the knack: your pelvic floor is for preventing urine leaks when you cough or sneeze

The Knack: my No 1 piece of physio advice for new mums

I still clearly remember  when I helped a client stop leaking in just one week by teaching her the Knack – and she was FURIOUS.

Sarah came to physio with the problem of urinary stress incontinence, leaking urine when she coughed and sneezed. It had been happening since her second son was born……….17 years before.

She had diligently practiced pelvic floor muscle exercises as everyone had told her to. When we checked them properly, with a vaginal examination, her muscles were firm, with an excellent strong contraction.  But, no one had ever explained the connection between practising strong muscle squeezes and WHEN TO USE THE SKILL IN REAL LIFE

I taught her about the Knack.  The next time she came back she was CROSS!  It worked – no leaks when she coughed – and quite rightly she was angry that no one had taught her something so easy, so simple and so effective sooner. It was humbling.  And my priority ever since to make sure I spread the word about this technique.  I don’t want today’s new mums to wait even 17 hours to figure this one out.

What is “The Knack”

The Knack is the magical art of drawing up your pelvic floor muscles just before you cough, sneeze, laugh or pick up something heavy.  Research has confirmed it works *

Your pelvic floor is like a trampette

You probably didn’t have to do this pre-contraction of the pelvic floor before you were pregnant, because a pre-pregnancy pelvic floor has a lot of the Knack: your healthy pelvic floor bounces pressure away like a new trampette natural tone and tension in it.  Like a trampette, straight out of the box from Argos, you can bounce up and down on itand your body weight barely makes a dent in the springy surface.  Pre-pregnancy, most of the down pressure when you cough or jump is deflected straight back up towards your head by the pelvic floor muscles.  Your bladder barely feels a bump.

However, you don’t need me to tell you that pregnancy and delivery have a notable affect on our soft tissues.  The abdominal wall is a clear indicator of what happens when you stretch  elastic slowly and steadily for 9 months.  Some are more lucky than others in the natural ‘spring back’ department.  Most women know that they are going to have to work the Knack: after a pregnancy the pelvic floor is stretched like a used trampetteto restore abdominal muscle tone and strength.   The pelvic floor has carried the same baby-burden and if you had a vaginal delivery (or pushed a long time before eventually needing a caesarean) there will have also been some micro tears to the muscle fibres and their connective tissue attachments.  Now, at least temporarily, the pelvic floor behaves like the well-used trampette – a sense that if you jump too hard your feet might touch the floor!

The Knack creates supportive tension

the knack: what your friends and your pelvic floor are forIf you tighten your pelvic floor muscles, in the exact moment before you cough, it is like two friends pulling your trampette tight for you just for that moment that you want to jump.  Yes, I admit its not ‘natural’, it’s not ideal, it requires thinking, you didn’t have to do it before……but it can make the difference between a bladder leak or not. 

Practice makes perfect

Practice  the Knack with a ‘pretend’ cough after you have had a wee. Your bladder is empty so you are unlikely to come unstuck. Challenge the system gently.  Hold your pelvic floor muscles firmly – cough lightly.  After a few days of practice, when that is feeling safe and secure, challenge the skill by coughing a bit harder.  Then increase your confidence by allowing an hour to pass so that your bladder is fuller when you cough (but start with the lighter coughs again!). 

With practice you will train a “learned-reflex”, a habit.  Your brain gets so used to the sequence of prepare, protect, cough that you do it on auto-pilot.

Sneezes are harder (and coughing fits, choking, vomiting….)

Sneezes are harder to resist with your pelvic floor than coughs, because you have less warning that they are coming and generally they create more downward abdominal pressure. Especially if you are one of those people who make everyone in the room jump out of their skin when you sneeze or are prone to 6 in a row?   A hacking cough with a head cold, or an allergy induced coughing fit are jolly tricky too.  Work on getting the anticipated, lighter coughs sorted first and then the rest can follow as your muscles strengthen.

Allow yourself some slack

Beware multi-tasking – I remember having a full bladder, baby in one hand, the folded Maclaren in the other, one foot on the escalator, and I sneezed – NOPE – the Knack did not work!!!  But hey, I could live with that – it seemed fair – it was a lot to ask of my pelvic floor system. 

If you can successfully use the Knack 9/10 times and only the occasional leak gets through that is excellent. 

