What happens with a Hypertonic Pelvic Floor
When we consider issues with the Pelvic Floor Muscles (PFM), we commonly think of the female population and the issue of urinary incontinence. To be truthful, most of the commercial literature describes this condition only. Dysfunction in PFM Muscle tone can be described as hypotonic or hypertonic.
A hypotonic PFM describes the weakness in the actual muscle fibre contractility, stretching of the fascia of the PFM or a neural deficit resulting in a lack of muscle firing. Often, we see a combination of at least two of these factors. This weakness could be represented as urge incontinence where one feels the need to urinate and lacks the endurance to hold on. The other is stress incontinence, where the PFM lack contractility (strength) to support the sphincters under load, resulting in a leak with a cough or a jump. I'm confident that we all understand that cueing of the PFM contraction to engage strength, is prescribed in these cases.
Incontinence can refer to both urinary and/or faecal leakage, occurring in 30% of the female population and 3-11% of males, according to the National Institute of Health Australia.
A dysfunctional PFM is not confined to weakness or instability. There also exists the hypertonic PFM. This refers to increased tone in the myofascia or tightness and shortening of the myofibrils. The PFM can be seen to be contracted at rest. If hypertonicity exists in the presence of a perfectly aligned bony pelvic ring, the sphincters will line up and close and we will be unlikely to see any incontinence. But we may see the lack of ability to relax the sphincter and allow urination. This will present the need to go to the toilet but once seated, they are unable to relax enough to allow flow. In this case, we would suggest that the client sits forward on the toilet seat with their pelvis tilted anteriorly. This acts to widen the Ischial tuberosities at the base of the pelvic ring, while stretching and opening the sphincters of the PFM.
Another symptom of PFM hypertonicity is pain arising from the contracted soft tissue structures. Pain may be felt during urination, defecation and during intercourse. In significant cases, pain may be felt on movement, walking and stretching the legs.
The PFM spans across the bony pelvic outlet and the fibers are multi-directional. Hypertonicity may occur through some planes of myofibers causing a soft tissue imbalance. This would effectively pull the bony pelvic outlet out of alignment. A mal-aligned pelvis can also cause secondary issues with the lumbosacral joint, the pelvic-hip joint or the sacroiliac joint.
Considerations of PFM Hypertonicity in the Pilates Environment
Over the past decade, we have seen a movement away from cueing the PFM whilst engaging the core. Why is this so?
In the normal state, the PFM will intrinsically contract and lift when one activates their core. The PFM sit as the base of the core, with the Transversus Abdominus being the circumferential wall and the diaphragm the lid. In a healthy human, these muscles act in unison and do not require supratentorial cognition.
Secondly, we may not know whether the client's PFM is related to hypotonicity (to weak) or hypertonicity (too contracted). This can only be diagnosed by a specialist doctor, chiropractor, physio or osteopath.
The PFM contraction does not need to be cued in the healthy individual, it should not be cued in a hypertonic pelvic floor and therefore only needs cueing in a state of accurately diagnosed weakness.
What can we do when working in the Studio?
If you're in a one-on-one session, you will have the privacy to ask your client…
1. Do you have any problems going to the bathroom?
2. Do you have any pain on going to the toilet?
3. Do you have pain during sex?
4. Do you have difficulty relaxing and being able to go to the toilet despite the sensation of needing to go?
5. Do you occasionally leak or dribble urine?
From these questions, you can gain an idea as to whether the issue one of hypotonicity or hypertonicity.
Ultimately, we will always refer our client on to a specialist in the area for complete assessment and diagnosis.
What if you are referred a hypertonic PFM client?
1. Do not cue them to contract their PFM during exercise
2. Focus on exhaling on effort to promote relaxation
3. Avoid overworking the adductors. The myofascial connection of adductors and PFM will act to pull and shorten the fibers further
4. Work on lengthening the hamstring group to allow the Ischial Tuberosities to widen, stretching the PFM
5. Avoid any movements that could result in a Valsalva contraction
6. Focus on stretching through the deep hip muscles, adductors and hamstrings
7. Enhance all stretches with an exhale
8. Choose to work with the legs in an abducted stance to open the lower pelvic ring.
9. Working into a slight anterior pelvic tilt (as long as not contraindicated) can also work to open the Ischial Tuberosities
10. Home exercises would include Foam Rolling or Spikey Balling of the leg muscles indicated. Sitting cross-legged with a small Ball, such as a Franklin Ball, positioned under the Perineum (the Pelvic Floor diamond)
Matwork Exercises indicated include…
1. The Bridge with TheraBand tied around the thighs to promote gluteal activation
2. Prone extension / Swan 1 with the legs abducted
3. Bent Knee Opening
4. Spine Twist
5. The Saw
6. Spine Stretch with the legs abducted wide
7. Rocking
8. Open leg Rocker
9. Rolling like a Ball/Seal
10. Mermaid
11. Standing Roll Down in a wider stance
12. Hamstring Stretch
13. Gluteal Stretch
14. Adductor Stretch.
So, when you next have a client tell you they have some incontinence or pain down there, ask them some further questions to help you understand whether they have a hypotonic or hypertonic PFM Dysfunction. If you have any concerns at all, refer them for assessment and correct exercise advice. If you are ever referred a Hypotonic PFM client, you now have some tools to assist in your exercise programming.
Jennifer Guest is a Senior Educator Polestar Pilates Australasia and Senior Physiotherapist Smart Health, South Australia.