Pilates and Pelvic Floor – Is Pilates Core Exercise Right for You?

Pilates and Pelvic Floor information by Physiotherapist and Pilates instructor Jenny Tweedie. Many thanks to Jenny for sharing her Pilates and pelvic floor expertise with us. Jenny writes …

Pilates and Pelvic Floor

Pilates has received mixed reviews over many years depending on where you read about it. You may hear claims by many models, celebrities and entertainers that daily Pilates is the way they stay looking the way they do. Others report that Pilates cured or caused their back pain.

Some women want to know whether Pilates will help or worsen their pelvic floor function. What about their pelvic prolapse? Yet again, others ask – What exactly is Pilates?

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What is Pilates?

Pilates is a method of exercise developed by and named after Joseph Pilates, which targets the spinal, abdominal, and pelvic floor muscles, often termed ‘the core’. The focus is on body alignment, muscle balance and correct breathing technique, with the aim being to improve body awareness and control, strength and flexibility. Basically the emphasis is on an understanding of how to move and efficiency of movement.

Joseph Pilates originally developed a system of exercises during World War 1 to help rehabilitate injured soldiers. Later in his life he moved to the USA where he opened his own studio, which became popular with dancers, athletes and entertainers and hence was more widely known. He died in 1967, however Pilates has continued to be taught in many countries around the world and was introduced to Australia in 1986.

Many methods of Pilates have been established, each one slightly different to the next. Very broadly speaking, ‘Traditional Pilates’ methods tend to stick a little more closely to Joe’s original teaching whereas ‘Clinical Pilates’ often means that the exercises have been modified and take into account more recent research in the areas of musculoskeletal research. A good example here is Pilates and pelvic floor muscles. In Joe’s original exercises, there is no mention of these muscles, however we now realized the importance of the pelvic floor muscles in any form of exercise, particularly when exercising the abdominal muscles. In fact, the ‘hundreds’ exercise, often regarded as the signature Pilates exercise, and one of the first exercises done in a traditional mat class, would be contra-indicated for anyone doing Pilates with pelvic floor muscle dysfunction, including those with pelvic organ prolapse.

Two Forms of Pilates: Mat or Studio Pilates

1. Mat Class Pilates Pilates and pelvic floor

• Suitable for those who are not injured,
• All exercises in mat classes with everyone doing the same thing, without programmes specifically tailored to each client
• Correct ‘core’ activation is assumed,
• Class sizes vary greatly depending on available space,
• Generally classes are specified as Basic/Beginner, Intermediate or Advanced,
• Specialty classes such as pregnancy or post-natal may be available,
• Some centres offer reformer classes where the same principles apply.

2. Studio Pilates

• Suitable for those who are injured and have specific rehabilitation needs, or those who require modification of the basic exercises such as the elderly, women who are pregnant or in the post-natal period, even elite athletes,
• Utilises Pilates equipment such as the Reformer, Cadillac (also known as the Trap Table), Wunda Chair, Spine Corrector and possibly others,
• Exercises are performed on equipment as well as the mat
• Emphasis is on the close supervision and individual exercise prescription
• Has a low client/instructor ratio to ensure close supervision and correct technique
• Each client has an individual exercise programme which may be different at each session and progressed according to signs and symptoms
• Generally each client has an individual initial assessment to determine focus areas and to ensure correct core activation. Commonly the real-time ultrasound is used. This is a similar type of ultrasound to that which is used for pregnant women. It is a very useful way of assessing correct pelvic floor muscle activation and assessing how the pelvic floor and abdominal muscles work together. If a client has difficulty in performing a satisfactory combined pelvic floor and abdominal muscle contraction, then he or she maybe referred to a Physiotherapist who has extra training in Continence and Women’s Health.

Pilates and Pelvic Floor Problems

So, let’s get back to the original question: Will Pilates help or hinder pelvic floor muscle dysfunction, prolapse or back pain? Unfortunately the answer is: It depends! Like any form of exercise, the way that you perform Pilates is crucial to gaining benefits.