Know when to ask for help

The Knack alone might not be enough for you.   Your pelvic floor muscles can be so weak that you need help to get them working again.  And it is possible to have muscles that have repaired too tight or are constantly overworking and becoming easily fatigued or sore.    Remember there are specialist physiotherapists attached to every UK maternity department who can give you an individual assessment, training and support.   Don’t hesitate to ask your GP to refer you to a specialist physiotherapist (full members of pogp.csp.org.uk have extensive post-graduate training).   

Does the Knack work for you? Any questions?  Please do ask, I am very happy to help.

*  Clarification and confirmation of the Knack maneuver: the effect of volitional pelvic floor muscle contraction to preempt expected stress incontinence.   Miller, J.M., Sampselle, C., Ashton-Miller, J. et al. Int Urogynecol J (2008) 19: 773. doi:10.1007/s00192-007-0525-3).

Drawings copyright of A M Savage  (Proudly using stickmen since 1991)

What's the difference between pelvic floor biofeedback and stimulation units?

What’s the difference between a pelvic floor biofeedback device and a stimulation machine?

There are two types of units you can use to help improve your internal muscles –  pelvic floor biofeedback devices and muscle stimulation units.

Pelvic floor Muscle Stimulation Units

These units are designed to be used at home to artificially stimulate the pelvic floor muscles to work. Electrical impulses are sent from the machine directly to the pelvic floor to mimic the messages that your brain is supposed to send. These units are ideal for people who really don’t know where their muscles are or what they are supposed to do. They are also good to use for very weak muscles that can only contract a few times before they fatigue or can only muster a very tiny amount of strength.

  • the sensations (a sort of tingly feeling) created by the electrical impulses help your brain to correctly identify the location of your pelvic floor muscles.
  • the machine will stimulate the muscles to work (contract). It is possible to change the settings to favour different parts of the muscle.
  • you can practice joining in with the machine to learn how to contract your muscles without help
  • the machine can help you to ‘hold’ a muscle contraction while you concentrate on learning to breathe and/or move at the same time
  • we usually recommend that you wait until 3 months postnatally before using a stimulation machine.

Examples of stimulation units:

To be professional, I cannot recommend a single specific product or supplier but I have aimed to narrow down the list of options for  you.  Please do read customer reviews to help you make your decision.  Remember that a specialist physiotherapist like myself has units in clinic for you to try out and borrow if you prefer to try before you buy.

  • Neurotrac Continence is a simple classic pelvic floor stimulation unit which we  have used inNeurotrac Continence is easy to use our clinic for many years.  The buttons are large and few!  It has pre-set programmes for both stress and urgency or your physiotherapist can customise it for you.  Available from Physio & Medical .  Stella is really helpful, you can phone her at 01629 735894.  She has arranged free p&p and a discount for readers £89.59 (includes periform probe) – QUOTE AS-2017 for when placing your order on the phone or use coupon code Conti2 for an online order.
  • Neen Pericalm was recently brought in by a customer.  I also found this one very easy to follow Neen Pericalm is discreet and easy to usethe instructions and set the programmes.  It is also very small and discreet.  Available from Physio & Medical .  Stella is really helpful, you can phone her at 01629 735894.  She has arranged free p&p and a discount for readers  £78.38 (includes periform probe) – QUOTE AS-2017 for when placing your order on the phone or use coupon code Neen3 for an online order.
  • Kegel 8 Mother Nuture (even though it is the cheapest one that Kegel8 offer it has all the Kegel8 Mother Nuture is also a TENS machineprogrammes you will need, plus doubles up as a TENS machine if you anticipate another delivery) £79.99. The kegel 8 Tight & Tone Electronic Pelvic Toner £98.99 looks like a re-package of the Neurotrac Continence which I have used in my clinic for many years (see above).
  • Nu-tek Levator mini continence stimulator.   Win-health  supplies our practice.  It is a Nu-tek levator minigood stimulator though the buttons and set up are a little fiddly until you understand how it works. I recommend you select the Periform probe (which has a hole in the middle rather than solid, most clients find it more comfortable).

Pelvic floor Biofeedback devices

Generally we advise that if you can already contract your pelvic floor muscles then you don’t need to do passive stimulation. The majority of women are ready to jump straight in with a biofeedback unit. Muscles develop quicker by doing ‘active’ exercises where the brain initiates the activity. When you use a biofeedback device to enhance your practice your brain is learning the skill-set that your muscles need to perform in every day life even when you are not plugged in to a machine:

  • With these units the action of your muscles contracting is relayed to a machine which “shows” you what you are doing.  There are several different ways this can be done.  Some machines pick up the electrical signal from your muscles while some respond to pressure.  Some give you a visual picture of what you are doing, others vibrate in response to your contraction.
  • These are great to correctly identify your pelvic floor muscles in different positions and ensure you are contracting correctly and also to help you focus on relaxing fully between contractions
  • to see how well your muscles contract and relax and give you targets to aim for to improve strength, endurance and co-ordination.
  • to practice more complicated tasks (mimic real life tasks)
  • to make exercising a bit more fun and interesting to help you to keep up long-term practice and awareness for your PF muscles (rather like a piece of gym-kit for your pelvic floor!)

