Everyone knows you should activate your pelvic floor...but why?
You do your Kegels but you still leak urine...why?
You saw a Pelvic Floor Physiotherapist...but you still want to keep squatting 220lbs (100kg)...did they teach you how?
In this post, I will be using Maria Hogan as an example. Maria is one of the "old guard" of CrossFit in Australia. She is an ex-rower who competed at a high level. She had a 150kg (330lbs) deadlift, 112kg (246.5lbs) back squat, 83kg (182.5lbs) power clean and 64kg (141lbs) snatch...at 3 months post partum! She is married to 3-time CrossFit Games athlete Chris Hogan and runs CrossFit 121 with Chris in Melbourne, Australia.
All of these are fair questions. I hope to briefly explain how to combine the good work that Pelvic Floor therapists have done over the years and combine it with the knowledge I have gained in the Musculoskeletal and Sports Physiotherapy field I have worked in.
For more information on the Pelvic Floor, I have written this one for CrossFitters and as a general explanation.
First Things First
If you have ANY incontinence (leaking of urine or faeces), ANY prolpase (internal organs bulging into your vagina) or ANY pelvic pain, please go see your doctor, gynaecologist or Pelvic Floor Physiotherapist (often called Continence and Women's Health Physiotherapists...but they treat men too!). These issues are too serious to be left to chance and if you are lifting or doing high intensity exercise, you need to know the status of your pelvic health. Google your country's Physical Therapy / Physiotherapy Association and search for a suitable physiotherapist. If you can't find one, just contact me below or search twitter for #pelvicmafia to ask there. I will provide links at the bottom of the page of therapists that have helped educate me over the years.
Why Activate Your Pelvic Floor?
If you have known me long enough, I don't actually like specific activation of muscles as a cue. I feel it slows you down during performance. You don't see a running back think about his pelvic floor before he hits the hole at top speed. I can pretty much guarantee that an Olympic Weightlifter is not thinking about their pelvic floor when going for the Gold medal lift at the Olympics.
Having said that, the research seems to suggest that using a preparatory pelvic floor contraction can help with pelvic floor problems. I have found that this is the case more often than not but I am very wary of "overcooking" the cue or having patients who develop overactive pelvic floors.
Still, it is better to know how to do it properly than not.
I teach this in many different ways because I observe the effect of my words and how it affects your body's responses. I am basically looking to see you respond in a "good way" or a "bad way".
Generally speaking, this is about right...
1. Take a breath in and then breathe out. This is important because we know from research that breathing out usually coordinates with a gentle pelvic floor contraction. As you try step 2, breathe out.
2. Can you tighten the back passage? Most people can because weakness back here is socially awkward. OK, tighten back there but not too much. I usually say "squeeze as hard as you can, then halve it, then halve it again". Remember to breathe in, breathe out and as you breathe out, do the squeeze. You are allowed to hold the squeeze and keep breathing - don't pass out...that would be embarrassing!
3. Ok, now take that tension and "zip up" your front passage/s - you can spread the pressure to include where you pee from.
4. Now, check to see that the pressure is going "inside" your body, not pushing out. I like the "Michael Jackson check" - you hold onto your genitals like MJ used to do and do the contraction. If you feel pressure increasing into your fingers/hand, we call that "bearing down"...we don't want that. We want a slight pressure away from your fingers/hand.
That's it! I have plenty of variations and so many cues it isn't funny. Ironically enough, cues that involve sex seem to be quite successful but I try lots of conservative options before we get to that!
That contraction is often referred to as Kegel exercises. Doing it before lifting is known as "The Knack".
Why Do You Still Leak Even If You Do The Knack and Your Kegels?
There are many reasons why and it is not the purpose of this article to go into them all...go see a pelvic floor therapist to get a proper diagnosis. I like to work with a pelvic floor therapist because there is some information I just cannot get without an internal examination. The information they give me helps me help you lift better...or maybe help you consider why lifting/certain exercise isn't suitable for you.
I see a lot of athletes in a gym setting. Most of them that I see have a coordination problem of some kind.
Quite often they are doing the Kegel but are not doing it correctly. Or they are doing them correctly but not SPREADING THE LOAD AROUND...this is what I want to teach in this article.
Intra Abdominal Pressure (IAP), The Valsalva Manoeuver (VM) and Bracing For A Lift - What Is Out There
We know that IAP helps to support our bodies when we lift. We know from research that the heavier the load gets or if we lift lighter loads to fatigue, we will basically hold our breath and increase the IAP to help us lift. This is normal and natural.