Some important considerations for Pilates and pelvic floor issues are:

A. Correct core activation Pilates and pelvic floor

This is particularly important with regards to the pelvic floor muscles. You must know that you are activating properly, and exercises must be prescribed that are appropriate for your level of function. If you are not performing an exercise properly you will not be gaining the maximum benefit from it, but more importantly you are at risk of causing damage. This can occur for a few reasons:

  • Pushing downwards (bearing down) through the pelvic floor muscles instead of the correct action of squeezing and lifting up puts you at risk of developing a prolapse and impairments in bladder and bowel function
  • Performing abdominal exercises which are too loaded, especially those where the head is lifted or those which cause you to hold your breath. Basically what happens is that the abdominal muscles ‘overpower’ the pelvic floor muscles, putting them at risk as above
  • In situations where the pelvic floor muscles are ‘overactive,’ the programme will be quite different to someone who simply has weak pelvic floor muscles. Continued holding of these overactive muscles may actually make the problem worse

B. Thorough initial assessment

Initial assessment is important to determine what your actual problem is. This will lead to developing a list of focus areas and your programme can be developed from there. This applies for problems in all areas – from back pain to pelvic floor problems.

If you consider the factors listed above, you can see why it can be difficult to gain benefits by simply following a DVD or participating in a very large mat class prior to any other form of Pilates.

So, in summary, Pilates can be a very helpful form of exercise as long as you are:

• Activating your core correctly
• Performing exercises correctly that are appropriate for your level of function
• Performing exercises which have been correctly prescribed to assist with your signs and symptoms.

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  1. Hi
    I have an aero Pilates machine, which I love using but am a bit concerned about some of the exersizes, i am 50 years old and had a hysterectomy 16 years ago and I for the past few years now and again I do get a heavy feeling underneath as if something is pressing down, it only happens now and again and I am not wanting to make it worse by doing the wrong exersizes. I have stopped doing the hundreds, but what about the legs in straps exersizes, thanks for your advice

  2. Very informative. I am one of those women who used pilates to strengthen my core as I have a bad back. So after 1 year of hard work, I have a fairly strong core-AND severe vaginal pain.
    I have recently been diagnosed with High Tone PFD.
    I am doing pelvic PT but I want to continue pilates… what are your thoughts?
    Thanks for your time.

    • Michelle Kenway says

      Hi Sandy
      Pilates needs to be modified for women with high pelvic floor tone. The first step is learning to relax the pelvic floor and the core abdominal muscles and until this is learnt, core exercises will continue to exacerbate pelvic floor dysfunction. Interestingly overbracing the abdominal core muscles and the pelvic floor will actually weaken back support as the cylinder of support for the spin will not be working as it should. Core relaxation training can take a few weeks to a few months. Then the Pilates exercises can be reintroduced with a focus on appropriate core abdominal contraction and relaxation.

      For more information this article on pelvic floor muscle tension may help you understand pelvic floor muscle tension. You can also learn correct core activation with this core activation video.

      I hope this helps you out Sandy.

      All the best

      • Thank you very much! I checked out the links and they were very helpful. Unlearning core activation that I worked so hard to learn is proving quite difficult, and I will order the CD (we will see how long it will take to travel to the US).
        I am so relieved that I found your site as I feel very alone and my coping skills are eroding.
        Thank you again!

  3. Cheryl Boettger says

    Hi Michelle,
    What in your opinion, are the best exercises for DRA post delivery ?
    Do you use any splinting techniques ?
    Keep looking for good research for best management for diastasis.

