Part I: Breathing Techniques for Pelvic Floor Health

By Melissa Patrick, PT, DPT and Jennifer Keesee, DPT

The Basics

Breathing may seem like a very simple task, but many of us breathe incorrectly. Poor breathing mechanics can affect us physically, mentally, and emotionally. Research has shown that breathing exercises can positively impact our nervous, cardiac, and musculoskeletal systems. When we pay attention to, and learn how to control, our breathing we can change how we feel almost immediately.

When it comes to the pelvic floor, how we breathe can acutely impact the muscles at the base of your pelvis. Many folks tend to breathe with their upper neck and chest muscles, which causes a decrease in movement of the respiratory diaphragm. If your respiratory diaphragm isn’t moving well, then that likely means your pelvic floor muscles aren’t moving well either. This can lead to decreased strength and increased presence of painful trigger points in the pelvic floor which may lead to urinary, bowel or sexual troubles.

Folks who are currently working with pelvic pain may have more shallow breathing patterns; this is due to the ongoing painful stimulus causing ‘fight or flight’ activation in the nervous system. This becomes a difficult feedback loop of pain causing shallow breathing and shallow breathing causing more pain. One of the best ways to break this cycle is by practicing breathing exercises.

The Diaphragms

Let’s take a closer look at the anatomy involved in breathing. The diaphragm is a dome shaped structure that runs horizontally at the base of the ribs, this forms the top of the abdominopelvic cavity. The pelvic floor muscles form the bottom of this cavity. With every breath, the pelvic floor and the diaphragm are designed to work together to create and regulate pressure in the abdomen.

As you inhale, the diaphragm descends and presses on the abdominal organs. The pelvic floor should follow by dropping to ensure the pressure in the trunk is regulated. On exhale, both diaphragms passively recoil coming back up and in. Breathing exercises help to improve this coordination between the pelvic floor and the respiratory diaphragm, which is essential for pelvic floor muscle health!

Breathing Exercises & Pranayama

There are a variety of ways to manipulate the breath to evoke a specific physiologic change in the body, aside from muscle coordination. Most breath exercises can be used as a tool to balance the nervous system. By balancing the nervous system regularly with breath practice, you may find that your body is more able to rest, digest and repair.

Many breathing techniques originate from the teachings of yoga and are referred to as ‘pranayama’. This term can be broken into two parts with ‘prana’ translating to ‘life force’ and ‘yama’ translating to expansion. Life force energy is the flow of oxygen throughout the entire body and pranayama is the practice of increasing that flow. The ancient origins of pranayama date as far back as 7000 years and since then have served as a powerful tool to heal illness and correct mental imbalances. Pranayama has well documented health benefits in addition to prevention and management of disease – see below for a short, but not complete list.

Below, we will review basic diaphragmatic breathing, which serves as the foundation for all of the other breath techniques. Take your time with diaphragmatic breathing, the more comfortable you are with it, the more success you will have when trying the other techniques in Part II of this blog. Stay tuned, in Part II we will cover specific pranayama techniques and other breathing exercises to help you reap some of the benefits below!

Benefits of Breathing Exercises:

Facilitate the relationship between the pelvic floor and the respiratory diaphragm
Reduce levels of anxiety and depression
Assist with emotional regulation and stress management
Improve mind-body connection and overall quality of life
Non-habit forming pain management
Lower heart rate and blood pressure
Increase delivery of oxygen & nutrients, removal of waste products throughout the body

Prepare to Practice

To practice breathing techniques, begin by finding a comfortable way to sit upright. Support your body in a way that allows your spine to be straight, this is important to optimize breathing mechanics and alertness. You can try leaning against a wall or using a lumbar support pillow. If you are unable to sit comfortably, you can perform (some of these exercises) lying on your back.

The first step to maximizing your breath practice is to simply become aware of how you are breathing. Breath awareness practice gives folks the opportunity to start to notice the correlation between breath, tension and pain. Then, changing and regulating your breath using breathing exercises to manage tension and reduce pain increases your ability to manage how you are feeling. Using breathing exercises empowers you to effectively self-regulate, improving your chances of changing a painful experience.

