Updated: Jun 16, 2018
Let's Evaluate Our Work with our Female Clients and Athletes
When I first started personal training in 2005, I was one of the few women on the gym's training staff. I was frequently the only woman in the weight room. Fast forward 13 years and it still sometimes takes my breath away to see just how many women are now confidently taking up their rightful space among the barbells, dumbbells, and kettlebells. As many leaps and bounds as the fitness industry has made to be truly inclusive of women, we still have some work to do. This is an invitation to roll up our sleeves and dig a little deeper into how we can fully service women in fitness.
There are many issues that we could discuss that tend to impact more female athletes than their male counterparts. Eating disorders, hypermobility, hormonal fluctuations (to name just a few) are more likely to be concerns with your female athletes (this is not to say that these issues don't affect men!). Throughout this blog, however, I'd like to focus on the deep core system, especially the pelvic floor.
As we intuitively know as instructors, trainers, and coaches: it's not just what you do, but how you do it. The strategy (breath, positioning, tension) we use influences not only the success of our lifts, but the impact on our bodies. Traditionally-taught strategies in hardstyle kettlebell practices (and throughout strength and conditioning) may not always be enough, or appropriate, to keep female bodies performing their best. In fact, some of those strategies may encourage scenarios for symptoms of concerns like pelvic floor dysfunction to be introduced, or persist.
Before we discuss strategy, I want to first make sure we're on the same page about what these considerations are, and how (at least some of) your training population is likely experiencing, or has experienced, them.
There are four key considerations that I would like to address, and of which, I believe, every strength coach, male or female, should have an awareness.
These considerations include:
Anatomical differences between female and male strength participants, particularly regarding the pelvis
Postpartum (which is a lifelong consideration, not simply 6 weeks!)
If we do not understand the specifics of these considerations, it is possible that the work we do with our clients and athletes could have consequences that significantly impact their quality of life.
Before discussing the differences between male and female bodies, let's briefly define the "core canister".
Our "core" is our deep central stability system which sets the stage for movement throughout the body. Anyone who has participated in fitness for more than, say, 3 seconds has heard of the importance of the "core". Frequently, the core is discussed as being an ab-only system that needs planks to thrive. Instead, it is helpful to recognize the dynamic and interactive nature of our deep core system. To fully appreciate it, we need to recognize that it's not simply our abdominal musculature that provides structural support, but the "communication" between our diaphragm (towards the top), pelvic floor (the bottom), transversus abdominis (the sides/front), multifidi (spinal stabilizers) and even our glottis (the top) (which allows for, or prevents air, from entering/exiting).
The entire system works as a team to provide centralized stabilization to our bodies. If any one part of the system is not working well, it can be difficulty for the rest of the "team" to work as well.
Our core has a postural role, as well as playing a role in respiration. On inhale, the diaphragm descends to allow for the lungs to fill with air, which pushes the abdominal contents down and out slightly, as the pelvic floor and abdominal muscular yields to the increase in pressure. On exhale, the pelvic floor recoils, the abdominal wall gently compresses in and the diaphragm ascends. The process of breathing manages pressure and is influenced by conscious muscular recruitment (meaning, if we are thinking about firmly bracing our abs, it's going to be more challenging for the abdomen/pelvic floor to yield).
Our core system manages pressure (intra-thoracic/abdominal/pelvic) which provides support to our trunk. In order to regulate pressure effectively, we have to think about managing it from the top, sides, and bottom. An excessive degree of pressure beyond what the players in the core system can manage can result in concerns like hernias and pelvic organ prolapse. Too little pressure does not allow for us to complete lifts effectively and safely.
Those of us who have been coaching strength understand the importance of pressure, but, in my experience, the emphasis has typically been on creating a maximum effort of pressure to keep our spines "safe" while we execute challenging feats of strength. We absolutely need pressure, yes, but the long-time focus on generating significant degrees of intra-abdominal pressure without also discussing what else is happening is a missed opportunity that could have detrimental impact on our health and our lifts.
When we cue women (or anyone, really) to have a very strong abdominal brace, we may be cueing an overwhelm of the deep core system. If I'm locking down my abs and holding my breath, for instance, that pressure has to go somewhere. Many women and many coaches are unsure of how to ensure that we aren't just bearing down on the pelvic floor at this point. We're unsure because we aren't talking about it and we haven't known what to look for, or even that it's a problem. The unfortunate reality, though, is that many female strength participants experience leaking, pain, pressure, bulging, and other symptoms that clue us in to the fact that their deep core system is not operating at its best.
