Stress and the core: the hidden effects on the pelvic floor

A dramatic rise in pelvic pain and organ prolapse during the global pandemic highlights the link between chronic stress and dysfunction in this area of the body, writes women’s health expert Dianne Edmonds. 

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KEY POINTS

• Hidden pelvic floor issues and pelvic pain affect both men and women 
• These are impacted by increased stress and anxiety as well as reduced sleep quality 
• Pelvic floor muscles can be either too weak or too tense 
• 1 in 2 women who have had children experience a pelvic organ prolapse, 1 in 3 stress urinary incontinence (leakage of urine with a cough, sneeze, laugh, lift or exercise) and 1 in 5 experience pelvic or sexual pain 
• Challenging emotions can result in breath holding and muscle tightening 
• The emotional ‘waves’ experienced during the pandemic may contribute to a build-up of muscle tension for some clients 
• Holding excess tension in the abdominal wall can put pressure down on the pelvic floor, increasing the risk of issues for some clients 
• Stretches, releases and ‘pelvic floor friendly’ exercises can be built into client programming, following screening for pelvic floor issues

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In the first few months of the global pandemic, Melbourne-based Specialist Pelvic Health Physiotherapist, and director of Women’s & Men’s Health Physiotherapy, Shan Morrison noticed a dramatic increase in the number of clients presenting with pelvic pain and pelvic organ prolapse. 

Pelvic organ prolapse is when one or more of the pelvic organs (the bladder, uterus or bowel) drops, and occurs in one in two women who have had children. It is likely, therefore, that some of your female clients will have a prolapse, which can impact how much and what type of training is suitable for them.  

The effects of the pandemic, including the changes to exercise patterns, the closure of gyms and training options plus increased time at home with children, have been some of the factors that may have led to the increase in women being affected by prolapse. 

Pelvic pain is a condition experienced by many Australian women and men, but is rarely spoken about.  Pelvic pain is pain felt in the pelvic area, including the genitals, and often involves changes in bladder, bowel and sexual function. Pelvic pain is unique to pain in other areas of the body, due to the pelvis containing our crucial organs for living – the bladder, bowel and reproductive organs. Problems in the pelvis are therefore highly distressing for many people. 

The stress associated with the pandemic has led to worsening pelvic pain for many people, according to Morrison; “Humans are not built to cope with constant stress. Chronic stress can lead to hypervigilance in the central nervous system (CNS) which has a negative effect on pain. Pain is felt when the brain decides that the perceived threat or danger of a current situation is greater than the perceived safety. When the brain is in a hypervigilant state, this threshold is lower, meaning pain is more easily experienced” she explains. 

Sleep disruption can also contribute to pain. Many studies have found that sleep disturbances lead to hyperexcitability of the CNS and lowering of the pain threshold. For example, one study found that a single night of sleep deprivation has been found to increase anxiety and pain in healthy people.  It is likely that a vicious cycle exists, with poor sleep leading to lower pain thresholds, which contributes to enhanced sensitivity to pain, which in turn worsens sleep quality. 

Being aware of hidden pelvic floor issues 

The pelvic floor is a group of muscles at the base of the pelvis in both women and men, which provides support to the pelvic organs. It forms the base of the core and its function can be affected by pregnancy and childbirth, constipation and straining, heavy lifting, types of exercise and the effects of physical and emotional stress. 

Having an awareness, through screening, of your clients, and being open to discussing pelvic floor issues and the effects of stress on their bodies can enhance your prescription of appropriate training programs for clients who have, or are at risk of having, a prolapse or other pelvic floor issues. 

Stress urinary incontinence 

Another pelvic floor issue more common in women than in men, is stress urinary incontinence (SUI), which is when there is involuntary loss of urine with a cough, sneeze, laugh, lift or exercise. Pregnancy, childbirth and menopause are contributing factors, however studies by Bo and colleagues show that that SUI rates are also high among women who exercise, and young female athletes who have not had children, including 80% of elite trampolinists. 

Men have a pelvic floor too 

The pelvic floor muscles have typically been seen as ‘women’s business’, but men have a pelvic floor too. Shan regularly sees men with pelvic floor problems in her clinic. “When a man’s pelvic floor is not working properly, it can lead to bladder problems, bowel problems, erectile dysfunction, or pain in the genitals and pelvis. Many of these problems can be improved, and often cured, by seeing a pelvic floor physiotherapist” explains Morrison. 

