Tuesday 14 July 2015

Breathing and Proper Techniques for Pelvic Floor Rehabilitation

Pelvic floor rehabilitation employs techniques and procedures that aim at improving the function of the pelvic floor. The rehab program focusses on improving the strength and maintaining optimal tone of the pelvic floor.

The pelvic floor, also know as the pelvic diaphragm, is a sheet of muscles, ligaments and connective tissue that extends from the tail bone to the pubis. It forms the base of the body’s cylindrical core. The core is surrounded by abdominals and fascia, which serve alongside deep superficial back muscles. Diaphragm forms the dome of this core. The muscular mesh spans the entire pelvic outlet and separates the pelvic organs from the perineal region.

The pelvic floor musculature, by virtue of its attachments to the anal and bladder sphincters and vagina, is responsible for maintaining urinary and fecal continence, as well as vaginal tone during sexual intercourse. It supports the pelvic organs that include: the bladder, the intestine and the uterus. The pelvic floor offers counter pressure during activities that increase intra-abdominal pressure and bloating; thus, preventing organ prolapse. During labor, the pelvic floor offers resistance to the descending fetus causing it to rotate towards a vertex presentation during delivery.

Coordinated contraction and relaxation of the pelvic floor muscles is essential for a healthy back and lower body, as the muscles of the core are connected together. Pelvic floor dysfunction includes weak hypotonic muscles or tight hypertonic muscles. A weak pelvic floor cannot provide support to the pelvic organs and a tense muscle can be a source of constant pain. Pelvic floor dysfunction can result in bladder and bowel incontinence or urgency, organ prolapse, pain during intercourse, recurring unresolved low back pain, unspecified hip and pelvic pain. The pain can at times radiate to the groin, lower abdomen and down the legs. It can be severe enough to restrict your daily activities.

A dysfunctional pelvic floor requires a systematic approach to rehabilitation that will completely address the pelvic floor and the core. Techniques for pelvic floor rehabilitation include:

1. Deep breathing – The importance of breathing deep and slow has been stressed many times but has rarely been said in the context of pelvic floor dysfunction. Deep breathing or diaphragmatic breathing is an excellent way to alleviate muscle tension. When you breathe deeply your diaphragm moves up, your abdominal muscles move out, and the pelvic floor drops down in a relaxed manner. When you exhale, the diaphragm comes down, the abs move in, and the pelvic floor moves up. This coordinated muscle action is rarely done by a majority of people. Most of us breathe shallow and fast which does not allow the core to open up and the muscles to relax.

A few things to keep in mind while breathing deeply is to breathe in through the nose and exhale through the mouth with your lips pursed. Try and emanate a sound that resembles ‘S’ while breathing out and prolong it for as long as you can.

To begin with, come into a lying down posture with a pillow under the head and between the thighs. This keeps your knees slightly bent and relaxes the lower back. The room must be quiet and comfortable. Keep your hand on your belly. Close your eyes and breathe in deeply. Feel the belly move out during inhalation and move in during exhalation. Imagine that the air is entering your belly. The aim is to keep the upper chest muscles relaxed and let the diaphragm preform the action.

Once you have mastered diaphragmatic breathing exercises in a lying down position, practice them in sitting and standing positions. Do it for a minute initially and extend it to at least 5 minutes every hour. Diaphragmatic breathing should become our normal pattern of breathing.

In case you feel short of breath while doing this technique, stop and resume your normal breathing pattern. Repeat deep breathing after some time.

2. Watch your posture – The way you sit or stand affects the functioning of the core muscles. Slouched standing and sitting will curl your spine and your abdominals will be shortened. Therefore, your diaphragm is restricted and has less space to move. This increases the intra-abdominal posture which in turn increases the tension in the pelvic floor muscles.

Keeping your spine neutral will help you maintaining a normal lumbar curve. Keep your shoulders down and slightly retracted. The feet should be supported on the ground and hips and knees should be bent at right angles. Try to walk with your feet in parallel and avoid duck footedness and pointing your toes inward.

To stand correctly, each foot must be equally weighted. Try rocking forward and back a few times in order to find the right balance. Then, look straight ahead with your chin tucked in slightly and your shoulders down and back. This is the correct position for maintaining a normal lumbar curve.

Even while performing deep breathing, it is important to maintain a good posture so that diaphragm can traverse easily. A good posture while sitting or standing ensures that the deep abdominal muscles also come into play while doing diaphragmatic breathing. A good diaphragmatic movement will ensure relaxed pelvic floor muscles.

3. Kegel Exercises – These are a great way to strengthen weak and lax pelvic floor muscles. Hypotonic pelvic floor muscles cause urinary and fecal incontinence and bladder or uterine prolapse. The muscles become weak following a caesarean section, hysterectomy or any other abdominal surgery. Kegel exercises must be properly performed and learned under supervision, as incorrect technique can lead to pelvic floor dysfunction.

Start with this technique while passing urine. Try to stop the passage of urine for a few seconds and then resume. Slowly increase the hold count to 10 seconds. Once you get the feel of muscle contraction and relaxation, practice them in other positions too.

Do not contract your glutei or abs while doing this exercise. Concentrate only on the pelvic floor muscles. Do not hold your breath during this exercise, as it can increase your blood pressure. These exercises should not be overdone as the pelvic floor muscles are small and easily fatigued.

4. Biofeedback is a great way to ensure correct recruitment pattern of muscles during contraction. Uncoordinated muscle action can lead to muscle strain, even in the small pelvic floor muscles. This is usually done in the office settings, where you will be given an audio and visual feedback, while attempting to do a pelvic floor contraction. The doctor will encourage the correct pattern and help you identify the incorrect contraction. Biofeedback can also help you to distinguish between a tense and a relaxed state of muscles, which is very important for resolving the pelvic floor muscle tension.

5. Manual therapy can be applied to these small muscles as well. A doctor will first palpate the muscles to identify the areas of tension. Deep circular massage and myofascial release techniques can help break the fibrous bands that are the cause of the pain. Stretching of pelvic floor muscles can be achieved indirectly by performing hip adductor and hip extensor stretches. Combining manual therapy with warm packs to the perineal region offers immense relief in severe cases.

These techniques are very effective in resolving pelvic floor dysfunction and alleviating non-resolving back, hip and pelvic pain. So next time you get this pain, do not curl up. Instead lie down straight and visualise your pelvic floor muscles contract and relax. A healthy pelvic floor ensures a healthy core and a pain free body.