Structural Considerations Make Women More Likely Than Men to Experience Symptoms Related to Pressure Mismanagement
To demonstrate why, I'm going to have to make mention of something we typically don't talk about in the weight room (but should!): the VAGINA! Caps lock was intentional there; go ahead and picture me with a megaphone yelling "vagina" in a room full of dudes getting ready for a season of football.
Anyway, yes, we need to talk about vaginas. Here's the thing with the female pelvis: there's this extra hole (we call her the vagina) that allows for pressure to have an extra "out". The vagina's lack of a true sphincter adds to the potential that things can begin to head south here. The pelvic floor and the pelvic organs provide support to maintain continence, manage pressure, and keep our organs inside our body, but this system does not always fire on all cylinders (get it?! core canister?! cylinder?! never mind....)
Women Experience Pelvic Floor Dysfunction at Significantly Higher Rates than Men
Nulliparous women experience stress incontinence four times more often than men, and women experiencing one or more pregnancies, more than fourteen times more often (MacLennan, Taylor, Wilson, Wilson, 2000).
Symptoms of pelvic floor dysfunction are present in approximately 1 in 4 women.
Symptoms of pelvic floor dysfunction include:
Pressure/heaviness in the pelvis
Aching/pain/discomfort in the pelvis
Needing to urgently use the bathroom
Constipation or other difficulty with bowel movements
Muscle spasms throughout the pelvis
Sagging or bulging of the pelvic organs into the vagina (pelvic organ prolapse)
These symptoms can range from mildly annoying (but still significant, from a function perspective!) to debilitating. Symptoms of pelvic floor dysfunction can prevent a woman from being comfortable participating in her favorite activities, including fitness.
Experiencing symptoms of pelvic floor dysfunction is a common reason for women to cease recreational physical activity. With so many benefits to physical activity, strength coaches and trainers need to fully understand the gravity of pelvic floor dysfunction as it relates to movement.
Strength/Kettlebell Training Can Make Symptoms of Pelvic Floor Dysfunction Worse
Any high(er) pressure activity can make symptoms of pelvic floor dysfunction worse. Hardstyle kettlebell training is no exception. This is especially true if we place an emphasis on frequently encouraging situations of maximum pressure and effort.
Concerns like incontinence and pelvic organ prolapse are not necessarily concerns of a failed muscle, but of a failure of the system.
Large increases in pressure that aren't able to be managed by the base of the core system (the pelvic floor) can lead to sagging organs, leaks of urine, gas, and/or feces, and a core system that can't perform at its best (which means your snatches won't be as sharp and your presses won't be as strong). When the pelvic floor is not working optimally, it isn't necessarily the case that it is simply too weak (as is often assumed, leading many women to perform endless reps of kegels which might actually be working against them). The pelvic floor can hold too much tension, or struggle to generate tension. Beyond the pelvic floor, an abdominal wall with excessive tension (think about the action of firmly bracing or sucking in one's belly as hard as one can) can create so much pressure, and direct that pressure downward, that even the most capable of pelvic floor muscles won't be able to withstand the demand, potentially leading to leaking, or increases in the risk, or symptoms of, prolapse.
Pregnancy Is One of the Most Transformational Processes Through Which a Body Can Go
Typically, when we discuss pregnant women and training, we cite the amazing benefits for both mom and baby. We're also likely to note that it's very difficult to come close to hurting baby with most exercise in which women participate. These things are all true, but there are things we aren't always considering, as well.
I won't be able to keep your attention long enough to fully explain the myriad ways in which a woman's body adapts to support the growing life of her baby, but I'll leave you with this nifty bulleted list to give you a small idea of how a woman's physicality is impacted.
She has a shifting center of gravity due to the increased anteriorly-placed load
The abdominal wall stretches, leading the abdominal musculature to move distally
The weight of the fetus (and all his/her accessories ;) ) increases the stress on the pelvic floor
The infrasternal angle increases to accommodate for the growing uterus and the abdominal contents being pushed up
An increase in laxity throughout the pelvic structures (to accommodate for baby's first Turkish Get-Out-of-the-Womb)
Changes in the foot structure (the arch tends to flatten)
Being really, really, really, really freakin' exhausted (everyone who has ever been pregnant nods)
While every pregnancy is different, certain things are fairly certain: one's abdominal wall will need to stretch to accommodate for baby. One's pelvic floor will become tasked with an increased demand.
