To Kegal or Not to Kegal

Last week we read a blog called Journey to Crunchville which talked about why we may not want to do kegels.  What?!  This confused me, werent we always talking about doing kegals and more and more kegals?  I found the article interesting and enjoyed the read but wanted to reach out to my trusted friend and PT on this issue.  Below, Alicia Willoughby writes a thoughtful response using her knowledge and experience as a physical therapist:

The article “Why you should stop doing kegals” brings up a lot of controversy for me, as a physical therapist, who advocates pelvic floor stabilization for all of my patients, and especially my patients who are moms.   The major issue I have with this article is the posture that the author describes.  Imagine that your pelvis is a bowl of water, and if you tuck your pelvis (bring your tailbone between your legs), you will spill the water out the back of your pelvic bowl, and if you tilt your pelvis forward (sticking your butt out), you will spill the water out the front of the bowl.  The author states that “Most women have become “tuckers””, which spills the water out the back of the pelvis.  This is the OPPOSITE posture of the vast majority of women that I work with in my physical therapy practice, especially mothers. 

When you are pregnant, the growing belly starts to pull the center of gravity forward, which tips your pelvis forward.  Then mom hyper extends her knees to prevent self from falling forward.  The pelvic floor gets stretched out as baby’s weight is being held up by the muscles.  The muscles and fascia in your abdomen get stretched out as baby grows, which compromises your ability to keep your proper posture.  Then baby comes out and you are left with stretched out muscles and fascia in the front of your body and a pelvic floor that was just stretched out from vaginal birth.  Cesarean birth moms do not escape pelvic floor effects, in that many women go through a certain amount of pushing prior to the cesarean.  Most women do not learn how to properly engage their core muscles (pelvic floor + deep abdominals) after having their babies so they still stand like they are pregnant with their pelvis tipped forward, belly hanging out.  The result of this posture over time is specific pain in the pelvis and/or low back, but also pain in the upper body from compensating for a weak core.

I not only observe this posture in the clinical setting but also in myself and all of my friends who are mommies.   Test yourself: stand up and let your body go where it wants to go to stand still.  Then take note of where your pelvis is, are your knees bent or locked straight.  Add the weight of holding a baby on top of that posture and you can see how it gets ugly real fast.  High-heels exaggerate the anterior pelvic posture because it hyper extends your knees and push you forward with your weight on the balls of your feet. The author states that high heels further the tucked posture, which I don’t agree with.   I’m not sure where this author is basing her information that women have become “tuckers”, because it’s definitely not what I see in my practice and not what my mentors, who have been treating the body for 25 years, have seen.  Yes, some have become tuckers, but the majority of women and the vast majority of mothers are forward tipped in their pelvis.  The author is a biomechanical scientist, but I’m not sure about her experience in the clinical setting.

What the anterior pelvic position tells us is that the pelvic floor is NOT being tightened because the tailbone is being able to move out and away from the pelvic bowl.  The pelvic floor muscles connect from the pubic bone back to the tailbone and form a hammock which hold up your organs and control your vagina and anus openings.   I teach women how to engage and connect again to their pelvic floor muscles to pull their tailbones back into their pelvis and bring their pelvis back to neutral.  By bringing the pelvis to neutral, the spine, shoulder and neck will be able to easily elongate and come to sit in the proper position on top of the pelvis.  After being pregnant and giving birth, the brain has lost most of its connection with the pelvic floor and with voluntary effort and training, the connection can be made again to activate these muscles and stabilize the body.  Once a woman can do this, we can then move on to reconnecting with the deep abdominal muscles which provide anterior support to our mommy tummies and then on to the gluts, which we should be using to further stabilize and power our bodies.

I do agree with the author about the issue of poor gluteus (butt muscles) activation in the general population.  Because we all sit too much, we don’t use our gluts to stabilize.  And the relationship of the gluts to the rest of the body is one in which they cannot work properly when the pelvis is not in the optimal position.  So whether your pelvis is tilted forward or backwards, the gluts will not work properly to stabilize the pelvis and spine. 

I should also add that pelvic floor activation should never cause any pain, so if someone does have pain while activating their pelvic floor, they need to be evaluated by a pelvic floor physical therapist, sometimes called a Women’s Health PT, who does internal assessments, to see if they have any adhesions of scar tissue or muscles that are spasmed.  You can find a pelvic floor PT here.

Alicia Willoughby is a physical therapist at Essential Balance Physical Therapy in Corte Madera, Ca.  She is also a mom to 16 month old Charlotte.   She considers the relationship of the whole body when treating a patient’s specific discomfort and is passionate about working with the pregnant and postpartum population.

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