What is pelvic floor PT, anyway?

So, your doctor told you that you should go to pelvic floor PT. Or, you’re recently pregnant and a family member is telling you to do your kegel exercises. Or, you’ve seen pelvic floor PT on social media and have watched a few cursory videos on the topic. But what the heck is it?

Pelvic Floor PT is a subspecialty of physical therapy, same as neurology or pediatrics is a subspecialty. It is very similar to going to physical therapy for any other reason. There are a few key differences, but the essence is the same. If there are muscles, joints, or nerves that aren’t functioning optimally, and your quality of life is impacted, we want to rehabilitate those areas and help you get back to function.

The pelvic floor is a group of muscles that form a sling at the base of your pelvis that support your organs and provide control over bowel, bladder, and sexual function. If everything is working well, you will be able to pee normally, poop consistently, avoid leakage during the day, and have comfortable sex. The pelvic floor also provides stability to the pelvis, helping prevent pelvic girdle pain and SI joint pain.

These structures can be impacted for a multitude of reasons, the top 2 being pregnancy and birth, however chronic stress, straining to have a bowel movement, or previous history of trauma (whether sexual assault, MVA, fracture, etc) can all impact how your pelvic floor is functioning. As a society that consistently does not hit the recommended levels of physical activity, doesn’t eat nearly enough fiber, and that sees rates of depression and anxiety go up every year, it’s safe to say that a good chunk of the people you interact with during the day are having some sort of pelvic floor issue. However, seeing as the functions of the pelvic floor are generally taboo to discuss, it can feel incredibly isolating if you are having some concerns.

Now let’s say you are recently postpartum, and having some stress urinary incontinence - every time you laugh or sneeze, you leak small amounts of urine. You tell a trusted friend or family member, and they tell you to practice kegel, or pelvic floor contractions. It doesn’t really change your symptoms. Why could that be? Aren’t you strengthening the muscles that will help?

Well, this relates to a phenomenon known as the length-tension relationship.

"The length-tension property of a whole muscle (or muscle fiber or sarcomere) is the relationship between muscle length and the force the muscle can produce at that length."

Each muscle in the body is made up of sarcomeres, which is the smallest functional unit. It is made up of proteins called actin and myosin that slide back and forth across each other, shortening and lengthening the overall muscle. The amount of tension that each sarcomere unit can produce depends on the length of the sarcomere. Therefore, if we want the muscle to be able to produce a certain amount of tension, it has to be at the correct resting length. Functionally, that means that if we want a muscle to be able to perform while we are doing certain tasks, it has to be at the correct length of not too tight, and not overstretched. Everyone’s correct length will be a little different, but it’s fair to assume that if a muscle isn’t working as you would like it too, it could be tight/short, or weak/overstretched.

When the sarcomere is at a certain length, it can achieve nearly 100% of maximum tension (think of a really good muscle contraction - holding in the urine when you are jumping!) As the sarcomeres get longer, there is some forgiveness if the muscle is a little longer than optimal, but if stretched to end range there is nearly no active tension generated. However, shortening has a rapid drop in tension - not as forgiving.

So, let’s put this in practical terms. Chronic stress, muscle tightness from sitting for prolonged periods of time, increased strain from both pregnancy and birth, potential perineum tearing causing pain and (you guessed it) more tightness, will all cause a global shortening in the muscle. It will not be able to withstand the pressures put upon it by, say, sneezing or jumping. More contractions when doing kegels alone will not improve the strength of these muscles. We need to improve the length-tension relationship!

So, Allison, how do we do that?

Thanks for asking.

There are a lot of techniques we can use to improve resting length of the muscle. If there is chronic stress from straining to have a bowel movement, working on increasing fiber intake, hydration, and proper bowel hygiene can take some of the load off. Deep breathing techniques and diaphragmatic breathing can decrease stress and allow for gentle pelvic floor lengthening. There are also stretches for these and surrounding areas, as well as targeted internal and external manual therapy.

Now, humans are not robots. The length-tension relationship is not the only thing impacting how we function. Pain can inhibit proper functioning of muscles, as well as scar tissue development from surgery or a perineal tear repair. However, this is a great way to illustrate how pelvic floor PT works. Every patient will respond a little differently to each intervention, and that’s why we have a lot of tools in our toolbox. However, emphasizing up to date research, muscle retraining, and appropriate lifestyle interventions can be life-changing.

Since pelvic floor PT can be more invasive than regular orthopedics (whether it be due to the nature of the symptoms, or performing an internal vaginal exam), the therapeutic relationship is even more important. Seek out a provider that you feel comfortable with! Don’t hesitate to explore your options, ask all of your questions, and take the time to consider who is best. But don’t delay receiving the care that you need!

Let me know if you have any questions! Hope you have a great week.