A Note on Trauma

Practicing pranayama and breathing exercises can be a great tool for trauma survivors who are struggling with overwhelming anxiety, dissociative coping mechanisms and hyperarousal. Because breath practice is one of the fastest ways to shift your physical and mental state, it can support trauma survivors in their ability to tolerate distressing feelings and memories. However, it can also intensify these challenging feelings initially, so please pace yourself and feel free to pause or remove yourself from the practice if the sensations become too intense. As long as you can tolerate what is coming up for you, see if you can sit with the feelings, identify them and acknowledge them. You can always return to these exercises and work up to the time parameters mentioned below.

Each of the breathing techniques listed in both Part I and Part II of this blog are meant to be calming for the nervous system. Nadi Shodana pranayama or alternate nostril breathing, for example, clears the mind by balancing the left and right hemispheres of the brain. It calms hyper arousal of the nervous system and alleviates tension, anxiety, and internal states of panic. Alternate nostril breathing is a grounding practice and helps to alleviate the sense of being frantic that many trauma survivors struggle with regularly. Stay tuned for Part II to learn more about Nadi Shodana pranayama. Keep in mind, other pranayama practices not listed in this post or in part II, are much more vigorous and may be too activating for the nervous system of a trauma survivor.

Tips for Finding Ease

Upon beginning a breathing exercise, many folks tend to over effort. Labored breathing will not induce calm in your nervous system or in your body so let’s think about finding a balance between effort and ease. Always try to be patient with yourself as you practice these techniques.

INHALE

As you get comfortable with diaphragmatic breathing to start, think less about inhaling “deeper” and more so about inhaling “longer, smoother, softer”. You can even think about “sipping” the breath. This will help you to be more calm and patient with the breath without rushing or forcing it.

EXHALE

Allow your exhale to “last and linger” without forcing it out. Explore the depth of your exhale, perhaps you are able to empty more completely than you previously felt possible.

PAUSE

Be sure, at the end of any breathing exercise, to pause. Sitting or laying quietly, simply observe the sensations in your body after you have completed the breathing. You may notice you feel a shift in your mind or body. It is important to give yourself the time, space and permission to feel what may come up for you.

Now that you’re informed and curious about your breathing, let’s jump in! Don’t forget: trust your breath and see if you can listen to what your body may be telling you.

Breath Technique Guides

Diaphragmatic Breathing

Using your largest breathing muscle, the respiratory diaphragm, takes more practice than you think! Take your time with this exercise and imagine the diaphragm moving in a 360* fashion. If you have a good handle on this technique, it will surely help you maximize the other breathing exercises.

Find a comfortable position either laying on your back with your knees bent or in a chair.
Breathe slowly through your nose and visualize drawing the air down towards your low belly and pelvis. As you take your deep breath in, think about breathing into yes, the belly, but also the sides and back of your ribs. Try placing your hands on the sides of your ribcage to feel this expansion. It’s important to note that you are not using your abdominal muscles to push out your stomach, but rather, allowing the air to fill the abdomen.
Exhale slowly through your mouth and allow the abdomen to recoil back down to its resting position.
You may place your hands on your chest and belly for this exercise to help you focus on feeling the breath in the middle of your belly and less in your upper chest.
Perform for 5-10 minutes. You can even practice a few diaphragmatic breaths during moments of stress or anxiety to avoid activating your body’s ‘fight or flight’ response.

Stay tuned for Part II of this blog post to learn more about other breathing techniques and pranayama practices, watch instructional videos and learn about the benefits of each technique.

If you are interested in working one on one with Melissa Patrick, our physical therapist who offers virtual therapeutic yoga, please visit our website here to learn more and sign up! She can assist you with practicing these techniques and help you to incorporate them into your existing stretching routine or yoga practice to optimize your pelvic health.

FAQ

What are pelvic floor muscles?

The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.

What is pelvic floor physical therapy?

Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.

What happens at pelvic floor therapy?

During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.

What is pudendal neuralgia and how is it treated?

Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.

Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.

What is interstitial cystitis and how is it treated?

Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.

Who is the Pelvic Health and Rehabilitation Team?

The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.

How many years of experience do we have?

Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.

Why PHRC versus anyone else?

PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.

Do we treat men for pelvic floor therapy?

The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.

Do I need pelvic floor therapy forever?

The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.