Should we talk about the pelvic floor in movement?

A healthy, resilient pelvic floor is crucial for good movement, no matter how you move your body. Our pelvic floor is essential for supporting our pelvic organs (bladder, intestines, and in women, the uterus), controlling continence, our sexual functions, facilitating childbirth, core stability and respiratory function.

For these reasons and more, the pelvic floor has been described and cued in both pilates and yoga for decades, and perhaps because of this both practices are often considered a safe next step for those returning to movement after physiotherapy rehabilitation, surgery, or postpartum.

That said, there’s a bit of debate within the movement industry about whether the pelvic floor muscles should be cued in group classes, or whether pelvic floor cueing is an effective tool at all - some reasons for this include:

• Due to the variation in individual needs, some individuals may need to strengthen these muscles, whilst others may need to focus on relaxation or proper coordination. Without a thorough understanding of a student’s specific pelvic health status, generalised activation cues might not be appropriate;

• limitations in our scope of practice as movement professionals in being able to assess for pelvic floor dysfunction (without referring to a pelvic floor physiotherapist or doctor for clinical testing);

• the lack of in-depth pelvic floor training within our industries (particularly for group class instructors) to adequately describe and cue the musculature and its functions, as well as understand the appropriate movement approach for a particular condition;

• cueing internal musculature can sometimes be confusing to clients and in some cases misconstrued, potentially leading to faulty activation patterns, which might worsen existing conditions or create new issues;

• constantly cueing the pelvic floor muscles can lead to over activation, especially if students do not fully relax these muscles between contractions. This can contribute to conditions such as pelvic floor muscle tension or hypertonicity, which may result in pain or dysfunction;

• cueing pelvic floor has its own inherent difficulties in correcting, due to the internal nature of the anatomy we’re working with, and the obvious professional limitations in offering tactile feedback.

  
  

Anatomically, the pelvic floor consists of a group of muscles, ligaments, and connective tissues that form a supportive and highly functional hammock within the pelvic bowl. The levator ani muscles are the largest part of the pelvic floor, and include:

• pubococcygeus: this muscle stretches from the pubic bone to the coccyx and plays a significant role in controlling urine flow and contracting during orgasm;

• puborectalis: a U-shaped muscle that wraps around the rectum and plays a crucial role in maintaining fecal continence by creating a kink at the junction between the rectum and anus;

• iliococcygeus: this muscle extends from the ilium (part of the hip bone) to the coccyx and helps support the pelvic organs;

• coccygeus (or ischiococcygeus): this small muscle extends from the ischial spine (bony projections on the posterior hip bones) to the coccyx, supporting the pelvic organs and stabilising the sacrum.

  
  

It’s also made up of the perineal body, the external urethral and anal sphincters, the fascia and ligaments, and the urogenital diaphragm. Working functionally together, the pelvic floor is a complex and dynamic structure that supports the pelvic organs, maintains continence, facilitates childbirth, and contributes to sexual function.

It critically works with other core muscles - including transverse and rectus abdominis, internal and external obliques, multifidus, erector spinae, quadratus lumborum and the diaphragm - to stabilise and support the pelvis and lower spine.

When you think about all of these elements together, its a lot to cue! The pelvic floor is an internal muscle group that can be challenging to identify or control. It can be understandable why some professionals might argue against cueing the pelvic floor during movement instruction, particularly in general fitness or Pilates classes.

But if we’re not talking about the pelvic floor in the movement space - when we’re educating clients about their physical form and developing their self-awareness - then when are we talking about it?

It’s generally agreed that pelvic floor dysfunction is not an inevitable consequence of ageing, pregnancy or childbirth, and most pelvic floor conditions are treatable.

Unfortunately, most of the time, it’s considered an awkward subject to discuss publicly, and as pelvic floor dysfunction increases in an individual, so does embarrassment, shame and the lack of inclination to discuss and address concerns with others.

This is alarming when you consider that one in four women and one in ten men will experience pelvic floor dysfunction at some point in their lives, including conditions such as urinary and fecal incontinence, pelvic organ prolapse, and chronic pelvic pain. These conditions can be utterly crippling in how they affect one’s quality of life, and yet the taboos around discussing pelvic floor health somehow seem a greater risk.

So, should we talk about the pelvic floor in movement?

If the only time we’re talking about pelvic floor health is with our pelvic floor physios and GPs, does this mean we’re reducing our already quite limited opportunities for life-changing conversations that could help in both addressing and preventing pelvic floor dysfunction?

