Kegels before resistance training… Do they help?

It’s the 2nd of April, I am a day late in sending this email out because of 2 reasons:

 

1. 1. I had so much on last month I did not prepare for this as early as I should have
   2. I thought about sitting down yesterday and whipping this up for you, but it was a public holiday, I had my friend visiting from the Gold coast and I thought ‘tomorrow will be fine’. 

I was really feeling a bit disappointed in myself and could have easily postponed this until next month BUT I made a commitment to send this out monthly and regardless of it being a day late, I am here showing up to the thing I told myself I would do. 

 

I wanted to share this because it is really easy to continue telling yourself you will commit to something and then not following through, especially if it’s something that feels a bit outside your comfort zone or feels a bit hard. If you are in that place now with a project you are thinking about doing or maybe it’s posting regularly on social media (I know this is a big one for many people) it is better to follow through with what you said you would do to build confidence and trust in yourself then to continue breaking the promises you make to yourself.

 

So this is your reminder to show up when you say you will.. It’s for your own personal growth!

 

Now onto this month’s research spotlight. 

 

Today’s paper…

Cross, D.; Kirshbaum, M.N.; Wikander, L.; Tan, J.-Y.B.; Moss, S.; Gahreman, D. Does a Kegel Exercise Program Prior to Resistance Training Reduce the Risk of Stress Urinary Incontinence? Int. J. Environ. Res. Public Health 2023, 20, 1481. https:// doi.org/10.3390/ijerph20021481 

 

I wanted to share this paper today because I work with a lot of active women and have been looking into the role of pelvic floor specific exercises as both a preventative strategy for incontinence but also as a treatment method and wanted to understand more about the effectiveness of them alongside strength programming. 

 

This comparative pre-post intervention study was designed to investigate whether performing kegel exercises prior to resistance training would improve pelvic floor strength and reduce the odds of experiencing stress urinary incontinence. 

 

In the early parts of the paper they discussed the varying results in some other papers as to the incidence of urinary incontinence among varying types of resistance training. A paper looking at a body pump program concluded resistance training did not cause urinary incontinence whereas a study looking at women engaging in Crossfit and Powerlifting did experience urinary incontinence. The goal of the paper was to determine if doing a Kegel based program prior to a progressive strength program would reduce stress incontinence and should be prescribed to women prior to beginning resistance training programs. 

 

Study outline:

 

• • 24 participants completed the study across 2 groups

     

    • • 9 in resistance training only group (RT)
    • • 15 in kegel exercises + resistance training group (KE+RT)

• • Pre existing data was used for the resistance training group from a study that assessed the impact of resistance training on stress urinary incontinence in a group a women participating in a resistance training program with no previous kegel exercises performed.

• • The KE + RT group consisted of 15 women who had previously undertaken a 12 week kegel exercise program under supervision from a pelvic floor specialist and then completed the identical 12 week resistance program as the RT group.

• • The 12 week resistance program was based on the Powerlifting Australia Level 1 Powerlifting coaching course and consisted of back squats, deadlifts, incline pull ups and push ups on knees. It was adapted to 2 day per week training sessions with a focus on squats and deadlifts as the major lifts as these 2 movements require significant pelvic floor engagement to counteract the intra abdominal pressure generated during these movements.

     

    • • Day 1 was programmed as a heavy lift day and day 2 was light lifting with a focus on speed. 
    • • The first 3 weeks of the program were focused on preparation for load which included broomstick back squats focusing on improved ROM until participants could hit a depth where the hip creases was lower than the top of their knee and they had progressed to a 20kg barbell. Deadlifts began at 25kg with increasing weight once they could complete 3 sets of 10 reps with safe form.
    • • Once participants hit these numbers load was incrementally increased as tolerated at 2.5kg-5kg per week. 
    • • As the program progressed repetitions reduced as the weights/intensity increased. 

• • Correct breath control and brace strategy was coached by trainers and they used the pebble analogy as a visual explanation of how to activate the pelvic floor during a lift.

     

    • • ‘They were asked to visualize ripples from a pebble dropping into a pond, and then rewind the image of the ripples becoming smaller and the pebble lifting out of the water.’ 
    • • They were told to perform this with every lift and if they lost connection with the pelvic floor they should stop lifting.

