trampolining to illustrate the Knack

The Knack: No 1 pelvic floor trick for mums

What is “The Knack”

Need a Quick Win with improving your bladder leakage?

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 to stop urine leakage *

So simple – yet not everyone knows about it

There can be Quick Wins with pelvic floor exercises.  I still clearly remember  when I helped a client stop leaking in just one week by teaching her the Knack – and she was FURIOUS to have waited that long!  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.

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 it and 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.

Then, 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  

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)

how to improve pelvic floor control by simply breathing

How to improve pelvic floor control by simply breathing

Do you wonder what BREATHING has to do with bladder control, prolapse support or vaginal or anal pain??

Physios are not going woo-woo

It’s rather because clinical research & our understanding of the body has deepened, so pelvic floor exercises exercises are evolving. It’s no longer one size fits all.

There’s a good place for the traditional squeezes, lifts and holds, but some mums need to focus their attention more on the “let go”, relaxing and releasing of their muscles.

Pelvic floor relaxation is a thing

Previously exercises were very linear.  Squeeze ON, release/turn off.  Our focus was on what our muscles needed to be able to DO in an emergency situation – when we cough, sneeze, pick up something heavy.  This is not wrong.  If you struggle with stress incontinence (leaks when there is high pressure on the bladder) then the best thing you can learn is The Knack of getting the pelvic floor to co-ordinate with perfect timing.  

However, we now know how our muscles should be doing when we are not thinking about them.  The resting pattern of your muscles has an impact on common problems like urgency, bladder frequency, vaginal heaviness and pelvic pain. 

#1 New thing we know

Firstly, our breathing pattern and our pelvic floor muscle movement pattern are similar and interconnected.   Breathing is easier to understand, feel and control than the hidden away pelvic floor.  So if you want to better connect to your pelvic floor – start by noticing how you breathe.

#2 Weird thing to notice

However, most of the day we don’t think about our breathing AT ALL.  You wouldn’t have been thinking about yours a few minutes ago until I brought the topic up.  Your brain operates your breathing system all day, all night, 24/7 without any conscious input from you.  A gentle in and out, muscles contracting and releasing, a continuum of movement like a swinging pendulum, you are only completely full of air or completely released for a moment in time.

#3 Amazing thing we can do

Yet, you can also have incredible control over this system.  For example, you could take a deep breath right now to blow out an imaginary candle; you could whistle a little tune;  you could shout (or yodel) or pant like a dog.  With training, you could develop sophisticated breath control  as well – as a singer, long distance runner,  athlete, deep sea diver, bird impressionist. Did you know that you need enormous breath control to accurately shoot a pistol or throw a dart?

And then, when you stop panting or wolf-whistling or humming a ditty, your brain just automatically puts you back into gentle breathing mode, no questions asked.  A-MAZ-ING.

a panther demo's pelvic floor relaxation

#4  Pelvic floor muscles should be super-skilled too

We want our pelvic floor muscles to have similar super powers.  When we are NOT thinking about them we want them to gently (gently!) contract and relax, very low key, very little. Just enough to keep blood flowing through them, to nourish their feeder nerves. We want movement to keep the tissues stretchy and flexible. We want to be on standby for whatever we decide to do next. 

Then, when you decide to pick up your toddler or dash up the stairs, we need them to move up a gear or two to help carry that load from below, preventing pelvic organ descent or a sudden urge to wee. 

Similarly, if you want to push shut a heavy door, or hit a tennis serve, or do one of your room shattering sneezes, we want them to go into full tension mode to prevent leaks. And most important of all, if you want to empty your bladder or bowel, or get sexy with your partner you want them to relax and release to allow things out or in.

#5 Best thing to work on

In contrast, if your muscles are always tense they become “crampy” with painful sensations associated with a build up of lactic acid or the soreness to be touched or if stretched. Then if your muscles are always “in gear” you can’t choose to have “more” or “less” for the activity you are doing.

So take moments through the day to tune in to your breathing and from there to your pelvic floor muscles. Find time to reset your background, automatic, movement pattern to line yourself up for a day with super-powers.

Video: How to improve pelvic floor control by simply breathing 

  • Firstly, tune into your breathing pattern.  Feel your rib cage lift and raise as you breathe in, drop and shrink as you breathe out. Play with it.  Breathe deep, blow out an imaginary candle.  Do this a couple of times.  Then stop.  Can you feel your body revert to your base breathing pattern?
  • Then, notice how your BELLY breathes.  Yes it does!!  Drop your hands to abdomen.  Channel your inner frog.  Notice that your belly mimics your breath.  As you breathe in your belly lifts as you breathe out it falls.
  • Finally, lower your consciousness to your pelvic floor.  It is the lowest moving set of muscles.  Can you feel how these move to, in time with your breathing, ever so gently contracting & letting go. Or gathering & releasing, or lifting & lowering – whichever words work best for you.

Have you improved your pelvic floor skills by practicing breathing? Please let me know if this video and explanation was helpful and how you are getting on?

can pilates strengthen the pelvic floor

Can Pilates strengthen the pelvic floor?

pilates for pelvic floor
Pilates exercises can be tailored to suit mums from the very Early Days postnatal

Yes!

IF you already know how to work your pelvic floor effectively, then YES! Definitely, Pilates can help strengthen the pelvic floor & teach you to use it in a functional way.   Many specialist antentatal & postnatal physiotherapists are also experienced Pilates Instructors. Exercise is a key pillar of our physio training and Pilates has proven to be a style of exercise to really suit mums’ needs. Chosen carefully, some exercises can be started from the early days, even after a caesarean.