The most common time for men to experience urinary incontinence is following surgery for prostate cancer. Seeing a physio before and after surgery helps speed up recovery of bladder control. 

Similarly to women, a man’s pelvic floor muscles can either be weak or tense. “A weak pelvic floor is often caused by years of heavy lifting, constipation and straining when going to the toilet, having a chronic cough, being overweight or inactive, or ageing” says Morrison; “A tense, or ‘overactive’ pelvic floor, is less well known, but something we see very commonly at the practice. A tense pelvic floor can be caused by stress or anxiety, doing too much core exercise, poor core stability, too much sitting or bike riding, or following pain, trauma, or surgery in the pelvic region, such as having a vasectomy.” 

How can you help your clients protect their pelvic floor?  

You can assist your clients in a number of ways: 

• Screening tools exist for pelvic floor issues. One option is to use the male or female form available on the Pelvic Floor First website. 
• Pelvic floor protection strategies (see References at end of article) can be considered during many aspects of training, with particular care being taken with clients who are at risk of pelvic floor issues. 
• Choose ‘Pelvic floor friendly’ training options for clients with pelvic floor issues or who are in the ‘at risk groups’ of pelvic floor problems. While more prevalent in women, men can also use ‘pelvic floor friendly’ training options if they are at risk. 
• Cue for good technique during resistance training – poor technique shows up with fatigue, the accumulation of muscle tension or due to muscle weaknesses 
• Encourage clients to exhale with effort during resistance training. Bring an awareness to their breathing patterns during training 
• Program for gradual increases in strength, especially if they have had a break from training, are feeling tired or fatigued due to sleep disruption 
• Monitor and observe changes in form with increased load or onset of fatigue 
• Look out for breath holding and excessive tension in the upper abdominals as this can cause pressure to be exerted down onto the pelvic floor and increase the load on these muscles 
• Advise your clients that if they feel any pain, pressure or heaviness in the pelvic area during training, these are warning signals. Modify their training by reducing their load or training duration. Direct them to seek further advice if they notice any development or worsening of pain or pelvic floor issues. 
• Encourage clients to listen to their bodies and to modify any exercises that make them feel vulnerable or that make them more aware of their symptoms. 

The physical effects of challenging emotions 

Dr Joan Rosenberg, psychologist, TEDx speaker and author of 90 Seconds to a Life You Love, explains that what we feel emotionally is experienced in the body first as a bodily sensation, for example, embarrassment is felt as a flush in the face. Dr Rosenberg explains that anger as an emotion may be felt as a tightening of the muscles around the jaw. 

She identified that there are eight common uncomfortable emotions, and these are normally felt as bodily sensations. Common ways to distract from the experience of these unpleasant emotions can include eating or shopping. Less obvious forms of distraction include holding the breath, tightening of muscles, and swallowing. 

Neuroscientists describe how, when these bodily sensations are triggered, a rush of biochemicals is released into the bloodstream, and are then flushed out of the bloodstream within 60 to 90 seconds. Rosenberg and neuroscientists describe this as ‘a wave’ and say that in order to ‘ride the wave’ an awareness of what the emotions are is required. This needs the ability to stay fully present in order to ‘ride the wave’ for an upper point of 90 seconds. There can be more than one ‘emotional wave’ in a row to be ridden. 

During this pandemic, the emotional ‘waves’ which clients have experienced have come as a surge for many. Without the awareness and ability to identify and fully process these emotions, for some clients can it be assumed there has been a build-up of muscle tension in the body? 

For those who hold their breath in response to experiencing difficult emotions, what effects does this have on the body? 

How can holding the breath affect the core? 

Breath holding as a pattern can alter the normal flow of inhalation and exhalation and increase the use of accessory muscles in the neck. Over time, rib expansion may be restricted, particularly if regular exercise patterns have been disrupted due to gym closures and restrictions around group fitness and outdoor exercise programs. 

Breath holding can cause tension to be held in the abdominal wall, and this also alters the excursion of the diaphragm (the movement of the thoracic diaphragm during breathing). Holding of excessive tension in the abdominal wall can put pressure downwards on the pelvic floor. If they have a vulnerability in this area, some clients may be more at risk of experiencing the increase or onset of symptoms involving the pelvic floor and pelvis. 

