Pelvic Organ Support

Pelvic organ support

In Pilates the ‘Core’ or ‘Powerhouse’ is often given a location and in true Pilates form a visualisation.

The visualisation I use is a tin can, the walls are the Transverses Abdominous, the connecting seam at the back of the can is the spine, the lid is the diaphragm, and the base is the pelvic floor. To have a strong, stable ‘core’ all of the can must be healthy and connected.

We use breath and positioning to engage our core but often resort to vague pelvic floor exercises to complete the structure of our imaginary can. Many clients have little idea where their pelvic floor is, how to connect with it and what its purpose is. Teachers pay lip service to ‘doing our pelvic floor exercises’ are we really giving our clients the best advice or help.

In a healthy uninjured body all the ‘core’ muscles co-exist and work in harmony with each other. You do not need to consciously connect to engage, but life gets in the way and particularly for women who have carried and given birth to children, the pelvic floor and pelvic organ support system is compromised, trauma and injury is somehow accepted as part of the birthing process. The stigma of incontinence however slight is now assuaged by adverts for Tena lady pads on prime TV slots. ‘Little ops’ are given regularly to sort out ‘the problem’ sadly many do not sort out the problem at all and are followed by more ’little ops’.

Pelvic support and a poor relationship with the pelvic floor is also a male issue, often over recruitment will be the cause of problems.

What can we, as Pilates teachers, do? The odd squeeze of an overball between the thighs may seem to answer the question but is it really helping the pelvic organ support question? The forced couple relationship between adductors and the pelvic floor will certainly get to the right location but is prone the best position to exercise the pelvic floor? How do we serve the over recruiters?

I am grateful to Janine who leant me a book written by Christine Ann Kent called ‘Saving the whole woman’, it is full of information on natural alternatives to surgery for pelvic organ prolapse and urinary incontinence. Christine runs a training course on-line which provides huge amounts of information, statistics and advice as well as suggestions for good pelvic organ support. The book is not comfortable reading, but did give me a starting point. I also looked at the fascial anatomy of the pelvic floor and am grateful to Divo Muller of the Fascial Fitness Association for the information she provided. My clients have all been ‘hip hoping’, swinging legs, releasing fascial structures and finding pelvic floor muscles all week, however the most important message I have been giving out is that posture and pelvic positioning is key to good pelvic organ support both pre and post trauma and certainly for the ageing process.

Pilates is perfect for regaining good postural habits.

As I am writing this I am aware that my pelvis is tipped under and I am sitting on my tailbone. My lower back is in a slumped position, my front line has collapsed and my head is forward with the chin tilted upward, all of which is providing no support for my pelvic organs. In the short term I am finding it reasonably comfortable but If I sat like this all day every day this would become a habit and become part of my posture, over months/years this habitual posture would become so set that it would become structural in nature. To change this would take effort and time. Luckily it’s almost time for my next client and I will move about, demonstrate exercises, stand, sit, jump, climb and engage with my body and my body will respond by not getting set in the slumped computer posture. However If I worked in an office all day with very little opportunity to walk about, drive home or sit on a train and then sit in front of the TV all evening, I am repeating the posture over and over again, my body would react by making it easier for me to achieve the shape of the posture and change it’s fascial structure according to the loads habitually placed upon it.

One hour in a Pilates class per week will not be enough to counter a week sat in front of a computer, a habitual pattern can only be changed by a regular intention to change our posture. Hopefully Pilates teachers can bring postural awareness to their clients and can provide incentive to undertake a bit of homework and to look at ways to improve posture on a daily basis.

Why is posture so important for pelvic organ support? Another visulisation is needed:

Imagine your pelvis is a house with two exterior supporting walls and a couple of interior supporting walls, two floors and some non-weight bearing partitions a foundation and a roof. If all is well the house will stand and provide shelter for everything inside it.

However:

If one of the internal supporting walls is removed without adequate propping then the house could collapse inward.

If the part of the foundations fail the house would tilt, all the contents slide to one side.

If the walls are too thin, too weak or crooked they could not support the internal partitions, the floors and the roof.

All of these and many more scenarios can be seen in the pelvis, removal of the broad ligament when the womb is removed, injury to the pelvic floor, poor abdominal and lumber muscle strength etc

By paying attention to pelvic posture whilst standing and sitting will help. Exercising in a position, which creates support for the internal pelvic organs will build strength in the abdominal wall.

The Sitz bones (Ischial tuberosity) can be considered the heel of the body, it is where our weight should be resting when seated. Most of us sit behind our sitz bones or on one side only, tilting our pelvis, sliding our pelvic organs about, and setting up intra-abdominal pressures. If we exercise in this non-optimal position we are strengthening our muscles to keep the pelvis in a non-optimal position.

In prone, where most Pilates exercises are undertaken, particularly for beginners, the pelvis has to deal with gravity and habitual patterns of movement ( all those aerobic classes, crunchies and flat back instructions). Proper direction to achieve a neutral pelvis and to maintain a neutral pelvis where appropriate is essential, I use a prop to help the client to maintain position by giving a proprioceptive cue. I have also started to introduce connective tissue stretches to release the pelvis and allow it to lie on the bed easily (several ligaments attach to the coccyx, sitz bones and pubic bone). Some clients may never achieve neutral on their own in prone. In my opinion there is no point building ‘core’ stability in position that is not functional or transferable to everyday living. Seated, standing or kneeling are better for pelvic postural position training, the abdominal wall is there to support the pelvic organs, the gentle round belly of a woman particularly post childbirth is natural and should be encouraged, not sucked in and removing the natural lumber curve. 

A strong abdominal wall is not necessarily a completely flat abdominal wall, whatever the tabloid newspapers say.

Fascially the pelvic floor has layers of fascial tissue contiguous with the fascial sheets of the abdominal organs, muscles and the body suit just under the skin. Each layer has fibers running in different directions creating a hammock. There are also ligaments, which support the various openings. Some movement models have the pelvic floor as part of a deep front line, contiguous with the diaphragms of the foot, lower leg, Diaphragm and throat (Anatomy trains). Other movement models suggest that the pelvic floor is a change in direction of continuous muscles, from front to back, left to right etc.(Philip Beech).

All agree that it is a complex area, this makes it hard to understand and to exercise. We have many pelvic floor exercises for the muscles of the pelvic floor; my favourite is one that involves a boat and a fisherman. Fascia responds to vibrations and rebound and recoil movements. It is important to hydrate this tissue and allow for glide between the fascial layers, knowing this can help to reach this region of the body, however direct fascial release techniques with rollers or balls is not recommended for everyone. By creating healthy fascial tissue elsewhere in the body will effect the pelvic floor, a good posture will allow the structures which help support the pelvic organs to be strong and stable, pelvic floor health is truly a whole body issue.

This week I am being very strict on the seated position, making sure that the clients posture in sitting is good, releasing the pelvic structure, breath, keeping a 90 degree angle or less at the hip (greater than 90 degrees, in any orientation, can create a posterior pull on the organs, stressing the structures of organ support (Christine Kent)). We will be using the chair, reformer and barrel, propping if necessary, making movements small and focused.

As Christmas is on the horizon, everyone will be sitting a lot, in cars, at tables and on sofas, we will probably be eating too much and our pelvic floors will be tested as we dance at party’s or join the kids on the trampoline. This is a great time to remind everyone of the importance of posture, it will also make us look great in our Christmas outfits.

Tracey Mellor

December 2016