I am such a Pilates enthusiast that have made a series of postnatal exercise videos taking you from “birth to 6 weeks”, via abs & gluts focus sequences to getting ready to run. With Pilates for Pelvic Floor Strengthening to really target this most elusive bit! Join me here….

And no….

NOT if your pelvic floor muscles are very weak. Or even completely ‘switched off’. That’s when you do have perfectly good muscles but your brain is not telling them to work. Maybe because of some nerve problems since your delivery. Rather like having windscreen wipers but no button to switch them on in the rain. Or working too hard. Sometimes you are subconciously over-gripping since you had your baby. Perhaps still tense around an episiotomy scar or going into spasm when you sit or walk too long?

tabletop & head lifts are classic Pilates exercises that need to be done with EXCELLENT technique to avoid abdominal doming or pelvic floor strain.

If your inside pelvic floor muscles are not ready (even if your outside seems fine), then unfortunatley, you could do an entire Pilates class with relatively little benefit. Some times things get worse:

  • you might feel more sore in your pelvis after a class than before.
  • it’s easy to accidentally bear down and stretch & weaken them more
  • or not reaslie that you have too much pressure on your bladder or uterus inside, encouraging a prolapse to appear as you exercise more.

Not sure what’s going on inside?

If you have any worries that your pelvic floor is not quite what it should be, or want to return to a high level of sport or fitness, get your technique checked before you do too much more DIY.


Ask your midwife or GP to refer you to a Specialist Physiotherapist. They will examine you and properly advise on your personal situation.

Why see a specialist physio?

There is so much a specialist pelvic floor physiotherapist can teach you to improve internal muscle strength, endurance & co-ordination. They will also check your posture, tummy gap, core strength & scars.

 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.

We aim to help you understand how your body works.  With a better understanding of your muscles’ strength, weakness or tension problems, your exercises will make sense & be motivating. We can show you how to help them to grow stronger or release & stretch. As well as how to be skilled at using them, to prevent incontinence and improve internal organ support! 

It’s not just up/down squeezes!  

We have lots of different ways of exercising. The standard post-birth exercises are great – but they are not the end of the story. See some new ideas in our Pelvic Floor School. To encourage proper muscle activation we have tricks & tips. We have more advanced and interesting exercises to get you back to higher level sport. Even great gadgets that can show you what you are doing and enhance your muscle work.  

How to get support?

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 or arrange a virtual appointment.  

Not near Cambridge? I believe finding a local physio is best for your longer term support. Women have a long journey from motherhood to menopause. Visit www.themummymot.com for a national directory of physios who specialise in caring for postnatal mums.

Mummy MOT practioner logo
standing pelvic floor exercises

My favourite standing pelvic floor exercise, ever

This is absolutely my favourite standing pelvic floor exercise.   I love that it anchors you to the spot with a quick little routine to stop you getting distracted part way through. 

Honestly takes 35 seconds but pings your pelvic floor muscles awake.  Little and often improves muscle memory, reaction times, and encourages quick muscle growth.

  1.  Turn your toes out, like a ballet dancer, 5 squeezes of the back passage

Turn your toes out, like a ballet dancer.  Tighten your pelvic floor and notice how this position favours the back passage (the anal sphincter) just like you are stopping wind.  Pretend you are having tea with the queen and made the mistake of baked beans for lunch.  You need to effectively close the anus opening, without clenching your buttocks more than a smidgen and without it showing on your face!  Do 5 on and off squeezes, not trying to hold, just a good squeeze, then let go completely.

2.  Turn your toes in, like a pigeon, 5 lift and tucks of the vagina/bladder tube area

Then turn your toes in, like a pigeon. Now when you tighten up underneath it should feel different.  Less going on at the back and more focus at the front, around the bladder tube and vagina area.  Let the area be soft, almost a bit saggy,  then lift and tuck the vagina up inside.  Let go – completely.  Then repeat 5 on – off contractions.  Best lift you can do ….and relax. Don’t worry if your abdominal muscles join in a little bit but keep the focus on your pelvic floor.

3.  Turn your toes normal, both areas together as a unit

Finally turn your toes into your normal standing posture.  Now try to do both the previous actions at the same time.  Most people start with the back tightening and then like a big zip come forward to lift and tuck the front.  When you let go each time now it should feel like there was a bigger ‘up’ and a bigger ‘drop’.  Repeat.  If you are feeling clever add in some side to side tension too (yes, the pelvic floor is bowl shaped, see this in my video showing a model pelvis in the pelvic floor school)

When you have done 5 squeezes with your toes turned out, 5 with your toes turned in and 5 with everything together you will have done 15 really good pelvic floor muscle contractions.  NOW your muscles will be thinking – hey she doesn’t normally work us like this – we are going to need to grow!

In this video I go through the exercise with Stephanie from Kegel8 and The Knack too.

When to do it?

Perfect exercise to do little and often through an ordinary day.  It tags on really well to cleaning your teeth – or after a wee.  At home, use that quiet moment in the toilet to focus on yourself.  If you are working, linger in the cubicle for an extra 40 seconds – you are getting paid to exercise!

Important note

If you think this exercise is mad and you couldn’t feel a thing when you tried to do it – try it  lying down, not so much the feet positions but focusing first on the back passage and then on the front.  This positon  takes the weight of your organs off the pelvic floor and gives you more chance to ‘feel’ the muscles working.  If that still leaves you cold – then I would recommend you have a chat to your GP and ask for a referral to a specialist pelvic floor physiotherapist for a full assessment and examination.  There are lots of things we can teach you in clinic 1:1 to help you find and improve your muscle function.