    • Michelle Kenway says

      Hi Cheryl
      Yes I use splinting in the form of tubigrip, support briefs and/or exercise pants. The amount of splinting I use depends upon the severity of the diastais. With the larger separations I use more and then gradually wean off with increased deep abdominal muscle control. I usually start with very basic TA activation, TA and pelvic floor coactivation with appropriate posture and breathing, progressing to floor exercises including bent knee fallouts, heel slides, add in upper body with legs, then external obliques as well as alot of fitball stability work with the types of exercises you can see on this core exercise video I made for hysterectomy recovery some time ago. Is this the type of thing you are doing?

      • Cheryl Boettger says

        Many thanks for your prompt reply!
        Yes, I certainly start low level TA with pelvic floor co activation, and then refer them on to our Pilates teacher for progressive training one to one.
        Just wondered if you had ever used the Tupler splint ?
        Always read your blogs with interest and direct my patients to your site. Shame your books are not available to purchase in the Uk !
        Cheryl MCSP

        • Michelle Kenway says

          Hi Chery
          No I haven’t used the Tupler splint – is it a form of tubigrip?
          My books and DVD’s are available in the UK and postage is free – they can be purchased here online locally in the UK from Stress No More

  4. Hi Michelle, I have a question about working on the Pilates Barrels. Is it safe to sit close to the barrel and roll back supine into thoracic extension for arm circles and then roll back up to sitting (maybe holding thighs for support so as to not “crunch” the abs so hard getting into the extension)? Also, what about supine leg stretches with the hips on top of the barrel (puts me in slight posterior tilt though, but sacrum is supported) whist doing open/close (adductor stretches) and psoas stretch keeping hold of one knee and extending the other leg towards mat (I also like doing these on my foam roll)? Also, my upper back is weak compared to my front (pec’s/abs) and I have some kyphosis I am trying to correct (especially now that the hystectomy has allowed my bladder to drop slightly–post op hyst 4months ago) and I realize how much my posture affects the pelvic floor and organs! So, is lying prone over the barrel ok and doing back extensions (from the mat just to hip height–or about a 6inch lift)? I feel the abs contracting to my back and wonder if this type movement typically is hard on the pelvic floor? I suppose you could also do this on top of a fit ball too, but did not see it in your dvd or book—WHICH I LOVE AND RECOMMEND TO ANYONE ON THIS SITE :). Yikes, one more question whilst here, side leg work for both inner and outer thighs…yes or no (again, haven’t seen it discussed)? THANK YOU SO VERY MUCH for all of your expertise and time sharing it! :)

    • Michelle Kenway says

      Hi Melly
      Sorry for the delayed reply here we go …

      Pilates barrel and supine stretch – yes agreed it is the crunch returning up to sitting which is the only issue, so yes use your hands on thighs to support return upright
      Take care to avoid not overstretching through the lower abs with the back supine over barrel stretch since you’ve had hysterectomy surgery, I notice supine stretch can cause some abdo discomfort post-op at times and so try to avoid overdoing this, foam roller is a better option especially in the early months after hysterectomy
      Posture does affect the pelvic organs there is no doubt about this and it’s due to the increase in pressure within the abdomen transferred to the pelvic floor with slumped forwards posture
      I agree that back extensions may have potential to increase pressure o the pelvic floor – not studies on it to my knowledge but I do suspect this to be the case when hyperextending and I am not sure why this occurs other than the fact that the abdomen may be squashed in prone so there is nowhere for pressure to go that downward (path of least resistance). Kneeling low dumbbell row, bending forward over a bench low dumbell row orprone push backs all seem to be far easier on the pelvic floor and highly effective postural exercises shown in this spine strength video video (I know it is for osteo but same exercise principles apply for postural strength)
      Side leg lifts will be unlikely to overload the pelvic floor – good pelvic floor safe hip strength and pelvic stability exercise.

      Hope this clears things up Melly and thanks for all your comments!

