1. BE STRONG: BUILDING STRENGTH FROM THE INSIDE OUT ©2015 National Association for Continence

2. Objectives  Learn the anatomy of the pelvic floor  Understand the role of the pelvic floor and bladder control  Discover your core from the “inside out”  Learn how to enhance pelvic floor muscle function  Incorporate the pelvic floor muscles in your daily activities

3.  First Layer (urogenital diaphragm) –Bulbocavernosus, Ischiocavernosus, –Superficial Transverse Perineal  Second Layer –Comprised of fascia to support the urethra  Third Layer (levator ani) –Pubococcygeus, Iliococcygeus, Puborectalis –Coccygeus, Obturator Internus Sources: 1.https://anytimeyoga.wordpress.com/2011/11/06/core-anatomy- pelvic-floor/ 2.http://www.pelvicphysiotherapy.com/learning-centre/pelvic-floor Clitoris Vagina Urethra Sphincter ani externus Know Your Pelvic Floor

4.  The Pelvic Floor Works With Your Inner Core ‒ Diaphragm: the dome shaped muscle used for breathing ‒ Transverse Abdominus: the deepest layer of the abdominal muscles used for stabilization of the spine and pelvis ‒ Deep Multifidus: the deepest layer of the back muscles used for stabilization of the spine and pelvis Source: http://fitforreallife.com/2015/02/training-the-core-how-a-physio-looks-at- building-your-core-stability-plus-3-core-stability-exercises-you-can-do/ Diaphragm Multifidus Transversus abdominis Muscles of pelvic floor Know Your Inner Core

5. Why Are These Muscles Important?  Support for the Abdominal Organs: “Holding Things Up”  Appreciation for Sexual Intercourse: “Use It Or Lose It”  Bladder and Bowel Control: “When You Gotta Go”  Stabilize the Pelvic Girdle: “Your Inner Core”

6. When Things Go Wrong…  If the pelvic floor is too tight… ‒ Muscles have too much tension in them; they are not able to contract or relax at a normal rate, making them weak  If the pelvic floor is too loose… ‒ Muscles lack tension and are too lax; they cannot contract and are weak ‒ If some muscles are too loose and weak, other muscles will often overcompensate

7. “Are my pelvic floor muscles too tight?”  Some symptoms of pelvic floor tension include: ‒ Constipation ‒ Painful intercourse ‒ Pelvic pain ‒ Inability to empty your bladder completely ‒ Painful urination  If you experience these symptoms, it is recommended you see a pelvic floor physical therapist prior to starting any strengthening program

8. “Are my pelvic floor muscles too loose?”  Some symptoms of pelvic floor weakness include: ‒ Urinary incontinence ‒ Urinary urgency/frequency ‒ Stool and gas incontinence ‒ Pelvic organ prolapse or the dropping of your organs through your vagina ‒ Sexual dysfunction ‒ Pelvic girdle pain This presentation will focus on pelvic floor weakness that comes from muscles that are too loose.

9. Types of Incontinence  Urinary Incontinence –“Any involuntary leakage of urine that is a social or hygienic problem and is objectively demonstrable” –Affects 1 in 3 women –Impacts women typically between the ages of 15-64 –Only 25% of these women seek help  Stress Incontinence –“Involuntary leakage on effort or exertion, or on sneezing or coughing” –Most common type of incontinence

10. Types of Incontinence  Urge Incontinence –“Involuntary leakage accompanied by or immediately preceded by urgency” –Often referred to as an “overactive bladder”  Mixed Incontinence (both stress and urge)

11. What Causes Pelvic Floor Weakness?  Pregnancy/delivery  Trauma to the pelvis/abdominal wall  Lack of pelvic floor/inner core exercise  Abdominal/gynecological surgeries  Bearing down/straining on the pelvic floor in daily life  Obesity  Menopause

12. How To Find Your Pelvic Floor Cues to contract the RIGHT muscles Tighten the muscles around your vagina like you are stopping the flow of urine Pretend that you are sucking a marble up from your vaginal opening Try tightening your muscles so you are bringing your pubic bones and tailbone together or trying to bring your SIT bones together 40% of women are doing Kegel exercises incorrectly!