I am going to guess that most pelvic floor therapists DO NOT LIKE raised IAPs. This has been my personal experience and most blogs warn women of the dangers of increased IAP and recommend you don't do sit ups or leg raises (despite evidence saying that standing up from a chair has higher pressures...but I digress).
Lots and lots of lifting websites, forums, blogs and training sites/manuals etc all extol the virtues of high IAP using the VM. but quite often they teach a "belly breath" and directing pressure into the abdominal wall. This often results in men having bellies that look like they are pregnant. This is not ideal!
Lifting with a belt also increases the IAP by bracing the back, sides and front of the abdomen...but what about the top (diaphragm) and bottom (pelvic floor) of the abdominal canister? What often happens is that the very strong diaphragm can hold its own and so the pressure gets directed downwards into the pelvic floor. This too is not ideal!
Before I go into how to do things properly, let me tell you about Maria Hogan (Maria has given me permission to tell you her story and use the videos we took).
Maria Hogan's Case
Maria is the co-owner of CrossFit 121 (www.crossfit121.com.au) with her husband Chris Hogan (who has gone to the CrossFit Games 3 times as well as being an excellent all-round athlete). As I wrote above, she is a former high-level rower that has been doing CrossFit for quite some time (7 years or so) and has recently had a baby 6 months ago. She had her 6 week exam from her obstetrician who cleared her back to training and lifting and told her to keep doing her pelvic floor exercises. We can only assume that she didn't have prolapse - she doesn't have any symptoms of it. Her only pelvic floor symptom is some mild stress urinary incontinence on the descent during a pullup and on the change of direction during movements like a push press. During the classically pelvic-floor-difficult movements of double under skipping and box jumps, she is fine. She can back squat 112kg and deadlift 150kg - in case you don't know, these are good numbers for a 3 months post partum mother!
In the film below, she does her usual push presses. At the end of the video, she says it is "ok" with a shrug but it doesn't feel right.
In the next part of the same video, I cue the technique of spreading the pressure around. I will explain it now. I then go on to teach her how to "cycle faster" through the movement using breathing techniques.
Step 1: Set The Pelvic Floor
Basically, you want to do what I described above - breathe in, breathe out, do a gentle contraction zipping up from the back passage to the front passage/s and ensuring it "lifts" up inside you.
Step 2: Set the Pressure - Spread It Around
Once you have Step 1 done, you take another breath in - often fairly big breath. This one you hold. Now, ideally, the pressure should be felt around your ribs on the front, back and sides. You should also be able to feel the pressure in the back and in your tummy muscles. Ideally, you shouldn't be bearing down onto the pelvic floor.
You can actually play with the pressure a bit. Take a breath in and put the pressure into your tummy - it will tighten up more. You can move that pressure to your back - those muscles will tense more. You can spread it around your ribs at the front, the sides or the back...Now try it so you can spread it around evenly.
This step is the key to my technique. I have not seen, heard or found anyone that teaches this method (I am sure someone out there does though)...
OK, once you have that down, you can start setting things up right.
Step 3: Breathing
Once you have step 1 and 2 done, I like to inhale when lowering the weight and exhale or hold and then exhale when pushing a weight. Some people like to do the opposite. I don't care to be honest. Just don't hold your breath the whole time or you might faint or basically have to stop early (in CrossFit, we try to complete as much work as quickly as possible so stopping just slows us down - breathe and you won't have to stop so quickly!)
Maria was unable to do even just the 15kg bar without feeling some discomfort in her pelvic floor - it wasn't painful, it just didn't feel right. Using the techniques above, she was able to feel a lot more confident in moving quickly. She is a strong woman so the repeated push presses at 15kg are no trouble to her strength but they were to how she felt in her pelvic floor. By doing steps 1-3, Maria was able to do 10 quick reps of push press with the bar without symptoms.
Sometimes, you have to breathe in the whole time for 1 rep and breathe out the whole time on one rep - that is easy to do when it is light but when it gets heavier or you get tired, you are going to have to regulate your breathing each rep.
When you get ok at that, you then progress to timing breathing and supporting with pelvic floor contractions (usually a pelvic floor contraction when breathing out) and holding your breath as above!
1. Doing your Kegels and The Knack is good - keep doing it
2. Pressure (IAP) is not the enemy - we can use this pressure to lift more weight. Learning how to regulate the pressure around the body is important - spread it around!
3. See a Pelvic Floor Physical Therapist / Physiotherapist to ensure you are safe to lift. If you have pelvic floor damage, prolapse or pelvic pain, lifting may not be appropriate for you...if you still want to lift, then find out the facts and make an adult decision.
I will try to make another video teaching this idea about spreading the pressure around - don't give up on it if you can't get it right...you often need someone to teach you correctly.
Have a play with these ideas and let me know how you get on.