  5. Hi Michelle,
    I love your website, book, video, and your generous advice. I’ve just started Pilates 9 months post-op a vaginal hysterectomy with anterior and posterior repairs. I went to a PF Physio over 3 months just after the op to strengthen the PF and retrain my bladder function (which wasn’t leaking before the op). I wonder about 2 of the exercises at Pilates, (my instructor has my PF physio’s reports), so I’m pretty confident but I thought I’d like to check it with you if you don’t mind.
    One is the scooter where I stand, one foot on the fixed platform, other foot on the moving section and push out with the moveable foot, then draw it back in.
    The other is on all fours on the moveable bed, hands forward on the rails, shoulders over hands, then push out with knees, draw in with knees, just a small movement.
    I’d appreciate your comment on whether these two exercises are ok for the PF. I don’t notice any strain when I do them, but I don’t want them silently destroying my PF either!
    My husband and I go walking 3-4 times a week. He really steps it out. I’m wondering if I should be walking 6-7 kmph or if it’s best to walk around 4-5 and still get the benefits. I ride an exercise bike for cardio/aerobic fitness twice a week for 40 minutes on a flat setting. My gynae said to keep off the real bike if there were hills involved, so I set the stationary bike on flat and go for it.
    Thanks for reading this, Michelle. Cheers, Veronica

    • Michelle Kenway says

      Hi Veronica
      Thank you for your comments! The exercise on all fours is the one you descibe that may have potential to impact upon the pelvic floor. This is a strong core abdominal exercise (as well as hip flexors) and it is important to be mindlful of intense core abdominal exercises as you will no doubt be aware. The resistance would need to be minimal and your pelvic floor functioning really well to perfrom this exercise safely. I don’t see an issue with scooter, again light manageable resistance through the springs.

      • Many thanks Michelle! That has settled many of my thoughts or ‘worries’ down. And strengthened my confidence in my physio/pilates instructor. Just one more question? Is there an optimum kmh for walking that is friendly to the pelvic floor?

        • Michelle Kenway says

          Hi Veronica
          Good question – this is not established in the literature. The issue is with impact so ideally striving to walk briskly for cardiovascular fitness and avoiding undue impact (like running impact) on the pelvic floor. I can see how brisk walking can potentially add to impact compared with slower paced walking however I can’t begin to think weher the cut off might be for impact. The goal would be to keep one foot in contact with the ground throughout walking.

  6. Hi Michelle,
    Thank you for all the information you have provided regarding pelvic floor safe exercises. I am a physiotherapist & Pilates mat instructor and am interested in a reliable way to determine if my average client 2-30yrs post partum (without any known prolapse or incontinence) does have sufficient pelvic floor control to perform double knee floats etc. I observe for signs of pelvic tilting eg heads moving and suggest the client performs a single knee float or similar instead. If they are controlling the pelvis & lumbar spine nicely is this enough to assume their pelvic floor is up to it?

    • Michelle Kenway says

      Hi Gillian
      Unfortunately being able to control the pelvis and L/spine in neutral doesn’t give you relaible indication of pelvic floor function or ability to withstand any exercise really. The only reliable way is to send patients to a Pelvic Floor Physio for internal assessment, or use real time ultrasound to assess the PF during the exercise in question. I do think that single knee float is fairly safe for most women as the requirement for abdo activation is not so great that it would overwhelm the PF for many women. I think that it is more likely to be an issue for women doing more intense core abdo exercises such as double leg raise. Does this answer your question adequately? Just let me know

  7. Sarah Matthews says

    Hi Michelle,
    I am a Pilates instructor, mindful of womens health issues. I screen clients for any indication of pelvic floor dysfunction and teach people how to engage the pelvic floor. I teach people to engage from back passage as well as front passage but I focus strongly on the pelvic floor muscles engaging through the internal front passage and maintaining this connection through the exercises. A recent conversation with a physiotherapist indicated that strongly emphasising the engaging of pelvic floor can become a bladder irritant! An exact reverse of the intended benefit. Are you able to clarify this.
    Kind Regards,