13. How To Find Your Pelvic Floor  Get familiar with yourself… ‒ Use a mirror to see the muscle lift of your pelvic floor ‒ Self Evaluation (yup, get up close and personal) ‒ Urine Stop Test

14. How To Find Your Pelvic Floor  Common mistakes ‒ Tightening the buttock muscles ‒ Tightening the inner thigh muscles ‒ Holding your breath ‒ Sucking in your belly Remember, this is a gentle contraction. If it feels like you are trying too hard, you probably are!

15. Myth About Kegels  Your pelvic floor needs to be able to work like any other muscle in the body. It has to: ‒ Contract ‒ Relax ‒ Elongate  Muscles need to be able to go through their entire range of motion in order to be strong! It’s Not Just About Tightening!

16. Taking Your Kegel To The Next Level  When activating your pelvic floor muscles, make sure you can feel yourself tighten, relax, and elongate. Note: When elongating your pelvic floor, don’t strain Pretend that your pelvic floor is an elevator. If your pelvic floor is at rest at the ground, tighten and lift up to the 2 nd or 3 rd floor, then relax back down to the ground. From the ground, see if you can elongate your muscles down to the basement.

17. Coordinating the pelvic floor with your inner core Now that you know how to find your pelvic floor, here comes the tricky part…

18. The Amazing Diaphragm  When you inhale deeply, your diaphragm pushes down into your abdomen, allowing your pelvic floor to relax INHALE = pelvic floor RELAXES  When you exhale, your diaphragm returns to its resting position and your pelvic floor contracts EXHALE = pelvic floor CONTRACTS Source: http://fitforreallife.com/2015/02/training-the-core-how-a-physio-looks-at-building- your-core-stability-plus-3-core-stability-exercises-you-can-do/ Diaphragm Multifidus Transversus abdominis Muscles of pelvic floor

19. The Amazing Diaphragm  It is important that you are aware of your diaphragm. Observe that a big, relaxed, cleansing belly breath results in belly rising. Place one hand on your upper chest and one hand on your belly. Breathe in deeply- a big belly breath. If you are doing this correctly, you should feel the hand on your belly move, not the hand on your upper chest as much. Now do this again and feel what is happening in your pelvic floor.

20. It’s Not Just About Sit-Ups and Crunches  Those exercises are just one-dimensional and only work the more superficial abdominals  We need to work the entire core, in all planes of motion, which means finding the deeper, inner-most muscles Layer 1: Immediately below the skin - Rectus Layer 2: External & Internal Obliques Layer 3: (deepest) Transversus Abdominus Source:http://fitforreallife.com/2015/02/training-the-core-how-a-physio-looks-at-building- your-core-stability-plus-3-core-stability-exercises-you-can-do/ Transverse abdominis Internal abdominal oblique External abdominal oblique Rectus abdominis Myth: Sit ups and crunches are all I need to do to get a flat tummy and work my abs.

21. It’s Not Just About Sit-Ups and Crunches  Find your Transverse Abdominus muscles by tensing your lower, inner-most abdominal wall while continuing to breathe. Bring your belly button back to your spine Hug your abdominal organs with your lower abdominals Like you are trying to get into a pair of slightly tight jeans

22. It’s Not Just About Sit-Ups and Crunches Core Activation: “On All Fours” Start in tabletop position (hands and knees) with the hips and knees at 90 degrees. Press hands into the floor and engage the transverse abdominals. Lift arm up towards the ceiling. Hold for 5-10 slow breaths. Option to extend the opposite leg behind you with foot on the ground, or leg in the air.

23. It’s Not Just About Sit-Ups and Crunches Core Activation: “Bridges” Flatten your spine and press your pelvis up toward the ceiling, rolling up one vertebra at a time. Keep the pelvis level. Hold for 5-10 slow breaths. Option to lift one heel or foot, keeping the pelvis level.