Whether you are a group fitness instructor, personal trainer or clinical professional, I believe we all have a responsibility within our industries to help our clients to understand their bodies better, to help direct our clients towards appropriate resources and skilled practitioners when things fall outside of our scope of practice, and to teach our clients not just to move - but to consider why movement and awareness together are transformative.

We also have a responsibility to keep up to date with what the latest science tells us - and most of the flack that comes with pelvic floor cueing originates from the effects of what was previously considered the correct approach - cueing pelvic floor activation only.

Whilst most people think of kegels ie. pelvic floor activation when addressing pelvic floor health, they don’t often think of what is equally important - releasing the pelvic floor.

Like a trampoline, a healthy and resilient pelvic floor needs full capacity to rebound after impact - pull the connections too tight, and it’s ability to rebound is limited, making impact a painful experience. Let the trampoline sag, and the ability to withstand weight and force is greatly reduced.

A healthy pelvic floor, much like a good-working-order trampoline, exists in an ideal range of tensile strength, with the capacity to return to this state after withstanding forces - for a pelvic floor, these impact forces include running, jumping, sneezing, coughing, pregnancy and childbirth, sex, and defecating.

A key to balancing the tensile strength of the pelvic floor is to consider breath and pelvic floor synchronisation. As the pelvic floor naturally works in sync with the breath, understanding this rhythm is incredibly useful. When we inhale, the diaphragm descends, and the pelvic floor gently lowers. On the exhale, the diaphragm rises, and the pelvic floor in turn naturally lifts.

For most people, the only time we really get a chance to unpack this is in the lead-up to childbirth, when breathing exercises to expand and contract the pelvic floor are encouraged to allow for greater control of the pelvic floor (as well as relaxing body and mind) during childbirth.

One of the strengths of our practice in both a pilates and yoga context is the emphasis on breath. Connecting breath into movement is one of the most powerful ways we can introduce pelvic floor control into our practice, regardless of what moves you.

Whilst it is outside of our scope of practice to diagnose or directly treat pelvic floor conditions, cueing the pelvic floor alongside breath during movement can be both beneficial and educational when done correctly and in appropriate contexts:

• Our job as movement educators is to help people understand their bodies, including the how and why of movement. Not only is it empowering for the client to understand their own anatomy and functions, but it can greatly deepen overall body awareness and muscular coordination;

• Group classes provide a unique opportunity to educate clients about their pelvic health in a supportive environment. Group settings are often where people are most open to learning about their bodies. By incorporating pelvic floor cueing into classes, we can normalize discussions about pelvic health, reduce stigma, and encourage clients to seek specialised care if they suspect a problem;

• Proactively addressing pelvic floor health in classes can prevent future problems. Many pelvic floor issues, like incontinence or prolapse, are preventable with early intervention and proper exercise. Cueing in group settings can be a form of preventive health care, giving clients the tools they need before they even realize they might need them. This proactive approach can be especially beneficial in settings where clients may not have immediate access to specialized care.

  
  

As movement practitioners, we can set our clients up for success by teaching them healthy body mechanics and creating a safe space for conversations about pelvic floor health, using inclusive language for all genders and giving the cues we use greater consideration.

If you’re cueing pelvic floor engagement 1:1 with a client, you might want to consider some of the following tips:

• Focus on the breath - coordinating pelvic floor engagement with the breath, especially on the exhalation, will help the client to integrate the pelvic floor and core in more dynamic movements.

• Keep things subtle - the pelvic floor muscles, whilst robust, only need a gentle contraction to be effective. Emphasising slow, gentle and controlled movements encourages awareness and coordination and avoids overstimulation of the muscles.

• Respect privacy - be mindful of personal boundaries and comfort levels. Ensure that cues are inclusive and respectful.

• Avoid over-cueing - balance pelvic floor cues with overall body awareness and relaxation.

Whilst the benefits are significant, it is essential that pelvic floor cueing is done thoughtfully and with respect to individual differences and needs. Proper instruction, context, and sensitivity can make these cues a valuable addition to any movement practice.

I’d love to hear your thoughts - where do you sit in the debate? Have you experienced challenges or breakthroughs with pelvic floor exercises? Let me know in the comments below.

For my female-bodied clients, you might be interested in an e-book I produced with The Main Method a few years ago called “The Main Method to your Best Pelvic Floor”, which talks through the steps to creating a healthy and resilient pelvic floor at home. You can buy it via my online shop here.