    • Michelle Kenway says

      Hi Sarah
      Yes this is a good point – unfortunately some women become so good at contracting their pelvic floor muscles, and so strongly especially with intense core exercise that they just can’t relax them creating overactive pelvic floor muscles, and a host of pelvic floor problems that go along with this including bladder problems. I think there has been a great focus on teaching women how to contract their pelvic floor and reminding them to do so, but sometimes at the expense of teaching them how to relax the pelvic floor muscles (and lower abdominal muscles too, espcialy in women who tend to coactivate pelvic floor and deep abdominals). So I think it comes down to 1. Avoiding overbracing 2. Teaching abdominal and pelvic floor relaxation 3. Cueing appropriate PF and abdominal contraction and relaxation to ensure that clients don’t keep pelvic floor and abdo muscles overbraced.

      Hope this clarifies for you, let me know.

      • Sarah Matthews says

        Thank-you for your clear and structured response. I am relieved to be appropriate with my teaching as I do teach a relaxation of the pelvic floor / lower abs and instruct the relaxation as a part of each exercise. Beginners to Pilates have explained to them that the pelvic floor is a muscle that needs to tone not over tighten, contraction/ relaxation. I think that people would benefit if instructors explained how it feels when you relax pelvic floor, because it feels like your bottom is spreading and this can be disconcerting and put individuals off relaxing the muscle. Explaining the sensation of movement will help to normalise it.
        I am so pleased to receive your newsletter, I have learned a great deal and apply what I have learned when I am teaching.

        • Michelle Kenway says

          Hi Sarah
          Agreed, beginners to Pilates do need pelvic floor relaxation and contraction explained to them.

          • Hi
            I have just been reading this and so wish I had known all of this prior to getting all toned up in my pelvic floor over the last 5 years pew and post natal to two children, so much so that now I struggle to release it. It frustrates me that during the hours and hours of information on core stability during pre and post natal pregnancy Pilates and physio even in the hospital i don’t recall ever there being much emphasis upon releasing and the risk over over tightening the pelvic floor.
            In fact my first trusted physio after the birth of my first child told me to lift the pelvic floor every time I lifted my baby.. Unfortunately I think I incorporated this far too much in my everyday life.
            Even just to search the net this is one of the few websites that discusses this in the context of pelvic exercises.

            Thankyou. And I only hope u can reach many instructors and teachers of the dreaded Kegels and remind them to remind the client just how important the relax side of it is and also to be sure it’s switching off.

            I would also love any advice u may be able to give with regards to that true feeling of switching off.

            • Michelle Kenway says

              Hi Kate

              Hmmm good question regarding the true feeling of switching off the pelvic floor muscles. I think it’s hard to put into words. The best I can do is to draw an analogy to contracting another muscle group for example imagine doing a bicep curl using a dumbbell weight and the sense of contracting the muscle with the effort as the weight is raised and then the sense of release when the weight is lowered. The release sensation is the muscle relaxing which then becomes really no sensation at all with the muscle at rest. The same holds true for a pelvic floor muscle contraction and relaxation.

              I recently made this video that teaches how to relax pelvic floor muscles you may like to view this.

              I hope the techniques help you out. I am keen to hear how you go if you have time.

              All the best

  8. Hi Michelle
    Other than pilates or yoga I would like to know of any other forms of excersise suitable for a bladder prolapse.
    My friend has just bought a weighted hoola hoop and I wondered if I could excersise safely this way?
    My only form of excersise is walking at the moment so I am very interested in learning more.
    Please keep up the good work with your very informative web site. We have nothing like this in the UK.
    Kind regards

    • Michelle Kenway says

      Hi Pamela
      Yes I don’t see an issue at all with hoola hoop, maybe the two of you could get together and do this to some music, sounds like great fun to me. Have you tried bike or stationary cycle? Also a nice low impact cardiovascular exercise for many with prolapse issues.

