Kegels alone don’t cure – a pelvic rehabilitation perspective.
A Kegel exercise is a voluntary contraction/squeeze of the Levator Ani muscles
performed to train the pelvic floor muscle. It has increased muscle tone and strength
as goal. It can be assessed by the Oxford muscle scale used for other skeletal
muscles. The reason why not all patients who do Kegels get better is because a
strength-only rehabilitation approach is not always to the benefit of the patient.
Patients with pelvic floor dysfunction are desperate for help. And unfortunately the
internet offers many “one size fits all” and “cure all” approaches, including pelvic
stimulators, cell phone applications, magnetic chairs, vaginal rejuvenation therapyand all claim to improve the strength of the pelvic floor muscles. But is a good pelvic
floor contraction enough?
The short answer is no.
As a pelvic floor physiotherapist, I explain pelvic floor muscle rehabilitation to a
patient by using a more visible muscle, namely the calf. If a contraction/strength
was the only goal for a muscle to be deemed effective, the calf muscle would lose
its ability to relax. Walking on the toes is not functional. The biomechanical impact
on the knees, pelvis, hips and lumbar spine would be significant. It is simply never
not only about contracting a muscle.
The calf muscle needs to contract and relax correctly to enable ambulation. The
contraction intensity varies and calves need to contract both concentrically and
eccentrically. Otherwise a static position of plantar flexion is all that is achieved
and will result in pain and fatigue. The calf muscles respond to proprioceptive input
from the whole lower limb. All the above functions are true for the pelvic floor. It is
not enough to be able to contract the pelvic floor. And no number of Kegels alone
can cure pelvic floor dysfunction.
The field of pelvic floor rehabilitation has thankfully developed extensively from the
original “Kegels” of yesteryear.
A pelvic floor rehabilitation plan may include:
● Evaluation of the correct contraction and relaxation of perineal muscles
● Education on anatomy and the present condition
● Pelvic floor muscle training which includes coordination, control, and
incorporating other muscle groups into activities of daily living
● E-stim, Biofeedback (EMG, RTUS), Electrotherapy
● Vaginal cones
● Hypopressive abdominal techniques
● Urotherapy
Physiotherapists also address co-existing lumbo-pelvic conditions and incorporate
the coordinated working of the Abdomino-pelvic synergists in individualised
rehabilitation programmes to suit the activity level of the woman.
Kegels alone don’t cure pelvic floor dysfunction
The proper assessment of pelvic floor musculature enables the pelvic floor
physiotherapist to establish realistic therapeutic goals. Muscle training should be
aimed at reaching the objectives. A functional pelvic floor will provide urethral support
as well as pelvic organ support not only in a static environment but during activities of
daily living. Correct rehabilitation will improve muscle strength, tone, resistance as
well as coordination to contract appropriately in response to increased intra-abdominal
pressures during activities of daily living. Rehabilitation should be aimed at both slow
twitch and fast twitch muscle fibres of the muscle group. The pelvic floor must lengthen
and shorten appropriately for each phase of movement in a coordinated fashion. A
constantly shortened and contracted pelvic floor prevents defecation, intercourse and
increases pelvic pain.
A sufficient supportive resting tone prevents prolapse. A strong and speedy
contraction will prevent leakage sudden surges in intra-abdominal pressures. The
therapist will progress the pelvic floor training by altering the position of exercise and
increasing complexity by increased resistance, adding more muscle groups and
functional movements.
Hypertonic pelvic floor muscles cannot contract effectively and require manual
techniques to enable relaxation to occur. Patients should be equipped with relaxation
exercises, breathing exercises, flexibility drills and awareness to enable them to
correctly use the pelvic floor in a relaxed manner during defecation, intercourse and
exercise.
The pelvic floor should never be used in isolation and needs to be incorporated into
activities of daily living for example: a mother who needs to lift her three-year old or
the older lady who carries shopping bags.
When patients are asked to carry out a voluntary contraction of the pelvic floor about
one third do not perform the contraction correctly or they perform a Valsalva
maneuver. In individuals with pelvic organ prolapse, this may aggravate the condition.
A correctly taught and executed pelvic floor muscle contraction will, in time,
hypertrophy the muscles, improve response time, strength and effectiveness of the
pelvic floor support and closure functions.
As pelvic floor physiotherapists we strive to rehabilitate a patient holistically, with a
variety of techniques depending on the presentation. Referral to a physiotherapist for
an evaluation and correct treatment program will benefit the patient more than Kegels
ever can.