 

What did they measure?

 

• • Strength of pelvic floor muscles → assessed by a female physiotherapist

• • Degree of urinary incontinence (assessing the frequency of leaking and severity of symptoms) → through self-reported questionnaire

• Heart rate, blood pressure, height, weight and body composition analysis

Let’s see what they found

 

• • The frequency, severity and overall stress incontinence significantly reduced over time for both groups however the improvement was larger in the KE+RT group. There was no significant difference between the groups.

• • Max voluntary contraction of the pelvic floor was reduced in the RT group however was not significant. The KE+RT group had a moderate increase in MVC over time.

• There was a strong correlation between Stress incontinence and pelvic floor muscle strength. 

Even though the participants in the KE+RT group had greater improvements in stress incontinence this study also showed that resistance training (without specific pelvic floor exercises) is also effective in reducing stress incontinence. Let’s dive into this:

 

• • We know participants were coached on correct breathing and bracing during their lifts → this could in fact aid in correct pelvic floor and deep core engagement with every lift helping to strengthen the deeper core system.

• The pelvic floor was therefore being overloaded in its functional movement of providing support to the organs during increases in intra abdominal pressure. Overloading is key for truly resolving pelvic floor symptoms and this cannot be done with Kegels alone.

How can we clinically apply this information?

 

• • Aside from baseline pelvic floor measures there was no mention of any participants having pelvic floor tightness and I wonder if someone is experiencing leaking as a result of tightness would it be as simple as modifying the 12 week pelvic floor program to a tightness specific program be helpful? Or did they only perform this program on women who had leaking as a result of pelvic floor weakness?

• • I would have loved to see what the 12 week Kegel program looked like. I could have searched the other studies but was too lazy to look so a quick recap or appendix of that program would have been insightful.

• • If clients come to you for pelvic floor symptoms in lifting they most likely will benefit from pelvic floor specific exercise prior to overloading a strength program.

• • Correct education about pelvic floor engagement during lifts is what will help overload the pelvic floor in its functional movement.

• • Progressive strength training is key for improving pelvic floor strength and symptoms of stress incontinence even without doing specific pelvic floor exercises. If you don’t know how to rehab the pelvic floor, strength training will still be beneficial for your clients who have pelvic floor symptoms. 

• • There is potential for MVC of the pelvic floor to reduce without prior pelvic floor exercises when undertaking a strength program. Over time (more than this 12 week study) will we see problems with muscle function and thus increased symptoms as a result of large amounts of intra abdominal pressure down onto the pelvic floor? Is this why we see women who have been training and overloading over years with pelvic floor symptoms related to their lifting? Do Kegel exercises produce a stronger PF muscle foundation that prevents this from happening? 

• The way this study was conducted almost replicates what I do with my clients. 12 weeks of pelvic health rehab followed by 3 months of strength training. This protocol has worked wonders for my clients in resolving their pelvic floor dysfunction. I definitely program with more intention in the 12 week rehab program but it builds them up to have all the strategies in place to get the most out of their strength blocks.

I love how simple this paper makes pelvic floor rehab sound; if you learn to correctly engage the pelvic floor prior to lifting, your symptoms will improve. I wish it was that simple, but sometimes this doesn’t always happen. Sometimes symptoms aren’t a result of pelvic floor weakness and we can’t just add Kegels into someone’s routine in the hope they will solve the problem. We need to consider many other drivers of pelvic floor symptoms and address them all individually. 

 

But one thing that is super clear is that the pelvic floor needs progressive strength training to see improvements. As clinicians we need to be helping people move beyond basic movements like sit to stands or body weight squats to really help someone. We have a massive role in bridging the gap between corrective rehab exercises to functional movements and into progressive strength programming. I see too many clinicians not moving clients beyond light loads and as a result are not quite getting their clients the results they were after. 

 

This gap is what I like to fill for my clients, but also for my mentees. Long term programming from acute rehab exercises all the way to heavy lifting and high impact training. A protocol I have refined and now teach inside the mentorship in the hope of helping more women access high quality women’s health care. 

So there you have it, another research spotlight email showing the role exercise prescription has in women’s health. 

 

See you next month!