B K S Iyengar describes pranayama as an “extension of breath and its control”1. Pranayama, or breathwork, includes inhalation, exhalation, and breath retention. As clinicians treating pelvic health, there are several clinical applications for breathwork.
Mechanical relationship to the pelvic floor
Physical therapists Paul Hodges (et al) and Julie Wiebe describe a piston-like relationship between the diaphragm and pelvic floor2,3. Applying mindfulness to breathing can enhance this relationship, especially if muscular holding patterns in the pelvis are secondary to pain.
On inhalation, the diaphragm moves caudally and the pelvic floor muscles respond to this change in pressure, also lengthening caudally. On exhalation, the diaphragm and pelvic floor muscles reverse direction and ascend cranially4. As clinicians, we can offer patients the tool of using the breath in coordination with the pelvic floor muscles.
We can tailor breath awareness to our clinical goals of downtraining or facilitating the pelvic floor muscles. Cuing to downtrain gripping patterns in the pelvic floor can be supportive for people experiencing pelvic pain. Facilitating the pelvic floor in coordination with the breath can help obtain optimal stability and continence.
Pelvic organ prolapse, stress urinary incontinence, and fecal incontinence are often associated with a lack of tonic support/muscular strength and coordination of the pelvic floor, core, and surrounding pelvic girdle musculature5. Optimizing pelvic floor support with adequate strength, core stability, and neuromuscular control can help improve continence and pelvic organ support.
The local core stabilizers (pelvic floor muscles, transverse abdominals, multifidi, and diaphragm) coordinate to provide optimal core stability6. Mary Massery conceptualized the “Soda Pop Can Model of Postural Control”. This illustrates how the pressure system of an aluminum soda will maintain the stability of the structure7. Non-optimal control of pressure can happen at the top of the canister (i.e. tracheotomy), front (i.e. diastasis recti abdominus), back (i.e. disc herniation), or bottom (i.e. pelvic organ prolapse or incontinence). A “leak” in the structural integrity could affect postural control, core stability, and continence. This concept underlines the importance of breath retraining as one aspect of our treatment plan.
Nervous system relationship to pelvic pain
Breathwork offers your patient an instant strategy to offset a rise in sympathetic nervous system activity, which happens when someone experiences pain. Creating a mindful pause can encourage a shift in the autonomic nervous system by invoking a parasympathetic response.
Diane Lee highlights some common areas of holding patterns in the body, including lateral and posterior-lateral expansion of the rib cage during inhalation8. By paying attention to our breathing we can increase range of motion in the thorax, especially for folks who wear sports bras or bind. We can practice exploring diaphragmatic breathing without gripping the chest and abdominal wall.
Example of pranayama
Dirgha
Dirgha is also called the Three-Part Breath.
- Inhale and allow the belly to fill. If this feels this challenging, you could place a book on your belly laying supine or try breathing in quadruped.
- Continue the breath up into the ribcage and feel the lateral and posterior lateral aspect of the ribs opening.
- Third aspect is allowing the collarbones to float up, unless you are trying to retrain dominant apical breathing
- After trying this for 10 breath cycles, stop and notice sensations in the body. It can be helpful to set an alarm during the day as a reminder to pause, move, and breathe.
Integrating into the clinic
Breathwork can be performed supine, sitting with hands for feedback on the abdomen and chest, or integrating with movement. These examples are only the beginning of possibilities!
To learn more, join Dustienne in her remote course Yoga for Pelvic Pain this year! Courses are scheduled for March 16-17, May 4-5, and September 14-15.
References:
1) Iyengar BKS. Light on Yoga: Yoga Dipika. Schocken; 1995.
2) Sapsford RR, Richardson CA, Maher CF, Hodges PW. Pelvic floor muscle activity in different sitting postures in continent and incontinent women. Arch Phys Med Rehabil. 2008;89(9):1741-1747.15.
3) Julie Wiebe, Physical Therapist | Educator, Advocate, Clinician. 2015; http://www.juliewiebept.com/.
4) Talasz H, Kremser C, Kofler M, Kalchschmid E, Lechleitner M, Rudisch A. Phase-locked parallel movement of diaphragm and pelvic floor during breathing and coughing-a dynamic MRI investigation in healthy females. Int Urogynecol J. 2011;22(1):61-68.
5) Sapsford R. Rehabilitation of pelvic floor muscles utilizing trunk stabilization. Man Ther. 2004;9(1):3-12.
6) Lee DG. The Pelvic Girdle: An integration of clinical expertise and research, 4e. Churchill Livingstone; 2010.
7) Massery M. THE LINDA CRANE MEMORIAL LECTURE: The Patient Puzzle: Piecing it Together. Cardiopulm Phys Ther J. 2009;20(2):19-27.
8) Lee DG. The Pelvic Girdle: An integration of clinical expertise and research, 4e. Churchill Livingstone; 2010.
AUTHOR BIO:
Dustienne Miller, MSPT, WCS, CYTDustienne Miller is the creator of the two-day course Yoga for Pelvic Pain and an instructor for PF1. Born out of an interest in creating yoga home programs for her patients, she developed a pelvic health yoga videos series called Your Pace Yoga in 2011. She is a contributing author in two books about the integration of pelvic health and yoga, Yoga Mama: The Practitioner’s Guide to Prenatal Yoga (Shambhala Publications, 2016) and Healing in Urology (World Scientific). Prior conference and workshop engagements include APTA's CSM, International Continence Society, International Pelvic Pain Society, Woman on Fire, Wound Ostomy and Continence Society, and the American Academy of Physical Medicine and Rehabilitation Annual Assembly.
She started her clinical practice, Flourish Physical Therapy, in Santa Rosa CA, and moved to downtown Boston. She is a board-certified women's health clinical specialist recognized by the American Board of Physical Therapy Specialties. Dustienne weaves yoga postures and breathing into her clinical practice, having received her yoga teacher certification through the Kripalu Center for Yoga and Health.
Dustienne's love of movement is apparent not only in her physical therapy and yoga practice but also in her career as a professional dancer. She danced professionally in New York City for several years, most notably with the national tour of Fosse. She bridged her dance and physical therapy backgrounds working for Physioarts, who contracted her to work backstage at various Broadway shows and for Radio City Christmas Spectacular. She is currently an assistant professor of jazz dance for the musical theatre department at Boston Conservatory at Berklee.
Dustienne passionately believes in the integration of physical therapy and yoga in a holistic model of care, helping individuals navigate through pelvic pain and incontinence to live a healthy and pain-free life. Find her on SM @yourpaceyoga and on her website, www.yourpaceyoga.com, where you will find her blog, guided meditations, videos, and additional resources.