Tuesday, 5 September 2017

Kegels Vs. Reverse Kegels


The term kegel was first coined by Arnold Kegel in 1948 (1). Although it seems like Kegels are relatively new, kegels were an important part of Chinese Toaist exercise programs for the last 6000 years (2). Kegel exercises are best described as, squeeze like you are stopping the flow of urine.

These exercises were found to be helpful in reducing urinary symptoms, pelvic organ prolapse symptoms and in some cases improving sexual function. Studies have found that more than 30% of women with pelvic floor problems are unable to contract the pelvic floor muscles correctly on their first consultation (3). So 3 out of every 10 ladies who are performing kegels are doing them incorrectly.

Women after childbirth are typically told to perform kegels daily, some might be provided a sheet with instructions but it is not common practice to actually check if this exercise is being performed correctly.

The Kegel itself is an inward lift and squeeze that occurs around the urethra, vagina and anus (3). The pelvic floor muscles contract as a whole but attention can be given to focus awareness to different parts of the pelvic floor.

When I assess the pelvic floor muscles I am looking to see the quality of contraction from left to right and from the front, middle and back muscles. I test for endurance to determine how long you can contract and how many times you can contract to 10 seconds before your muscles get tired. I also test for speed.

The 30% of women that do not perform kegels correctly are usually squeezing around the abdomen, butt muscles or inner thighs. These muscles are around the pelvis but play no part in preventing urine leakage. Another thing I often see is a lack of coordination between the pelvic floor muscles and the diaphragm (our breathing muscle).

You may be wondering why that’s even important. Well, because the diaphragm and pelvic floor move together firstly. Secondly they both are part of the “core” muscles. But let’s look at the first part. When you inhale, the diaphragm muscle flattens downward creating pressure on your abdomen and intestines. To release this pressure generated by the diaphragm and lungs the pelvic floor relaxes so the intestines have more space and therefore less pressure. When you exhale, the lungs deflate and the diaphragm moves upwards allowing the pelvic floor to lift back up.

In the beginning just performing kegels without breathing is fine, but then it needs to be coordinated with breathing. We need to train the “brain” that on exhale the pelvic floor needs to contract. What is a cough or a sneeze? Well it’s a high pressure exhale! What do we need the pelvic floor to do during an exhale? We need it to contract and lift up so we don’t leak.

For those ladies looking to get back into fitness and high impact exercise: regular kegel practice may not be enough for that. With exercise the kegels need to be coordinated with the rest of the core which is made up of the diaphragm, pelvic floor, transverse abdominis (TA) and multifidus a deep back muscle. These muscles turn “on” before movement occurs. They need to contract before a jump, contract before a dead lift, etc.

Ok, so let’s say you’ve been practicing your kegels, but they don’t seem to be helping. What might be some of the reasons.
  • Performing them incorrectly
  • Exercise program not specific enough for your needs.
    • What I mean by this is that the intensity, frequency and duration of your kegel training may not be enough. Exercise programs can vary from 30-360 contractions daily. Length of the hold can vary from 5-30 seconds and programs can run from 6 weeks to 6 months (2). Also the coordination thing I mentioned above, may apply here too. 
  • The pelvic floor is too tight!   
I have been talking a lot about kegels and they are important, BUT, they are NOT for EVERYONE. In some cases kegels can actually make your symptoms worse. Researchers were curious why in some cases women got worse with kegels. They had weak pelvic floors, so naturally kegel training would help. What they found was that women can have “short” pelvic floor muscles which can make them weak and painful (4). By “short” we mean tight/tense.

So why would that matter? If the pelvic floor muscles are tight they will have limited ability to move. If the muscles cannot move through the full range of motion, the muscles cannot generate enough force a) to stop the activity/contraction of the bladder b) generate enough contraction to close the urethra during a cough or sneeze and c) if the muscles cannot move well, you can’t strengthen them well.

Kegels should never be painful when you are performing them. This may be an indication that you are tight and should stop kegels and seek help. If you have to pee a lot and feel that urge to go all the time, you may be too tight. If you are doing kegels and are not getting better you may need to learn the REVERSE kegel.

In some cases, once you learn to relax the muscles properly, strength and endurance comes back on its own. If not, then kegels may need to be re-visited.

To find a therapist local to you for assessment and advice, go to www.pelvichealthsolutions.ca


The Pelvic Health Lady

1.        Wikipedia. 2017. Kegel exercise. Accessed on August 10, 2017 from https://en.m.wikipedia.org/wiki/Kegel_exercise.
2.        Bø, Kari. 2004. Pelvic floor muscle training is effective in treatment of female stress urinary incontinence, but how does it work? Int Urogynecol J, 15: 76-84.
3.        Bø, Kari. 2012. Pelvic floor muscle training in the treatment of female stress urinary incontinence, pelvic organ prolapsed and sexual dysfunction. World journal of urology. 30:437-443).

4.        Fitzgerald, MP and Kotarinos, R. 2003. Rehabilitation of the short pelvic floor. I: background and patient evaluation. Int Urogynecol J. 14: 261-268.

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