A Clinical Approach to Pelvic Floor Exercises. The Essential Guide to Technique (Part 2)
I started writing this blog post and I noticed that it became too big, as you can see there is quite a lot to take on on just do your kegels (and I quite like a bit of detail). So I decided to divide it in 3 parts. Today, we will learn about your breath.
In my clinical practice, I often debate the utility of publishing generalised guides on "how to do pelvic floor exercises." As a specialist physiotherapist, my core clinical philosophy is that true pelvic floor restoration extends far beyond the repetitive, isolated "squeezes" we have been historically taught to perform.
When we reduce pelvic health to a mechanical clench, we miss the most critical element of rehabilitation: proprioception.
Proprioception is your nervous system’s ability to sense the position, movement, and tension of your body in space. Basically, understanding where we are and what we do. For many of my patients, the primary dysfunction is not an absolute lack of muscle strength, but a profound disconnect between the brain and the pelvic floor. Before we can strengthen a muscle, we must first be able to feel it, isolate it, and integrate it into our wider functional movement. (2)
If you are looking to truly engage your pelvic floor, we must shift the focus from forceful exertion to mindful, sensory awareness. Here is my clinical approach to re-establishing that vital brain-body connection.
1. Re-establishing Proprioception: The Breath as the Foundation
For the mums that participated in my postnatal classes, you might remember that this was the first thing I wanted you to learn:
B R E A T H
You cannot effectively engage a muscle that you cannot feel. Because the pelvic floor is situated internally, many individuals suffer from sensory motor amnesia in this region. We don’t remember how it works because we are barely taught about it, or not taught at all. When asked to engage the pelvic floor, they will frequently bear down, hold their breath, or aggressively clench their glutes and inner thighs to manufacture a sensation of "effort." (4)
To bypass these compensations, we must start with the breath.
Position: Lie on your back with your knees bent. Place your hands on your lower ribcage and abdomen.
The Yield: Breathe deeply into the bases of your lungs. As the diaphragm descends, your internal organs shift downward. To accommodate this, your pelvic floor must naturally lengthen and widen.
The Proprioceptive Focus: Do not try to contract anything yet. Spend several minutes simply trying to feel this subtle, downward yielding at the base of your pelvis as you inhale. If you cannot feel the muscle relax and lengthen, you will not be able to effectively recruit it to contract.(1.3)
2. The "Lift" vs. The "Squeeze"
Once you can sense the natural movement of your pelvic floor with your breath, we can introduce active engagement. We must move away from the aggressive "squeeze" and instead focus on a nuanced, coordinated, elegant "lift."
The Exhale: Begin a slow, controlled exhale.
The Subtle Closure: Gently close the physiological openings of the pelvic floor (visualise stopping the flow of wind and urine simultaneously). I always mention to squeeze the back passage first(stopping wind) and then, to add into your squeeze, the vagina (stopping wee). This should require perhaps 30% of your maximum effort. It is not a rigid clench. ()
The Internal Lift: Once closed, draw that tension gently upward into your pelvis, toward your navel. Imagine your sit bones subtly drawing toward each other.
Checking for Compensation: This entire movement should be completely invisible from the outside. If your pelvis tilts, your buttocks tighten, or your jaw clenches, your brain is recruiting secondary muscles to do the work of the pelvic floor. Stop, breathe, and try again with less effort.
3. Release
In my practice, I find that a hypertonic (chronically tight) pelvic floor is just as common as a weak one. A muscle that is held in a state of constant, low-grade tension loses its dynamic range of motion. (5)
The Eccentric Return: After holding your subtle lift for a few seconds, do not just let the muscle drop. Slowly and consciously release the tension.
Finding True Resting Tone: Follow the release with a deep diaphragmatic inhale, consciously directing your awareness to the base of your pelvis to ensure the muscles have returned to a completely softened, neutral state.
Moving Beyond the Basics
Pelvic floor rehabilitation is an exercise in neuromuscular retraining. It requires patience, deep sensory awareness, and often, highly specialised guidance. When you understand how to feel and coordinate these muscles in isolation, we can then begin the vital work of integrating them into your dynamic, everyday movements.
If you are struggling to find this mind-muscle connection, or if you are experiencing symptoms like heaviness, pain, or leakage, it is time to move beyond generic exercises, you can schedule a comprehensive, individualised assessment at Flor Pelvic Health Physiotherapy
References
1.Bordoni, B., & Zanier. (2013). Anatomic connections of the diaphragm influence of respiration on the body system. Journal of Multidisciplinary Healthcare, 281. https://doi.org/10.2147/jmdh.s45443
2.Díaz-Álvarez, L., Lorenzo-Gallego, L., Romay-Barrero, H., et al. (2022). Does the Contractile Capability of Pelvic Floor Muscles Improve with Knowledge Acquisition and Verbal Instructions in Healthy Women? A Systematic Review. International Journal of Environmental Research and Public Health, 19, 9308. https://doi.org/10.3390/ijerph19159308
3.Hwang, U., Lee, M., Jung, S., Ahn, S., & Kwon, O. (2021). Effect of pelvic floor electrical stimulation on diaphragm excursion and rib cage movement during tidal and forceful breathing and coughing in women with stress urinary incontinence. Medicine, 100, e24158. https://doi.org/10.1097/md.0000000000024158
4.Piernicka, M., Błudnicka, M., Bojar, D., Kortas, J., & Szumilewicz, A. (2022). Improving the Technique of Pelvic Floor Muscle Contraction in Active Nulliparous Women Attending a Structured High–Low Impact Aerobics Program—A Randomized Control Trial. International Journal of Environmental Research and Public Health, 19, 5911. https://doi.org/10.3390/ijerph19105911
5. van Reijn-Baggen, D. A., Han-Geurts, I. J. M., Voorham-van der Zalm, P. J., et al. (2022). Pelvic Floor Physical Therapy for Pelvic Floor Hypertonicity: A Systematic Review of Treatment Efficacy. Sexual Medicine Reviews, 10, 209-230. https://doi.org/10.1016/j.sxmr.2021.03.002