 Examples of pelvic floor biofeedback devices:

To be professional, I cannot recommend a single specific product or supplier but I have aimed to narrow down the list of options for  you.  Please do read customer reviews to help you make your decision.  Remember that a specialist physiotherapist like myself has units in clinic for you to try out and borrow if you prefer to try before you buy.

Electrical biofeedback devices:

  • Peritone EMG biofeedback unit and Simplex EMG biofeedback unit are  the ones we have used in our clinic for many years (same device in different packaging).  They are effectively two parts.  You place a small internal electrode (called a Periform, £20, which is single person use,  into the vagina, put your clothes back on, and then link your internal device by a cable to the handheld Pelvitone or Simplex unit (we can loan one of these to you).  When you contract your pelvic floor muscles their electrical activity registers on the screen making the  lights change from orange to green and giving an audible beep.  You can practice your quick maximum power squeezes seeing how high you can make the lights go, practice keeping the lights green while you cough or try moving your arms or legs and there is also a work/rest function which ‘counts’ the endurance holds for you and tells you your average squeeze score at the end.

These devices are widely available from lots of online sellers +/- £160 (including the Periform).  Our practice is supplied by WinHealth –and  Physio & Medical (use code pelvi5 for a small additional discount) both of whom can offer a VAT exemption if the unit if for personal use for a medical problem.

Peritone Biofeedback unit

Peritone EMG biofeedback unit

Neurotrac Simplex

Neurotrac Simplex Biofeedback unit

 

Periform + is very comfortable

Periform internal device

 

 

 

 

 

  •  ELVIE.   This is a new release last year and updates the design of the traditional units above. It is becoming very popular as it has modern smart phone visuals, easy charting and they are developing a sense of community amongst users.   I have one I can show you in clinic but the internal device (the pebble) is the expensive part, and understandably single use only, so I’m afraid you can’t try before you buy.
Elvie pelvic floor tracker and app

Elvie pelvic floor tracker and app

It is a discreet, attractive, wireless bluetooth pebble
shaped device to go inside the vagina and then an app to turn your phone into the biofeedback monitor/exercise tracker.  No cables between you and the phone but you can’t put knickers back on or the bluetooth can’t connect. It is beautifully packaged and well designed by women. It can be used in the second trimester of pregnancy but is not recommended for the 1st and 3rd trimesters.   Available directly from  Elvie £150 for the pepple device,  the phone app is free.  Enter PHYSIO at the checkout for a 10% discount.

Pressure Biofeedback devices

Kegel8 pressure biofeedback

  • Kegel 8 Biofeedback Pelvic Trainer Kegel8 are not offering an electrical biofeedback unit in their products any more. They have a product  which uses a pressure system where you squeeze on a larger tube which moves a dial on the hand held unit.  Relatively unsophisticated but an inexpensive option at £79.99 including VAT.

 

  • Epi-No Delphine Plus £89.99 This is another non-electrical device, which monitors the amount of squeeze pressure you
Epi-no Delphine Plus pressure biofeedback can be used in pregnancy

Epi-no pressure biofeedback

are creating with your muscle contraction.  Though, as with the Kegel 8 Trainer, this is less sensitive than the electrical one the advantage of the Epi-No is that it is  certified for use through your whole pregnancy. It can also be used in the latter part of pregnancy (after 37 weeks) to help to stretch the vaginal opening.  Though a recent study * did not show evidence of a protective effect of the Epi-No device on birth trauma, anecdotally many women feel it has helped with their confidence to relax the vaginal opening in preparation for birth.

*Kamisan Atan I, et al. BJOG 2016  Does the Epi_No birth trainer prevent vaginal birth-related pelvic floor trauma? A multicentre prospective randomised controlled trial.

 

  • The Vibrance Pelvic Trainer  was released in the UK this January, though it has been available in Asia and USA for several years.  It is a petite internal device which vibrates when you correctly contract your pelvic floor muscles.  The device is  discreet and easy to position correctly. There are no wires and you don’t need a handheld device as the vibration is felt in the device itself.