Providing clients with opportunities to open up the ribcage, lengthen the upper abdominals and focus on diaphragmatic breathing may assist them in reducing the effects of excessive tension or breath holding. For clients who spend more time sitting, hip flexor stretches can also be an area to focus on. 

Exploring 90-second stretches 

Rosenberg suggests one strategy to deal with the effects of difficult emotions is to count to 90 seconds, bringing an awareness to the bodily sensations occurring and their reduction as the neurochemicals leave the body. 

In considering ways to enhance this skill and awareness, could elongating some stretches for clients to a duration of 90 seconds give them the opportunity to feel the bodily changes that occur during this length of time, while simultaneously releasing muscle tension? 

The following stretching exercises may be appropriate for this purpose: 

Extension stretch over ball 

• Seated on the floor with the ball supported, the client leans back on the ball, opens up the chest and lifts the ribcage. 
• To extend the stretch (ensuring that no pressure is felt down on the pelvic floor) the client lifts their buttocks to roll their upper back onto the ball (photo 1). 

• A client can be guided to move further back, adding further release through the shoulders, anterior ribcage and the upper abdominal wall (photo 2). 

• For clients feeling stable on the ball, lowering the neck can stretch the anterior neck muscles and further open up the chest, also lengthening the abdominal wall (photo 3). 

Prone lying/propping stretch  

At each stage of this stretch, a client may choose to stay in that position or to progress to the next position to feel a comfortable stretch with no pain. 

• Instruct the client to move into a prone position. 
• Prop up on their elbows to feel a gentle stretch in their lower back (photo 4). 

• Push up to lift elbows and add an upper abdominal stretch (photo 5). 

• Extend the stretch to the hip flexors, lengthening the abdominal wall further through extending the elbows to straighten the arms (photo 6). If there is soreness or an uncomfortable restriction, drop back down into the prone lying or elbow propped position. 

Sitting – rotation 

• In a seated rotation stretch clients can feel the release through their obliques (photo 7). They can focus on their breathing while holding the stretch and feel where any overpressure (additional manual force application) is needed.  

Referring your clients  

Clients can be referred to their GP for any mental or physical health issue or you can directly refer to a women’s, men’s and pelvic health physiotherapist in your area for pelvic floor issues. More information on the location of physiotherapists is available from The Australian Physiotherapy Association. 

For further information you can also call the Continence Foundation of Australia Helpline on 1800 33 00 66 or visit pelvicfloorfirst.org.au 

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REFERENCES & FURTHER READING 

Bø, K., Nygaard, I.E. Is Physical Activity Good or Bad for the Female Pelvic Floor? A Narrative Review. Sports Med 50, 471–484 (2020). 

Hannibal KE, Bishop MD. Chronic stress, cortisol dysfunction, and pain: a psychoneuroendocrine rationale for stress management in pain rehabilitation. Phys Ther. 2014;94:1816–182 

Nijs, J., Mairesse, O., Neu, D., Leysen, L., Danneels, L., Cagnie, B., Meeus, M., Moens, M., Ickmans, K. and Goubert, D. (2018). Sleep Disturbances in Chronic Pain: Neurobiology, Assessment, and Treatment in Physical Therapist Practice. Physical Therapy, 98(5), pp.325-335. http://www.wmhp.com.au/blog/link-between-sleep-and-chronic-pain 

Dr Rosenberg: https://drjoanrosenberg.com/  

Pelvic Floor First: http://www.pelvicfloorfirst.org.au/pages/pelvic-floor-resources.html and http://www.pelvicfloorfirst.org.au/data/files/Pelvic_Floor_First/10_step_guide_to_pelvic_floor_safe_exercise.pdf 

Jean Hailes: https://www.jeanhailes.org.au/health-a-z/bladder-bowel/prolapse-bladder-weakness 

Women’s & Men’s Health Physiotherapy: http://www.wmhp.com.au/blogs/men-have-pelvic-floor-too and http://www.wmhp.com.au/blog/stress-anxiety-pelvic-pain-a-challenging-combination 

Australian Physiotherapy Association https://choose.physio/find-a-physio

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Dianne Edmonds 

A physiotherapist based in an obstetric GP clinic, Dianne is a course creator, Women’s Health Ambassador for Australian Fitness Network and the Director of The Pregnancy Centre. She has worked in women’s health and fitness for 25 years and was integral in the development of the Pelvic Floor First resources.