How we coach movement during this time, and the programming decisions we make can potentially impact a woman's life for not only the duration of her pregnancy, but into every chapter thereafter.
Positional considerations (a flared rib cage, a significantly posterior or anteriorly tilted pelvis, etc.) can impact the degree of stretch her abdominal wall endures, or the degree of load her pelvic floor must handle. Positional changes are associated with changing muscular recruitment (a concept we understand as coaches), and they impact the pelvic floor/deep core system, as well. For example: a posterior pelvic tilt (something coaches often cue in response to the commonly held (but often erroneous) belief that pregnant women always find themselves in excessive degrees of anterior pelvic tilt) might reduce the bony support to one's pelvis (the pubic bone's relative position to the pelvic organs, when the pelvis tilts posteriorly, may make it, theoretically, less able to provide some bony support to the organs of the pelvis), and can also be associated with a lower or higher (than typical) recruitment of pelvic floor musculature.
When working with pregnant athletes, it's helpful to understand how her changing body could influence her muscular recruitment, pressure distribution, and ability to perform a movement the way it's intended.
While we anticipate the abdominal wall broadening for baby, we also are aware of a concern called diastasis recti which refers to the degree of "separation" between the two rectus abdominis (RA) bellies. Diastasis recti, most frequently a concern we're discussing postpartum, is typically identified at a measurement beyond 2.5 cm between the two sides of the RA. What we are learning, through the most recent research, is that it is not nearly the distance, but the ability for the abdominal wall to generate and transfer force, that matters. However, a greater degree of separation can increase the likelihood that the abdominal wall struggles to withstand the pressures it is tasked to contain. We are more interested, typically, in diastasis recti in a postpartum context, but there is a possibility that the decisions and strategies we adhere to during the prenatal period could influence the body's ability to function postpartum, as well.
Movements that place a significant stress on the abdominal wall could increase the strain on one's stretching linea alba (the connective tissue that divides the two halves of the abdominal wall) and the potential exists that one could exacerbate the degree of diastasis recti, or increase the potential of a hernia (another demonstration of overwhelming pressure) being introduced.
The movements that challenge the abdominal wall to a degree significant enough to raise concern can vary from woman to woman. Some will be able to manage higher tension planks and pull-ups, while others will have difficulty with seemingly-simple tasks like a goblet squat. The best way to gauge an individuals' abdominal wall's ability to cope with a movement is to individually assess. Bulging/coning/doming refers to the connective tissue at the midline of the abdomen (the linea alba) poking out beyond the level of the RA bellies/rest of the abdominal wall suggest a difficulty of the abdominal wall to withstand pressure. What we're seeing here is pressure needing to go somewhere. The current consensus is that we want to avoid this bulging of outward pressure in a pregnant woman's abdomen, as it suggests an inability to manage pressure within the abdominal cavity.
The pelvic floor is significantly taxed by the end of pregnancy due to the increase of load placed directly on it. The pelvic organs are shifted by the weight and size of the uterus. The ligaments, tendons, fascia, and muscles of the pelvic floor are loaded beyond their norm. Whether these findings are significant enough to lead to symptoms of pelvic floor dysfunction will depend on each individual. Remember: pelvic floor dysfunction is more a systems failure than an individual structures' failure. But if we are choosing to load what is already loaded, let's make sure we're doing so in a way that supports the workings of the base of the deep core system.
Additionally, the pelvic structures experience greater laxity and movement, leading to less support.For instance, the pubic symphysis increases, on average, 2-3mm during pregnancy. For some, this instability might contribute to discomfort, particularly during unilateral and rotational movements, typically. While TGUs, for example, are often part of the bread and butter of our programs, are they going to feel great for someone having trouble finding enough stability/mobility in their pelvis?
Increases in pressure significant enough, combined with a pelvic floor that is not able to cope with the influx, can lead to leaking, or pelvic organ prolapse. These concerns can last well beyond one's pregnancy.
