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

Hyper mobile?

Hyper mobile?

I maintain that a sign of a good training course is that it stimulates a change in thought patterns. Last week I was blown away by Yin Yoga, I still am. However there are other aspects of the training provided by The Yoga People which have really impressed me, and if I ever design a training programme, I will ‘borrow’ this practical session.

The area of study is functional anatomy, and we spent a considerable amount of time comparing the differences as well as the similarities in the shape and construction of the pelvis, using the 30 people in the room as a study population.

This little bit of research revealed an interesting and blindingly obvious result,

EVERYONE IS DIFFERENT.

The purpose of this study is to bring home the importance that, as everyone is unique in pelvic shape and form, and unique in movement history and use, and individual in every other way, it is impossible that one pose, movement or asana (it is yoga) can be achieved in the same way for everyone- obvious isn’t it. So why do trainings and teachers, even with huge amounts of experience insist that a pose is only correct (I hate that term) if it looks perfect? Why do teachers force legs wider, turn hips square, push bodies down, make forceful adjustments to achieve the perfect (who defines perfect?) shape, and why is achieving that perfect shape so important. I suspect it’s aesthetics, it looks beautiful, and ease and grace are often used to describe someone who has a perfect practice, all very judgmental and not very yogic!!

I’m not really knocking yoga, but I am critisising teaching that places clients, who are ‘naturally’ bendy ahead of the ones who struggle to long sit or drop into splits. How many clients have tried yoga only to be disillusioned because they are not ‘doing it right’ can’t bind or do inversions or have to use a block! It seems to me that some yoga classes are full of people who do not need more flexibility, how many participants know the original reason why yoga asana were performed? Great for the Pilates teachers out there, our classes are full of failed yoga participants who think yoga is not for them, but I think it is sad that many miss out on other aspects of yoga, in it’s widest definition.

Why this little rant? Well the functional anatomy observation session made it easy to see that huge ranges of movement of the femur in the hip socket is only available to some, the rest are not hindered by short muscles but by the shape of their bones. Some cannot go further into a wide legged position, internal or externally rotated because of compression, literally the bone of the pelvis hitting the bone of the femur. No amount of stretching can change this situation. No amount of manual adjustment can make it better unless breaking a bone is thought appropriate.

In the arts, where range of movement is important, such as ballet, Xray’s of the pelvis are used to check out the shape and depth of the hip sockets, no amount of stretching can significantly change basic bone structure without injury and the dancers with inadequate pelvis shapes are not offered places at ballet school, ballet however is all about aesthetics.

This is important to know in all movement disciplines, a simple change in angle can facilitate a huge difference in Range of Movement, being pedantic about foot position or pelvis direction is not serving the client and may create unnecessary pain or injury both physically and mentally.

The question is; when is a huge range of movement due to a lack of compression (the skeleton restricting the movement) and when is it due to joint hyper mobility syndrome. I often hear people describe themselves as hyper mobile because they have a huge range of movement, is this really the case?

Joint Hyper mobility syndrome is not to be admired or wished for, it is caused by genetic defects affecting the encoding of collagen( Beighton et al.1999, Bird.2005, Grahame.2009) anyone who has this syndrome is susceptible to trauma/overuse injuries. It is a complex condition, with a wide range of clinical features:

• ·      Neurophysiological
• ·      Musculaoskeletal
• ·      Skin
• ·      Cardiopulmonary (asthma)
• ·      Chronic pain
• ·      Gastro- intestinal dysmotility
• ·      Postural orthostatic tachycardia syndrome.
• ·      Etc…..

Hyper mobility can be inherited, easily tested for, using the Beighton Scale and currently there is no cure, so management of the syndrome is the only option. The spectrum of the disease is from being bendy with generalised joint hyper mobility to not being able to walk because the joints are too floppy to stand up.

It is a connective tissue issue, Collagen is one of the components of Fascia or connective tissue, and Fascia is ubiquitous in the human body, if there is an issue with this tissue it will affect the whole fascial network, hence the huge range of possible clinical features. For many hyper mobility can be an asset but it comes with risk of injury.

I think that we all have areas of our body which exhibit an ease or flexibility in the joint, often they are the site of chronic injury, this can be caused by so many factors, I see very few truly hyper mobile people, Pilates being one of the management options available to this population. 

Fascia is plastic in nature, think about pushing your finger into a plastic bag, the resulting blister will not return back to the original shape, if too much pressure is applied the plastic will break. If ligaments are forcefully stretched they will break, or the resultant stretch ‘blister’ will not return to its original length. Fascia can survive the melting stretch as the tissue creeps back to it’s original length, however whilst it is creeping back it is vulnerable to injury.

So next time someone tells you they are hyper mobile, check if it is caused by lack of compression or by a connective tissue issue. It may be that the lack of compression creating a huge range of movement (a cause of pride in many) is masking an imbalance. Simply by adding variations in movement vectors/angles or bending a limb will provide more space for movement or elicit a stretch where it was not felt before.

November 2016

Thanks to The yoga People and Dr Jane Simmonds.

Melting Stretches and Yin Yoga

Melting stretches

I have just returned from a 4 day introduction to Yin Yoga.  Those of you who know me well, know my questioning nature, also my drive not just to read or be told about different movement modalities but to really understand them and to feel them in my own body.

