Pelvic Floor Article

Yoga for the Pelvic Floor by SANDI TENFELDE PHD, RN, APN; RICH LOGAN CYT, CMT; and MELINDA ABERNETHY MD

THIS ARTICLE APPEARED IN “BEGINNINGS”  published by the American Holistic Nurses Association in 2014

Yoga is a centuries-old tradition that encourages an integration of the mind, body and spirit. In contrast to a medical model in which a physical system is treated in isolation, yoga, like nursing, requires a focus on the whole person. The act of pratyahara, or turning your attention inward, not only increases awareness of the physical body and the movement of one’s breath, but also deepens one’s consciousness of the spiritual nature of the human condition. Mind-body therapies can be effective for optimal health, and yoga incorporates breathing techniques, visual imagery, and meditation along with physical movement of the body. The non-pharmacologic benefits of yoga for physical and mental health are now being recognized. Yoga has been shown to be effective for helping women with multiple chronic health conditions. Research indicates that yoga has positive benefits on abdominal muscle tone, digestion, lower back pain (Sherman, Cherkin, Erro, Miglioretti, & Deyo, 2005) and dysmenorrhea (Rakhshani, Maharana, Raghuram, Nagendra, & Venkatram, 2011). A recent meta-analysis suggests that yoga therapy may be helpful for pain and associated disability (Büssing, Ostermann, Lüdtke, & Michalsen, 2012). Fewer studies have specifically investigated the impact of yoga on pelvic floor function. Two small studies have examined the effect of yoga on sexual function: for premature ejaculation (Dhikav et al., 2010a) and female sexual function (Dhikav et al., 2010b). However, the effects of yoga on the function of the pelvic floor have not been thoroughly examined. The pelvic floor is considered the root of the physical body—both metaphorically as well as physically. While the terminology of “pelvic floor” is often misleading, it describes the musculoskeletal system that allows for upright mobility and support. This system protects and supports the organs of reproduction, voiding and defecation. Proper function of the muscles within the pelvic floor has an impact on proper postural alignment, spinal movement, as well as supporting respiration. A pelvic floor that is too tight may lead to pelvic pain, rectal spasm and constipation, and sexual dysfunction, as well as limit physical mobility. Musculature that is too relaxed may contribute to problems with urinary and/or bowel incontinence and pelvic organ prolapse. Understanding Pelvic Positioning Figure 1 illustrates the concrete structures within the bony pelvis that are often the focus of kinesthetic awareness of one’s pelvic positioning. The anterior superior iliac spines (ASIS bones) are the bony protrusions just below the waist line, and can help an individual find the tilt of the pelvis and determine how to create a neutral pelvis. Using mental imagery is an effective way to understand the orientation of the pelvis. If the pelvis is visualized as a bowl filled with water, tilting it forward (pelvic anterior) or back (pelvic posterior) would tip water out of the bowl. When there is no tilting of the pelvis, a neutral pelvis is obtained. The sacrum is another critical landmark. This flat bone located at the base of the spine is broad across the top and narrows to the coccyx. The ischeal tuberosities (“sitting bones”) are covered by the gluteus maximus when standing. However in a seated position, they come in contact with the floor, encouraging a sense of grounding. When an individual can focus the mind and attention to this area and do the movements of pelvic tilt, then the deeper, more subtle work involving the musculature of the pelvis can begin. Pelvic Floor Awareness The work of breathing can help to bring awareness to the pelvic floor. The pelvis begins at the base of the diaphragm, and the nutation of the pelvis can be connected with the work of respiration. With inhalation, the diaphragm pulls down and the pelvis untucks while the abdomen distends, increasing the cavity within the pelvis (see Figure 2).  With exhalation, the diaphragm domes upwards and the pelvic floor rises up, increasing support of the abdominal organs (see Figure 3). In yoga, lifting the pelvic floor muscles up and into the body is considered mula bandha, or the “root lock.” However, the use of the word “lock” may be too strong of a mental image for the subtle work of internal contraction of the pelvic floor muscles. A comfortable cross-legged, seated position works well for increasing pelvic floor awareness—either crossing the legs at the shins (sukhasana) or widening the knees until the heels come into the midline of the body (siddhasana). In general, when someone is sitting on the floor, the legs should relax so that the knees can be lower than the hips. There are several exercises that help to build awareness and tone in the pelvic floor. Similar to the Kegel exercise, an individual can gently contract the pelvic floor and release it in a comfortable rhythmic pattern. With exhalation, there is a subtle lift of the pelvic floor as the diaphragm domes upward. If the awareness is weak and the tonus of the musculature is flaccid, then there will be minimal sensation and movement. The situation can be improved from above by engaging the abdominal muscles. Imagery of a belt cinching the waistline engages the natural girdling muscles of the tranverse abdominus, and the external and internal obliques, gently drawing the rectus abdominus toward the spine. There are many yoga standing postures, or asanas, which can help to create awareness. Open hip postures, such as Warrior 2 (virabhadrasana 2) or Side Angle (parsvakonasana), are useful for engaging the pelvic floor. In these postures, squeezing the heels isometrically toward the midline creates a lifting sensation in the pelvic floor. Through yoga practice, individuals can help to connect the mind, body and spirit. The increased awareness to the pelvic floor region can help to develop new insight into how the body moves, how to improve posture, as well as improve strength and flexibility. Yoga may promote pelvic floor health and prevent or minimize long-term pelvic floor dysfunction. Centuries of yoga practice have provided a guide to help practitioners of yoga reconnect to the power of the pelvis. Additional research is needed to help understand the benefits of yoga for the pelvic floor.

References Büssing, A., Ostermann, T., Lüdtke, R. & Michalsen, A. (2012). Effects of yoga interventions on pain and pain-associated disability: A meta-analysis. The Journal of Pain, 13, (1), 1-9. doi: 10.1016/j. jpain.2011.10.001 Dhikav, V., Karmarkar, G., Gupta, R., Verma, M., Gupta, R., Gup- ta, S., & Anand, K.S. (2010). Yoga in female sexual functions. Journal of Sexual Medicine 2(2), 964-970. doi: 10.1111/j.1743- 6109.2009.01580.x Dhikav, V., Karmarkar, G., Verma, M., Gupta, R., Gupta, S., Mittal, D., & Anand, K. (2010). Yoga in male sexual functioning: A noncom- pararive pilot study. Journal of Sexual Medicine, 7(10), 3460-3466. doi: 10.1111/j.1743-6109.2010.01930.x Rakhshani, A., Maharana, S., Raghuram, N., Nagendra, H.R., & Ven- katram, P. (2011). Effects of integrated yoga on quality of life and interpersonal relationships of pregnant women. Quality of Life Re- search, 19(10), 1447-1455. doi: 10.1007/s11136-010-9709-2. Sherman, K.J., Cherkin, D.C., Erro, J., Miglioretti, D.L. & Deyo, R.A. (2005). Comparing yoga, exercise, and a self-care book for chronic low back pain: A randomized, controlled trial. Annals of Internal Medicine, 143(12), 849-856.