  9. Hi Michelle,
    My aerobics class instructor is not convinced about the adverse effects of doing squats. What can I say to her? I have a vaginal and rectal prolapse . The former some years ago – the latter last year.
    Thank you

    • Michelle Kenway says

      Hi Kathy

      It seems to be the depth of the squat that is the issue, I don’t think the legs wide apart position of the traditional squat is too helpful especially with weighted squats, the deeper the squat the greater the pressure so we try to promote shallow squats. My personal preference is for mini squats or ball to back wall squats where the feet and knees can be kept narrow and the depth of squat controlled. Maybe refer your instructor to this site or the Pelvic Floor First website run by the Continence Foundation of Australia where she will see that this pelvic floor safe exercise is supported by the Australian Fitness Network, here’s a link to send her to http://www.pelvicfloorfirst.org.au/pages/fitness-professionals.html

      Hope this helps!

  10. Jeanette says

    Thank you for your website, I find it very informative and interesting. I do not suffer any incontinence or prolapse issues but as a woman heading towards 50, I am very interested in health and well being. I would like to know that when I am doing a class that I am working at the right level for me and I am never really sure if I am doing things correctly. Are all physio pilates classes equal? (I am not so sure)! After checking your exercise directory, I must ask, is there anywhere north of the river I can attend that you might recommend?

    • Michelle Kenway says

      Hi Jeanette
      Lovely to hear from you, and great that you are being proactive. I believe that all Pilates classes are not equal – there is a great deal of variability in terms of the intensity of the exercises, use of equipment, instructor styles, understanding of pelvic floor safe exercises and avoiding core overload etc. Jeanette which state do you live in, and perhaps I can help you out from there.
      Kind regards

  11. Hi Michelle

    Wow thanks for such a wonderful website, I would like to enquire do you Pilate Classes, or pelvic floor classes ? I am nearly six weeks post op hysterectomy and prolaspe repair and so looking forward to returning to running eventually, I know this is a slow process but I want to do things right! Any advice would be much appreciated.

    • Michelle Kenway says

      Hi Amanada
      Thanks for your feedback. Yes both Jenny and I take regular exercise classes for women, as well as numerous other pelvic floor safe exercise instructors Australia-wide. You can find our contact details, and those of instructors in your location by visiting our pelvic floor safe exercise directory
      All the best for your recovery!

  12. Hi there, thank you very much for this article. It’s great. I do have a doubt though… I think I didn’t quite understand when you mentioned that Pilates matwork is for people who are not injured only. I have to disagree with you on this one, ’cause in my opinion, as a physiotherapist, I think we can work “one on one” with our patients on the mat and they can benefit from it. We don’t necessarily have to work with the Pilates equipments to do a good job. what do you think? Anyway, thank you again for the great article. looking forward to reading more from you :)

    • Michelle Kenway says

      Hi Kelen
      I think you are absolutely correct and Pilates mat work can definitely benefit recovery from musculoskeletal injury. I think that the message intended that wasn’t originally clear is that one problem with group mat work is that some women with pelvic floor dysfunction get caught up doing higher level/more intense core work than they should, and it can be difficult to cater to all levels of pelvic floor function in the class situation – especially in classes where a woman’s pelvic floor risks and capacity are unknown to the intructor.

      This is a good point and I am glad you clarified that matwork can be highly beneficial for those with injuries, as well as without.

  13. Stephanie Taylor says

    Valuable information – thank you Michelle. So often, women with pelvic floor problems become paralysed with fear (literally and metaphorically) after being diagnosed with a pelvic organ prolapse. It is vital that we see prolapse as a catalyst to changing how we move our bodies, and use it as an incentive to us regaining the strength in our bodies that we used to have. The worse thing any woman can do is accept the diagnosis of prolapse and become sedentary – but care must be taken with exercising, and as long as women know what they have to do, and the care that should be taken they really can become empowered.