    Vibrance personal trainer

My instinct is that this device could also be useful as a ‘bridge’ back to penetrative sex  if you were a bit nervous of what things will feel like or having trouble relaxing.  You could practice inserting the trainer at your own pace and might find the vibration element helpful to re-sensitise your tissues.   We have one available to try in our clinic (using a condom cover protocol).  They are available directly from  www.vibrancepelvictrainer.co.uk  £140.83 with VAT exemption.

This links to a digitally annotated instructional video for Vibrance PFT on youtube:https://www.youtube.com/watch?v=n8IoqefRzTU

 

Note about VAT exemption

If you have had a problem for more than 3 months you can declare yourself as having a ‘chronic medical condition’ and do not have to pay VAT. There will be a form to complete. This does not apply to the Elvie which is registered as an exercise tracker not a medical device. Not all the online suppliers can offer this service.

Combined Stim & Biofeedback Machines

You can also buy combined units which do both functions but these are surprisingly expensive (and a bit fiddly) so if you feel you need both systems I usually suggest you buy two separate simpler units and switch between them.

Lubricating gel

You will need a water-based lubricating gel to help the insertion of the devices and it is essential to help the electrical devices to operate correctly. A simple, in-expensive, chemist-own or basic brand name  is all you need unless you  have concerns about ingredients and prefer an organic version.   Do read my posts about the difference between water-based and oil-based lubricating products.

Where to start?  

If you are not too sure how good your muscles are then my role at physiotherapy is to do an internal assessment of your pelvic floor muscles to check how well they are working and teach you how to get the best from them. We can loan you both muscle stimulation and biofeedback units to try out at home to see how well they work for you before you consider buying your own. It is particularly important to consider an individual assessment by a specialist physiotherapist if you are at all worried that your pelvic floor muscles might be too tight rather than too weak.

I can also teach you exercises , which require no equipment at all (!) to get your muscles to the best possible condition. I usually combine pelvic floor exercises with appropriate abdominal muscle work as these two areas need to work well together for best support of our internal organs.

Please don’t hesitate to be in touch if you have further questions.

Can Pilates strengthen the pelvic floor?

If you already know how to work your pelvic floor effectively, then yes, definitely, Pilates can help strengthen the pelvic floor.   As both a specialist pelvic floor physiotherapist and an experienced Pilates Instructor this is my area of expertise and I have made a video of my favorite pelvic floor friendly pilates exercises (see below)..

BUT, if your pelvic floor muscles are weak, or ‘switched off’ when you are doing pilates (so they could be perfectly good muscles but your brain is not telling them to work) then you could happily do an entire Pilates class with relatively little impact on the muscles at all. 

Without a proper pelvic floor contraction, challenging Pilates exercises (or aerobics or gym work) might be working you hard, but you will not be getting the proper benefit, and you could even risk making your problems worse by stretching the pelvic floor rather than strengthening it.    So if you have any worries that your pelvic floor is not quite what it should be, do make sure you get your GP to refer you to a Specialist Physiotherapist to get your technique checked before you do too much more with an unprotected pelvic floor.

Video: Pilates for your pelvic floor

In this video I have chosen pilates exercises that my clients find help them particularly focus on the pelvic floor.  I give you lots of extra cues to keep you thinking about the muscles even while you think about your breathing, your abdominals and which way to move your arms and legs!  Pilates done well is a real ‘brain exercise’ too!

Below you can view a (silent!) trailer, then CLICK HERE  to view the full video at pactster.com.  Use my code AmandaPostnatal to view any Pactster video for free for a month.

SPECIALIST PELVIC FLOOR PHYSIOTHERAPY

There is so much that a specialist pelvic floor physiotherapist can teach you to improve internal muscle strength, endurance and co-ordination.  Through post-graduate training we have the skill to properly assess and examine the pelvic floor muscles with a vaginal examination.  We do this in a kind and gentle way putting you as much at ease as we can and aiming to help you understand how they work.  Once, together, we have a better understanding of where your muscles are at presently, we can then show you how to help them to grow and improve your skill at using them to prevent incontinence and improve internal organ support.  It’s not just up/down squeezes!  We have lots of different ways to the standard exercises you may have already tried! To encourage proper muscle activation we have tricks & tips, more advanced and interesting exercises, even great gadgets that can show you what you are doing and help your muscles work.  

Specialist physiotherapists have passed exams to become full members of the Professional Network of Pelvic, Obstetric and Gynaecological Physiotherapy (POGP).    Ask your GP to refer you to the local NHS services (if you are Cambridge-based you can self-refer) or do come to see me at my practice (South Cambridge Physiotherapy).  

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