During the off-season they build strength maximally and as they near the start of the season, strength work is decreased, skill work is increased, and the total volume of work declines slowly.

Part 4: Use it or Lose it.

Don’t be afraid to challenge your patients; Kegel isometrics are really only the beginning. Training this muscle requires the same amount of consideration as training any other muscle group. Rules of periodization should be followed. Variation for Kegels can be achieved by simply using Kegels concurrently with virtually any other movement.

Quinn Henoch, PT, DPT of Darkside Strength and Juggernaut Training Systems, often stresses the importance of progressing and incorporating core work and breathing through neuromuscular retraining by an athlete and using active, sport specific warm-ups to retrain posture. As we think about retraining a movement, let us envision a pyramid. At the bottom of the pyramid is the simple act of breathing and maintaining a neutral posture; if trained properly, proper breathing/posture/bracing should eventually be a reflexive act. At the top of the pyramid is skill work. Skill work can take many different forms. It might be the ability of a high school quarterback to maintain a neutral spine pre-snap and it might just as likely be the act of standing over the sink doing the dishes but maintaining that same neutral spine. The objective for each person should be the same: to maintain the proper position to decrease their risk of injury and stay in the most efficient position possible. Without the necessary work on the base of the pyramid, skill work at the top level will nearly always crumble as result. This idea transfers to the world of PFM very easily. Without a strong base ability with simple isometric Kegel holds or pulsing Kegels, maintaining a Kegel during a 200 kg front squat attempt is not going to be natural and reflexive.

Therefore, I have provided a simple chart, one column for a higher level athlete and one column for a patient that requires less complex activities. You may be surprised by the similarities. This is only meant to be a jumping off point.

	Higher Level	Lower Level
Static Stability	Maximal contraction isometric, progressing to multiple pulses for time
	Long isometric holds
	90-90 breathing getting the ribs down and bringing in an ab and glute isometric
Dynamic Stability	In hooklying, bring in the abs, Kegel, and glutes, then relax one of the aforementioned, hold the other two. Alternate which is released and which are held.
	Bring in all three, alternate arm movement. Then alternate leg movements, ie marching.
	Dead bug with holding all three isometrics, or pulsing Kegel.
	Psoas marching in the same fashion as above.
Specific muscle strengthening needed to aid in success with high level demands	Perform a sit to stand, from elevated position down to low position, holding the Kegel for one stand then relaxing on the sit, then vice versa	Half kneeling chop, either pulsing a Kegel or with a low grade sustained hold.
	Hip hinge	Reverse chop in a lunge
	Good morning	Overhead pressing with rear foot elevated while in a lunge
	KB DL from elevated box	Push Press
Highest Level Activity Needed	Being able to wash the dishes in the sink with pain not exceeding 1/10	Power Clean and Jerk

As you can see, it isn’t until the more skill specific areas that the programs start to diverge, and even then the exercise selections are pretty similar. These two programs had specific patients in mind, but in reviewing the selected exercises, it should be clear that each exercise builds on the last and slightly progresses to the end goal in mind.

Tomes of novels have been written on the subject of periodization, so I could do little to add to this topic. I will provide this one bit of advice, however: if nothing else, have a general idea of how your total volume of PFM work is being affected as you progress towards the patient’s end goal. Volume should build quickly at the beginning of PFM training with all the isometrics they can start doing. But as they near their goal, don’t forget that the PFM can fatigue, so taper off the simple stationary isometrics and utilize Kegels mostly during skill specific work.

One final area I would like to briefly touch on is this, I hope that readers will take away this realization if nothing else: incorporating Kegels into a patient’s exercise protocol really is pretty simple; it should require relatively little on your end as a therapist in terms of changing your plan of care for a patient. The biggest time commitment will be the 15 minutes you spend explaining the importance of PFM and how to perform the isometrics on the first session. After that, most of the coaching is complete, you simply have to cue them, “Abs, Kegels, Glutes, now… (fill in the blank with whatever exercise you are teaching).” Don’t just settle for good enough. Strive to be better. Your thoroughness could be life changing for a surprising number of your patients.

I would like to briefly thank Jennifer Hughes, PT, DPT of Atlanta Falcons Physical Therapy for originally inspiring me to utilize more PFM techniques on my clinical rotation and Quinn Henoch, PT, DPT for his contributions on Darkside Strength and Juggernaut which have motivated me to apply postural restoration techniques combined with pelvic floor strengthening principles with patients of such a wide variety.

For Part 1 of this series entitled "Pelvic PT Part 1: It's Not Just for Women," click here. Stay tuned for "Pelvic PT Part 3: Patients Who Don't Fit the Usual Boxes" about how sexual minorities fit into the physical therapy paradigm. 

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References

1. CrossFit. Do you pee during workouts? [Video]. YouTube. https://www.youtube.com/watch?v=UKzq1upNIgU. Published June 16, 2013.
2. Screenshot. In: PelvicGuru. Dear CrossFit and “CrossFit Gynecologist,” I’m Appalled. There’s Help For ‘Peeing’ During Workouts! [blog].
3. Sher T. Dear CrossFit and “CrossFit Gynecologist,” I’m Appalled. There’s Help For ‘Peeing’ During Workouts! PelvicGuru. https://pelvicguru.com/2013/06/22/dear-crossfit-and-crossfit-gynecologist-im-appalled-theres-help-for-peeing-during-workouts/. Published June 22, 2013.
4. Rogers M. In: mattiecakesssss. Instagram [application]. 2015.
5. Newman DK. Kegel exercise. Seek Wellness. http://www.seekwellness.com/incontinence/pelvic_floor_muscle_rehab.htm. Updated March 2013.
6. Nuckols G. Training Based On Muscle Fiber Type: Are You Missing Out? Strengtheory. http://strengtheory.com/muscle-fiber-type/. Published June 15, 2016.
7. Morton R, Oikawa S, Wavell C, et al. Neither load nor systemic hormones determine resistance training-mediated hypertrophy or strength gains in resistance-trained young men. J Appl Physiol. 2016:30. doi: 10.1152/japplphysiol.00154.2016.
8. Miller J, Aston-Miller J, DeLancey J. The Knack: Use of precisely-timed pelvic muscle contraction can reduce leakage in SUI. Neurol Urodyn. 1996;15:302-393.
9. Winer L. A simple guide to periodization for strength training. Breaking Muscle. http://breakingmuscle.com/strength-conditioning/a-simple-guide-to-periodization-for-strength-training. Publication date unknown. 

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About Dr. Matthew Schmidt, PT, DPT, CSCS

Matthew Schmidt is a physical therapist in Bedford, Texas at Riata Therapy Specialists. He splits his days working with outpatient neurological patients (MS, Parkinson’s, post-concussion, vertigo, etc.) and outpatient orthopedic patients. He enjoys participating as an amateur natural bodybuilder and applying what he has learned in the gym through personal experience to his varied client’s interests.

 “Non nobis solum nati sumus. Not for us alone are we born.” -Cicero