Beyond Kegels: 3 Types of Pelvic Floor Physical Therapy Treatment
There’s a common misconception that pelvic floor therapy = kegels. I hear time and time again, “Why would anyone need pelvic floor therapy? Why can’t they just do 100 kegels at home?” or “I’ve been doing my kegels and I’m still not better, what’s wrong with me?” 2 things:
Yes, kegels (or pelvic floor muscle contractions) CAN be a PART of pelvic floor physical therapy. But they may or may not be what your body actually needs. Frequently, the pelvic floor muscles are too tense/tight and doing kegels will actually make your symptoms worse.
No, kegels are not all that we do. In fact, if your provider or therapist just tells you to do kegels and nothing else, you need to find a new provider. They are doing you a disservice.
The pelvic floor is part of a much larger picture (YOU)! Remember…you? A real person with stress, physical demands on your body, a history of chronic ankle sprains or low back pain, etc? No two people are the same, so no two treatments will be the same. In order to treat you as a whole person with pelvic floor symptoms, a whole body approach to treatment should be utilized. This approach is divided into 3 separate types of pelvic floor physical therapy treatments:
Direct
Indirect
the Nervous System
Graphic made by Jennifer Dickinson, PT, DPT of Mid-Missouri Pelvic Health
Direct Treatment
This is exactly what it sounds like. Treatment directly on the pelvic floor. This can be done internally via the vaginal or anal opening or externally to the to tailbone or perineum. If you are uncomfortable with any internal assessment or treatment (totally valid), just have that conversation with your therapist. Kegels (or pelvic floor strengthening) would fall into this category. This can also include homework of dilator training, use of a pelvic wand, or perineal stretching for labor and delivery prep.
If you've been to pelvic floor therapy and they say they "don't do internal" or "don't need to do internal" work, chances are high that they are not actually trained in how to effectively treat the pelvic floor. Unfortunately, this often happens with clinics that say they offer pelvic floor therapy as a way to market to new patients.
Indirect Treatment:
Indirect treatment involves manual therapy or exercise to body parts that attach onto the pelvic floor or have direct influence on the pelvic floor. Therapy can include stretching, strengthening, or manual therapy to muscles, joints, connective tissue, or organs in other parts of the body.
This includes, but is not limited to:
spine
ribs
hips
ankle/foot (yes…there is a connection between your ankles/feet and your pelvic floor)
abdominal/chest/back scar tissue
inner thighs
diaphragm
core
bladder or bowels
AND MORE!
Nothing in your body moves in isolation. All of the above body parts have strong influence on the pelvic floor and can often be the culprit as to why the pelvic floor is misbehaving the way that it is.
Nervous System
I know this next section may sound a little “woo woo”, but stay with me. I promise it’s all connected. :) Your nervous system is an incredibly dynamic and complex system that has many influences within your body. I’m going to over simplify some things for the sake of clarity. So if you’re a neuroanatomy/neurophysiology nerd, please forgive me for not going into every detail. I’m only going to focus on the information that is pertinent to pelvic floor issues.
Your body is really good at adjusting things within your body to maintain what’s called “homeostasis” or equilibrium. I often use the analogy of a thermostat in your house (either the AC or the heat comes on to keep your house at it’s “set” temperature). You have a spectrum of available temperatures you can set your thermostat to and depending on what’s going on inside and the weather outside your home, you may need to adjust the temperature to keep you comfortable. Your hormones and nervous system are in charge of making those adjustments.
Your autonomic nervous system (see picture below) is broken down into 2 categories: your sympathetic (think fight or flight) vs parasympathetic (think rest and digest) systems.
Isn’t science fun?! Ok…real life example time. Imagine that you are walking down the street and encounter a tiger. Your body is going to make some adjustments to help you run away from that threat to save your life. Your sympathetic (fight or flight) system will pump adrenaline, increase your heart rate and blood pressure, dilate your pupils, slow down digestion, and increase muscle tension (especially your pelvic floor) to keep you safe. Now, our bodies were designed to react to all stress (physical danger, exercise, emotional stress, etc) the same way. So someone who is constantly stressed out and in a state of "fight or flight" is going to have a lot of tension in her pelvic floor. Your body is getting ready to attack whatever has you so stressed out. This can contribute to pelvic pain, but can also be contributing to leakage (a blog for another day).
Your parasympathetic (rest and digest) system does the complete opposite. It aids in digestion, lowers blood pressure, helps muscles relax, and helps you fall asleep. Lots of important things happen down at this end of the spectrum. Your body is going to feel and function very differently if you’re stressed vs after Thanksgiving dinner. Being able to turn the thermostat (nervous system) both up AND down at appropriate times is key to optimal pelvic floor function.
You also have TONS of nerves in your body (see above picture with blue lines) and many of them function in or pass through your pelvic floor (see above picture with yellow nerves) to get to their final destination. These nerves should not be ignored with pelvic floor physical therapy. Often times the nervous system is the missing piece. You can do all the stretching and strengthening you want, but if you don't adjust the "thermostat" or makes sure your nerves can do their job, your pelvic floor will go right back to where it was before (no symptom improvement).
Moral of the story is...
Pelvic floor therapy is (or at least SHOULD be) whole-body, not just kegels. Mid-Missouri Pelvic Health prioritizes a multi-pronged approach to pelvic floor physical therapy. Your therapist should both zoom in to your pelvic floor function, but also zoom out to assess the other parts of your body and your nervous system to make meaningful change.
