Stop looking for “prolapse safe” workouts, and start doing this instead:
If you have pelvic organ prolapse and you want to remain (or get back to) being active, it’s likely that you’ve sought out “pelvic floor safe” or “prolapse safe” exercises and workouts. This, of course, makes sense! We all want to support our pelvic floor and avoid doing activity that’s going to put us at risk. But here’s the thing: we don’t actually think “prolapse safe” exercise lists are helpful, and we don’t necessarily think they’re keeping you “safe”, either!
What’s the problem with “prolapse safe” exercise lists?
Binary lists of “safe” and “unsafe” exercises don’t actually take you into consideration.
We all have a different capacity and tolerance for exercise. Even if you have the same grade of POP and the same degree of pelvic floor strength as another person, your needs, goals, and considerations will be different! Some people are running ultra marathons with POP, competing in the CrossFit Games, or lifting 3x their body weight! Having POP doesn’t mean you are forever stuck doing bridges and bird dogs.
For one person, sticking to exercises on a “prolapse safe” list will have them exercising in a way that is too easy, doesn’t allow for progression, and doesn’t meet their goals and daily demands. Another person might try movements on a “prolapse safe” list and find them too challenging!
“Prolapse safe” lists are often centered around the idea that exercise selection should be based on what movements lead to increases in IAP
Lists of “prolapse safe” exercises are often constructed based on the idea that certain exercises will lead to overwhelming amounts of intraabdominal pressure that cause harm to the pelvic floor of a person with POP. First, it’s important to note that “there is as yet no IAP cut-point that is known to place women at higher risk for pelvic floor disorders “ (Hamad et al. 2013). Second, we need to recognize that IAP is highly variable between individuals. Research evaluating IAP and movement has consistently shown large ranges in IAP readings between different participants performing the same task.
The following values demonstrate the broad spectrum of IAP generation between participants. While this is just a small sampling of the data available, the variance in values is consistent throughout the literature:
“Normal” Speed Walking 1.8–88.6
Sit-to-stand 35.9-144.3
Plank 22.8-59.6
Full sit-ups 14-129
Jumping 26-154
Research on suggests that IAP is influenced by breath, muscular activation, speed, positioning, type of movement, body mass, degree of familiarity with the task, and circumstances such as pregnancy. Assuming the measurements recorded were not influenced by sensor error, the way an individual performed the activity (and the individual characteristics of that person) likely influenced the degree of IAP accompanying the task.
Additionally, tolerance for IAP is highly individual. The theory that a uniform tolerance of IAP exists for all with POP ignores the highly individual nature of humans. We instinctively understand that capacity for loading is dependent on several variables beyond the load itself but many of the recommendations regarding POP and IAP ignore this.
Tolerance to IAP is dependent on the characteristics of the pelvic floor that enable it to withstand it. A young, active (trained) person with a small urogenital hiatus, pelvic floor strength of 5/5 with good reflexive activity, and mild POP is likely to have a much different capacity for IAP influxes than an older, detrained individual with a large urogenital hiatus, pelvic floor strength of 0/5, and more significant anatomical POP. Similarly, two individuals could have the same degree of POP but still have varying degrees of pelvic floor strength, passive support structural components, and urogenital hiatus measurements; each individual likely differs in their capacity for tolerating IAP from the next.
Another consideration is the capacity for change. The ability to withstand an influx to IAP could theoretically be improved in the event of levator ani muscle hypertrophy, connective tissue healing/integrity, reduction of the urogenital hiatus, muscular strength/endurance/activity. The ability to withstand increases of IAP could theoretically be hampered by increased muscular/connective tissue laxity, increases in the measurements of the urogenital hiatus, decreased hypertrophy, strength, endurance, reflexive activity.
Recommendations “Based on IAP” are Often Inaccurate
Commonly held beliefs that assert the need to avoid certain activities due to the fear that certain IAP increases would be inherently too high to overcome are often erroneous.
For example, a common belief is that abdominal curl-ups (crunches) should be off-limits for those with POP because they are associated with too great an increase in IAP. Abdominal curl-ups have been found to be associated with a lower mean maximal IAP than sit-to-stand. Abdominal curl-ups had a mean maximal IAP range of 6.5- 82.3 while the sit-to-stand task had 20.6–99.7.
This study evaluated the difference in IAP for various exercises and commonly suggested modifications and found no statistically significant difference in the versions of lunges, squats, push ups, crunches, ball rotations and a greater difference between planks, shoulder pressing, step ups, running, cycling. Higher BMI was associated with higher pressures and coughing was associated with higher IAP than any of the tested exercises.
“Performing the recommended pelvic floor ‘safe’ version instead of the discouraged conventional version may not necessarily protect the pelvic floor and vice versa.”-Tian et al. (2017)
So, if “prolapse safe” lists aren’t helpful, what is?
Thankfully, there are so many things that are so much more helpful than these lists!
Here’s what we suggest focusing on:
Learn your unique considerations
Are you experiencing any symptoms or functional concerns? Do certain movements seem more likely to provoke these? This info can help us figure out where we need to put our focus!
Get clear on your movement goals to help with exercise selection
What do you want to be able to do? That knowledge will help guide which exercises make the most sense for you!
Want to be able to pick up your toddler? We’re probably going to want to include deadlifts and carries! Want to get back to running? Let’s work on total body strength and get a gradual return to running plan going!
Learn how to scale and modify exercise to meet your needs
Because ANY exercise can be made more appropriate for you!
We can manipulate the load or volume of an exercise and our strategy (breathing, tension, positioning) to make movements accessible to us
Learn some exercise science basics (really basic, we promise!)
You don’t have to become a trainer here! But understanding the basics of intensity, volume, progressive overload, principle of adaptation, etc. can make managing your exercise so much easier!
Work within your capacity
Find an entry point: this is going to be an exercise(s) that you can perform that does not provoke symptoms beyond a tolerable range. Ideally, this is an exercise that you like, that will help you meet your goals, and that is easy to scale or progress!
Consistently perform this exercise at a dose you can tolerate!
Gradually increase the degree of difficulty to progress
If the idea of trying to figure out all this on your own intimidates you, we’re here to help!
We think education is one of the most powerful POP management tools. Learning about your body, symptoms, exercise and more can give you the freedom to move away from arbitrary “safe” and “unsafe” lists. That’s why we created POPUp: An Uplifting Resource. Co-written by a pelvic floor physical therapist and strength coach and mom with POP, POPUp aims to make you the expert. We have over 80 sections covering symptoms, exercise, sex, body image, the perinatal period, self-management strategies, physical therapy, and so much more! And our exercise programs give you the guidance you want while still prioritizing your autonomy! We’d love to help you manage POP with more confidence! You can read more about the course and sign up to join us by clicking this link.