24. It’s Not Just About Sit-Ups and Crunches Core Activation: “Clamshells” Lay on your side with knees bent. Roll the entire trunk slightly towards the floor so you feel the abdomen engage. Keep heels together as you lift the top knee. You want to feel the action in the rear end, not the front of the hip. (If you are feeling the action in the front of the hip, try rotating your trunk closer to the ground.) Repeat 20 times on right and left sides.

25. Putting It All Together  If you feel some tension in your low back as you contract your transverse abdominus or even feel that you lifted your pelvic floor…you got it!  This is the ultimate coordination of transverse abdominus, deep multifidus, diaphragm and pelvic floor

26. Use Your Core Throughout The Day  Use your deep inner core with every day activities such as: ‒ Lifting ‒ Going from sit to stand ‒ During other exercise ‒ Coughing/Sneezing ‒ Squeeze before you sneeze - “the knack”

27. Finding Balance  There are 45 muscles that attach to the pelvis!  It is important to help optimize the pelvic floor function by balancing the strengthening with stretching of other muscles surrounding the pelvis  Let’s practice stretches for some of the more commonly tight muscle groups

28. Finding Balance Piriformis Stretch Lay on your back with knees bent. Place your right ankle on your left knee. Reach for your left thigh and pull it towards your chest to feel a stretch in the right buttocks. Repeat on other side

29. Finding Balance Hamstring Stretches: Downward Facing Dog Start in Table Top (hands and knees). Send the sit bones back to where the wall meets the ceiling, keeping the back straight. While breathing in this posture, visualize the tailbone reaching toward the ceiling during inhalation, allowing the pelvic floor muscles to release.

30. Finding Balance Hamstring Stretches: Active Hamstring Stretch Stand with feet wider than hip distance apart and knees bent. Clasp hands and place elbows above the knees. Inhale. Exhale, begin to straighten knees, keeping the back straight, and raise the pelvis toward the ceiling. Extend the knees to feel the first sensation of stretch in the calf/posterior thigh.

31. Finding Balance Hamstring Stretches: Standing At Step Place heel on the step with your toes pointed up to the ceiling Hinge forward at your hips, so you feel the stretch in the back of your leg. Repeat on opposite side. Option to use a strap to deepen stretch.

32. Finding Balance Adductor Stretch Sit tall, with the bottoms of your feet together, your ankles open wide. If your knees don’t open to the ground, place pillows or blocks underneath to help support them. For a deeper stretch, hinge forward from your hips. This move can also be done in a lying down position to be more restorative.

33. Finding Balance Hip Flexor Stretch Stand with your feet hip distance apart, left leg in front. The left knee is bent, knee aligning over the ankle and second toe. The right knee is straight. Press the pelvis forward and tuck your tail under to feel a stretch in the front of the right hip. Repeat on the opposite side.

34. Finding Balance Deep squat position for pelvic floor relaxation Standing with feet hip width apart, squat down to lower the pelvis below the knees If this is too difficult, practice laying on your back, making a deep squat position by pulling knees toward chest, and out to the sides. Use your hands to hold and support your legs.

35. Finding Balance Pelvic Floor Decompression: Legs Up The Wall Lie on your back, and slide your bottom as close as you can to the wall. Place your straight legs up the wall. If this is difficult, place a pillow under your hips.

36. Are You Aligned? http://highpointetn.com/high-pointe-blog/are-you-a-donald-duck-or-pink-panther/  Alignment is key in optimizing your pelvic floor and deep inner core function.  Finding the body’s position of natural ease avoids overworking certain muscles unnecessarily. Keep your rib cage over your pelvis Keep your spine and pelvis in a neutral position, not tucked underneath you (Pink Panther) or tilting your pelvis forward (Donald Duck)

37. Questions?

38. Help Us Help You!!  The National Association for Continence is a not-for-profit providing education and support to those touched by incontinence. We are proud to partner with your instructor to offer this free class on pelvic floor health.  Before you leave, please sign in with your instructor to receive the NAFC Newsletter, “On The Go”, and to pledge your support to NAFC. Please DONATE to NAFC at www.nafc.org, so that we may continue to provide programs and support like the class you attended today!