An increase in the infrasternal angle, combined the shifting distribution of load, can make for overhead movements that are less effective. A flared rib cage can create a greater line of pull on the abdominal wall. If a pregnant woman's shoulder/thoracic mobility is not excellent, her overhead positioning can increase the degree of stretch that is placed on her anterior core, influencing the length-tension relationship of her abdominal musculature, potentially inhibiting adequate performance in her core musculature. It can also encourage her to tip back more at the rib cage in an effort to get the kettlebell overhead. This influences the ability of the diaphragm to go through its full excursion, influencing how the rest of the deep core system (and body) functions.
We've all seen the stereotypical image of a pregnant woman waddling down the street. This waddling gait can occur as a result of our body seeking to maintain efficiency and not have to work too hard to do basic movements like walking, but it can also begin to show up in technique.
With all the changes at the core and pelvis, is a pregnant woman able to withstand the shear forces of the kettlebell swing, identified to be of significance by research from McGill et al (2012)? Will she be able to cope with the increases in intraabdominal pressure from heavy ballistics, or squats? Are breath holding, breathing behind the shield, and tension breathing appropriate strategies for women during pregnancy?
"Postpartum is Forever" - Brianna Battles
If you are training women who have had children, you are likely training women with diastasis recti (DR).
Sperstad et al. (2016) identified that 32.6% of women in their study had a DR of greater than 2 finger-widths at 12 months postpartum. The degree to which movement will be impacted by a DR (and vice versa) is not necessarily represented in this statistic, but it is important to recognize that many of our clients could be managing an anterior abdominal wall that is not as supportive as it once was.
You are likely training women with pelvic organ prolapse.
The prevalence of POP varies, but some research has identified that, when a POP diagnosis was based on clinical examination, as high as 50% of women were identified to have some degree of POP (lifetime risk, all grades included). Other research has pointed at lower, but still significant numbers like 27% of women between the ages of 30-49 who have had children were found to have some degree of POP (Luber, Boero, & Choe, 2004; Barber M, Maher, 2013).
You are likely training women with incontinence.
Twelve years after first delivery the prevalence of stress urinary incontinence was 42% (
(Viktrup, Rortveit, Lose, 2006). Most women wouldn't describe themselves as "new mothers" when they have a 12 year old, but incontinence isn't something that is just a "new mother" concern! In fact, Nygaard et al (1994) identified 28% of female elite athletes who were nulliparous (never had children) experienced incontinence. How many of our female clients line up for the bathroom when they hear they're doing max deadlifts or jumping rope that day?
You are training women who are risk of developing these things.
For a variety of reasons, they may not mention these concerns. First, many women have been led to believe that leaking, painful sex, back pain, etc. are concerns that come with the territory of being a mother. Many believe that there is nothing to be done. It has only recently become typical to hear of pelvic floor physical therapy being discussed as an option for women.
Most women who have had children are not properly screened afterwards, and do not get the opportunity to participate in a comprehensive rehab program. Think of it this way: if someone had a complete ACL tear that required surgery, but they didn't go to any physical therapy after their surgery, would you want them to jump in with you? I hope not! But so many of us are working with postnatal women without considering if they have properly rehabbed. Yes, they may feel fine, but women often have no idea what to look for and are embarrassed to seek help. Women wait an average of 6 years to seek help for their symptoms of pelvic floor dysfunction (Muller, 2005). It is your job to make sure you are identifying if your postpartum clients (remember: that doesn't just mean 6 weeks postpartum! That could mean 60 years postpartum!) are in need of more appropriate movement coaching in the form of rehab before returning to (or in conjunction with a return to) the gym.
Vaginal birth is often accompanied by nerve trauma, injury to the pelvic floor ligaments, fascia, muscles. For some, lifelong concerns with have poor surgical repair outcomes are encountered. Others put up with nagging symptoms that are bothersome, but that they feel are unavoidable. Coaches and fitness trainers can increase this risk, by the way. When we aren't screening appropriately, and aren't noticing clues, or (worse) ignoring symptoms or telling women these are normal things to just "get over", we are doing our clients a major disservice that could have lasting implications.
Women who have given birth via Cesarean have had major abdominal surgery. Many experience numbness and a loss of sensation in their core system.
In most cases, a woman will be given the "all clear" at her 6 week check up. Also in most cases, this is not a sufficient evaluation to determine physical readiness. Most OB/GYN/ Midwife appointments at 6 weeks are not evaluating the function of the pelvic floor, or assessing for a diastasis recti.
