By Dianne Edmonds and Marietta Mehanni

“Lower back pain is also strongly linked with pelvic floor weakness and there is certainly an awareness that aqua aerobics provides a safer choice of fitness program for these individuals.”

Introduction

Many people who want to continue exercising without the implications of impact, joint stress, post-exercise muscle soreness and overheating issues will prefer to exercise in water. This cliental group is usually, also the population group that is challenged by pelvic floor issues. It is well known that mature adults and certainly menopausal or post-menopausal women would also prefer to exercise in water because of the issues with ‘wetting themselves’ during land-based exercise. Pregnant women and obese clients would also prefer to exercise in water for the obvious reduced impact benefit, but also because the pelvic floor is more protected in water.

Lower back pain is also strongly linked with pelvic floor weakness and there is certainly an awareness that aqua aerobics provides a safer choice of fitness program for these participants. It is clear, then, that aqua aerobics has not only massive appeal for these population groups for the benefits of exercising in water but also because of the potential pelvic floor issues that they will face with land-based exercise. This provides aqua aerobic instructors with a huge opportunity to provide much-needed education, information and instruction on what is the pelvic floor and how to use it during the workout.

Teaching correct pelvic floor technique

A lifting and hold action is desired when activating the pelvic floor inside the pelvis, and the muscles will work more effectively when the lumbar spine is in neutral. Clients need continual reminders and instructions on what an accurate pelvic floor contraction is so that they don’t breathe hold or bear down while they exercise.

In aqua classes pelvic floor muscle exercises can be included in standing, during cool down, stretch or postural awareness components.

Verbal cueing phrases that can be used in an aqua class include:

“Focus on lifting your pelvic floor on the inside”

“Drawing up inside, tightening around your front and back passages”

“Imagine you are holding onto a full bladder and wind at the same time” (in whatever way you feel most comfortable saying this)

Another way to cue is to also suggest what not to do:

“Breathe, don’t suck in the ribs and upper abdominal area (under the ribcage)”

When the pelvic floor and the transverses abdominus are working well with correct “patterns of recruitment” then they should work together. Descriptions to explain this to participants may include:

“The pelvic floor and low abdominals are wired up to work together”

“They work best when they work together”

Between contractions, advise participants that it is OK to feel their lower abdominals tighten, but that they shouldn’t feel tightening under their ribs or in their upper abdominal area.

Hold times for contractions can vary from 2-3 seconds up to 5-10 seconds, although long holds may mean the clients will cool down in the pool environment.

Relaxation needs to be emphasised to clients also

• “When you relax you should feel your pelvic floor muscles release completely”. If they don’t feel a relaxation – their pelvic floor muscles have fatigued, and they have relaxed already, or they may still holding them tightly and they should focus on relaxing between the contractions. To check if the muscles are fatiguing, they can do a shorter contraction eg 2 -3 seconds, and if they then feel the muscles relax, they will gain the awareness of their own PF muscle hold time, and be able to work on building that ‘hold’ time up over time.

Further variation includes pelvic floor exercises with movements such as pelvic circles and figure eight exercises.

Land verses Water

Buoyancy

The effect of buoyancy decreases the gravitational forces acting through the pelvis and therefore a decrease in the pressure on the pelvic floor with exercise compared with similar exercises on land. Buoyancy does not simply affect the force of the internal organs on the pelvic floor, but also in fact ‘floats’ the internal organs, so even jumping and jogging exercises that would normally be not recommended for land-based activities are still appropriate in the water. This is of particular benefit for clients who are pregnant or obese. There is a precaution here – this depends on how jogging is performed.

Fast verses slow

When performing either a fast or slow jog, there are marked differences between the two activities. Similar responses were also found with other exercises, for example, cross-country ski, jumping jacks and kicks. What was discovered with these classic aqua moves was that when they were performed with speed and consequently more turbulence, the pelvic floor responded by lifting and engaging with the transverse abdominals to create a stable torso. Slower rebounding actions created more force on the pelvic floor. Very slow actions allow for more attention to pelvic floor activation, but it is not effective for cardiovascular training.

Buoyancy equipment – Dumbbells, Noodles, Kickboards

Buoyancy equipment is predominantly used for buoyancy-resisted and buoyancy-supported exercises. Buoyancy-resisted exercises are when the buoyant tool is pushed down into the water or kept submerged whilst performing various shallow or suspended exercises. Quite often participants hold their breath and thus bear down onto their pelvic floor when performing buoyancy-resisted exercises, which is problematic if there is pelvic floor weakness. This inappropriate use of the core muscles could be a factor leading to pelvic floor weakness.

Buoyancy-supported exercise is when the body is fully supported by the buoyant tool. This method is often used for suspended exercises and is the recommended alternative to buoyancy-resisted suspended exercises. Buoyancy-supported exercises provide the opportunity for clients to focus on recruiting the pelvic floor and breathing correctly whilst performing the exercises. When using dumbbells and noodles for buoyancy-supported exercises, these tools need to be held under the armpits, below the buttocks or between the legs. Gripping with the hands may encourage some participants to hold their breath, thus defeating the purpose of performing buoyancy-supported exercises.

Breathe

Breathing is an essential component when performing buoyancy-resisted exercises. Forced exhalation is required when the buoyant equipment is pressed downward and inhalation is when the tool is released to the surface. When the buoyant tool is submerged for a lengthy period to either suspend the body or to develop muscle endurance, breathing cues are extremely important. The verbal cues need to be graduated and layered slowly to ensure that participants are not overwhelmed with too much information.

References:

1. Bump, R C; Hurt, G; Famtl, A and Wyman, J (1991). ‘Assessment of kegel pelvic floor muscle exercise performance after brief verbal instruction’. American Journal of Obstetrics and Gynaecology. pp 322 – 329.
2. Sapsford, R R, Hodges, P W, Richardson C A, Cooper, D H, Markwell, S J and Jull, G A (2001). Co-activation of the abdominal and pelvic floor muscles during voluntary exercises. Neurourology & Urodynamics, 20, 31-42.
3. Thompson, J.A., O’Sullivan, P.; Briffa, K.; and Neumann, P.  Assessment of pelvic floor movement using transabdominal and transperineal ultrasound. International Urogynecology Journal 2005; 16: 285-292.
4. Thompson, J.A., O’Sullivan, P.; Briffa, K.; and Neumann, P (2006). Differences in muscle activation patterns during pelvic floor muscle contraction and Valsalva manouevre. Neurourology & Urodynamics, 25, 148-155.