Yin Yoga has been bouncing around on the edge of my understanding for several years, initially in my Yoga training, one of my fellow students introduced us to Yin Yoga, I remember walking around the garden of the house where we had our retreat, trying to understand TCM 5 element theory and not much else. However the seed was sown and so when Yin Yoga resurfaced at an International Fascia Congress in Washington, I sat up and listened. The speaker was Paul Grilley and he took the podium with Robert Schleip and explained about compression and tension in yoga poses. Because of his use of the words Compression and Tension, I thought he was talking about biotenegrity and I struggled to fit his explanation into the model of biotensegrity I held in my head. Today I think I was adding 2 and 2 and making 5, however I am still not 100% sure of that, and somewhere just out of reach, there is a connection but probably not the obvious one.

Yin yoga has also surfaced in the Fascial Fitness training relating to melting stretches.

Fascial stretches are part of the Fascial Fitness training, the principles of which are the activation of long chains and tensegrity structures, Pendiculation and variations in direction of stretch, and loading of the stretch using weights, resistance and bounces.

So when a Yin Yoga course based on the work of Paul Grilley popped up on Face book I didn’t press delete, I followed the link. The course was in London and offered the option to take the first weekend of a 200 hour Training as an introduction.

So what is Yin Yoga? My understanding was that it was mediation in a pose. Why is it so Fascial?

After 4 days of Yin yoga (2x 2hour classes per day), meditation, Traditional Chinese medicine (meridian theory) and psychology, including a good dose of energetic anatomy, classic anatomy, functional anatomy and a sparse sprinkling of fascial anatomy;  here is my understanding based upon my own experience.

Like all yoga it’s not all about the asana or poses, Yin seems to take more from the Chinese philosophy than the traditional yoga practice which is based on Indian.

Yin is the opposite of Yang, however they are co-dependant each having a little of the other in them, think of the symbol.

Yang is all action, masculine in nature, a yoga practice/exercise/movement practice or lifestyle, which focuses on exercising muscles and moving blood around the body is Yang.

Yin is calm and nurturing, feminine in nature, a yoga practice/exercise /movement practice, which focuses on the connective tissue.

The balance between the yin and yang is essential for wellbeing and this is what practicing Yin yoga along side yang forms of exercise aspires to bring.

The plastic nature of connective tissue, according to Yin Yoga, enjoys gentle pressures, applied for longer periods of time in order to grow strong.

These are my personal observations and may not be true for others however the classes for me where both extremely challenging, at times painful (in a good way), and wonderfully calming and releasing. You moved into the positions slowly, each position targeted different areas of the body which correspond to meridian theory, you are not in the pose until the target area to be ‘stressed’ by stretching has been found, this involved a lot of bolsters, blocks and experimenting with different foot/leg/body positions before the target area was found, some poses just didn’t work because of my unique pelvic shape/ femur head angle, tight tissues, past injury etc etc. The idea is to find a point of stress in the target area, which is not injurious or painful in a bad way and surf that point. This is a self practice, you have to trust your intuition your own awareness of how your body feels, everybody looked completely different, we were not adjusted or assisted in progressing the stretch just in finding the target area, the bolsters were not there to support as in restorative yoga, but to allow the practitioner to work around natural compression felt in their own body and to allow the muscles to turn off and a melting stretch of the connective tissue to occur. You then stay in that pose for anything between 1-5 or more minutes depending upon your experience. The time in the position was the challenge, I noticed how muscles I didn’t know I was contracting became obvious and so I released them and I sank deeper and deeper into the stretch. In order to feel the melt it helped to close your eyes and look inside your self, quiet and still. The hardest bit was yet to come but the reward was so wonderful. Coming out of the ‘melted position’ was far harder than going in, everything was done slowly and no-one was rushed. I often had to use my hands to move my legs out of the pose, there was a lot of groaning and grimacing. You then take a ‘rebound’ position, prone, supine or pose of a child where the most popular, sometimes taking a counter pose first, in the rebound time of around 2 minutes you could feel the connective tissues rebounding, slowly returning to their usual length, your body felt open and released, a cooling flow and such a peace and tranquility. The Yin yoga says that this is a restoring of the flow a Chi. My Fascial Fitness inner teacher probably would say it was also a rehydration of the tissue. What ever it was it was worth the wait.

After the class we went into mediation so easily.

Will I go back and continue the course?

This morning when I woke up I actually missed the early morning yin class. I also seemed very alert and ready to get going (unusual for me as I am not a morning person). I do ache in parts of my body, which I probably pushed to hard because I thought I could, after all I couldn’t let the youngsters in the room see that I was struggling could I! a lesson learned, it is my practice and no-one else was looking anyway.

The melting stretch was delicious and pleasurable, everything a fascial movement should be, I’m not sure I would be happy for a hyper mobile client to take a class and the usual contra-indicated population, pregnancy, joint replacements etc would need extra care but it is an experience I would recommend to my over stressed, anxious over exercised clients who need the repeated buzz of the Yang.

So now I know what a melting stretch really is, and I will do it again. Sadly I can only get to a couple more days of this course because of studio commitments.

The course was run by The Yoga People and well taught, bringing in experts in the various disciplines. The classes were amazing.

My fellow participants were lovely and very generous towards me. Thank you.