It is highly recommended that every woman who has ever been pregnant sees a pelvic floor physical therapist. This, ideally, needs to happen before she steps foot in the gym.
It is also important to mention that the postpartum period is hardly noted for its similarities to a day at the spa! Sleep deprivation, suboptimal nutrition, and psychological stress can hinder healing.
Breastfeeding also continues to alter one's hormonal composition from her pre-pregnancy state, making her potentially more susceptible to concerns affected by fluctuating postpartum hormones (pelvic floor symptoms, laxity, etc.).
Getting back to training is a goal of many active women who have had a baby. We want to help them do that, but we also want to keep them active for life. The decisions we make in the early phases of postpartum recovery can impact her ability to train well into her later decades.
We know we want to keep our older clients moving to take advantage of the significant benefits of strength as they reach midlife and beyond.
Benefits of training during menopause and beyond include:
Improvements in cariorespiratory function
May decrease likelihood of weight gain
Offset the decline of bone mineral density (preventing osteoperosis)
Reductions in low back pain
Improvements in mood
May help reduce hot flashes
Mishra, N., Mishra, V. N., & Devanshi. (2011).
Let's clarify the three stages of the menopausal chapter:
Perimenopause: this can begin up to 10 years before menopause, and is when the ovaries gradually start to produce less estrogen
Menopause: determined at the point at which a woman has not had a period for 12 consecutive months. Estrogen production extremely low.
Postmenopause: this describes life after menopause. Women’s symptoms will vary, and can be impacted by hormone treatment.
The onset of menopause can cause the pelvic floor muscles - just like the rest of the muscles in the body - to weaken. The weakening of these muscles can result in pelvic floor concerns. Reduced pelvic floor muscle function around the time of menopause can also be due, in part, to weight gain, which is common during menopause. While not all women will experience a decline in pelvic floor function significant enough to experience symptoms, 34.9% of postmenopausal women were found to experience urinary incontinence, 16.6% had stage 2 or greater pelvic organ prolapse (POP), 48.4% were found to have both POP and urinary incontinence (Frota et al. 2018).
While not specific to women in menopause (but more common by a certain age), a hysterectomy can also increase the risk pelvic floor dysfunction. First, pelvic surgery is considered a risk factor in and of itself, and the loss of the uterus results in some of the loss of support that the pelvic organs provide each other. Certain types of prolapse (vaginal vault, where the vaginal canal collapses on itself) are more likely after hysterectomy. Again, this is a woman who needs an assessment with a pelvic floor physical therapist.
It simply isn't a holistic approach to strength if we aren't considering the deep core system and the impact symptoms of dysfunction can have on a woman's performance in the gym, and in her daily life.
So, are we ready to start considering that our female athletes may need us to consider their pelvic floor and core system function?
If women are susceptible to symptoms of pressure mismanagement, and if a significant percentage of women are already experiencing symptoms independent of high-pressure training, shouldn't we consider the ways we're using pressure and tension?
Is it enough to leave the discussion at how to generate enough intra-abdominal pressure without assessing whether there are clear signs that a woman cannot manage the pressure we're asking her to generate?
From my experience, we, as kettlebell instructors and strength coaches, can do better at considering how our approaches have potentially encouraged strategies that have not supported the deep core system, especially the pelvic floor, of our female athletes.
Modulating Pressure, Modifying Movement
While it might be tempting to throw in the towel and say that training women who have been pregnant, or going through menopause should be left to specialists, (or, worse, that we just shouldn't bother considering the implications), there are simple ways we can work to improve our coaching of these athletes. Also, remember that pelvic floor dysfunction is not specific to mothers!
Any female client who is demonstrating symptoms or pelvic floor dysfunction OR who has ever been pregnant, had a baby, or is menopausal can likely benefit from a visit to a pelvic floor physical therapist. Coaches are often the first line of defense and we can do an incredible service for our clients by providing them with the best resources in managing their long-term athleticism, continence, and sexual function.
First, let's talk about strategy objectives we should all be addressing with our clients:
1. Include Pelvic Floor Questions in Your PAR-Q and Refer Out When Indicated
Just as we would ask about orthopedic injuries and medical conditions, it's important to screen our clients to pelvic health concerns. Here's a questionnaire that you can use to help guide this process.
2. Consider Not Coaching Women to Clench Their Abs All Day/During Movement