Empowering Women Through Pelvic Floor Strength with Dr. Kari Bo

In this episode, I have the opportunity to speak with Dr. Kari Bo, a respected physical therapist and exercise scientist from Norway, known for her extensive research and education on the pelvic floor. 

Dr. Bo discusses the importance of pelvic floor muscle training, debunking myths regarding its effectiveness and emphasizing evidence-based practices. She highlights the necessity of supervised training for significant improvements, the adaptability of pelvic floor exercises to online formats, and the critical aspect of progressively increasing exercise intensity. 

Dr. Bo addresses common misconceptions about exercise postpartum and advocates for regular physical activity incorporating pelvic floor strength for aging gracefully, emphasizing the role of lifestyle, social connections, and nutrition.

00:28 Introduction to Dr. Carrie Bo: The Mother of Pelvic Floor Physical Therapy

01:43 The Importance and Effectiveness of Pelvic Floor Muscle Training

02:03 Challenges and Misconceptions Around Pelvic Floor Training

03:45 Optimizing Pelvic Floor Training: Techniques and Maintenance

06:25 Incorporating Pelvic Floor Training into Regular Exercise Routines

15:00 Addressing Pelvic Floor Training Post-Vaginal Delivery

18:17 Exercise Classes and Pelvic Floor Strengthening: A Personal Approach

23:05 Aging Gracefully: Lifestyle, Exercise, and Nutrition

25:44 Cultural Differences in Diet and Portion Sizes

28:43 Closing Thoughts and Goodbye

Transcript

Hi there. This week, I had the opportunity to talk to Dr. Carrie Bo. Dr. Bo is a trained physical therapist and exercise scientist from Norway. During her career, Dr. Bo has been busy seeing patients, performing research, as well as educating other physical therapists and practitioners who are interested in the pelvic floor. 

She is internationally known for her work on the pelvic floor, and she has published more than 330  peer reviewed scientific papers on pelvic floor dysfunction, on the treatment of incontinence,  on low back and pelvic girdle pain, exercise during pregnancy and after childbirth, diastasis recti abdominis, measurement methodology, fitness, and women's health.

And she has given over 340 invited international keynote presentations worldwide. Dr. Bo has made amazing contributions to pelvic floor research, and I really consider her to be the mother of pelvic floor physical therapy and muscle training. I'm so very excited to share our discussion about the pelvic floor with you.

So let's go ahead and get started. I have to say that, you know, I'm a urogynecologist in the United States. I'm such a fan of your work. I feel like you emphasize. Being healthy and exercising more than treating an illness, which I think is a message so many women need to hear and I, I feel like your message is always very positive and I, I really appreciate that.

My first question for you is I've heard a lot of physical therapists say that, um, Kegels don't work. What would you say to that? I think it's so bad because then they cannot be updated at all. And our profession, as we are physiotherapists, we should really be updated on the evidence that is in this area.

And this is just really lying. to patients to say that this is not working because we have so many randomness control trials of high standard, high quality. We have systematic reviews. We have Cochrane reviews. They all conclude that there is one A level of evidence and recommendation for peripheral muscle training.

And this is based on these high quality studies that takes more than four years for each of them to be conducted. And. Planned and, you know, conducted and published. And then people can just go on social media and say, well, they are not working. It's to me, it's, I don't know how to deal with it because it's so bad.

It's so bad because they are lying to people. Um, And just by saying that without having any data themselves on whatever they want to do instead of peripheral muscle training or what they call Kegel, it's, it's, we call it peripheral muscle training. Now it's the same. It's not, it's what they are saying is not based on anything, but we spend four years in trying to conduct a very high quality study.

So it's amazing. And it's embarrassing for our profession. I think that still there are physiotherapists who can do this. I think people don't realize how much work goes into a randomized controlled trial, right? And when someone like yourself says, Oh, the data really supports this because you're right.

Those, those trials take a long time and they take a lot of, it takes a lot of money. It takes a lot of, um, patients, you know, so many people have to be involved. So in, you know, in the United States, a lot of times, um, physicians will tell women to go and do, you know, kind of 30 Kegels a day on their own. Um, and then just kind of send them off.

And I wonder if that's where part of the problem comes from, um, versus pelvic floor physical training with a physical therapist. We know also from these randomness control trials that the best evidence and the best effect is if you are training with Trainer, uh, can be a nurse or a physiotherapist or a medical doctor, uh, as long as they do the correct things, 

Uh, but it should be done at least once a week with, uh, supervision. So just to tell them to go home and do the exercises is not going to work. And we show that in, actually in my first random control trial, even if they had once a month with a physiotherapist for seven. Times compared to meeting in a group training session for once a week for for six months. 

Those who had these only once a month meeting with a physiotherapist it was really not very effective at all compared to those who trained once a week with a physiotherapist. So this is very important that we just. don't give them a sheet of paper and believe that they will do it because this is also um, a lifestyle change in a way you have to start to train and you have to continue to train and it's also if you want to do any lifestyle changes, you need follow up, you need someone to support you and, and a good physiotherapist can be Amazing in that sense, because we have time with the patients and we have the knowledge if we are basing this on the evidence we have, we can really motivate them and talk them into doing this.

And the group training session is a very good thing because then they meet other people who have the same problem, they can help each other, they can motivate each other. So it's also a good thing. But of course, not always we can do group training because it doesn't fit into their schedule. So then you have to go for individual, but it's a combination of these things.

It's a very good thing for physiotherapists to do, to have both options for the patients to either be in a group or individual settings. Do you think it can be done online as well, or do you think it has to be done in person? I think online is much better than not doing anything or just giving them a sheet of paper.

We, I don't think we have any studies that really compare this, uh, with this comparison between online and personal. Uh, I always believe in more in the personal because we also know with Zoom meeting and with, uh, courses given in personal, it's, it's more, you get more out of it because you can talk to each other, you can discuss and it's, um, it's a way, it's, it's better, but it's, Probably much better than only giving a sheet of paper. 

Yeah, the sheet of paper may be a little bit lazy on on the physician's part. Um, I've heard you say that like all strength training when you're doing pelvic floor muscle straining, you, the exercises have to get harder over time. How do you recommend doing that? This is the most, uh, difficult and challenging thing about the pelvic floor because unlike the biceps or other muscles in the body, you can really not put on resistance.

Uh, so we need to make the patients, uh, or individuals who are training, uh, stronger. Try to get as high up to a maximal contraction as possible. And that will be relative because if you're very weak, you, your starting point is a very weak contraction, but still you need to get as close to that as possible.

And then when you get stronger, you have to really encourage and make the participants work harder. And we know that strength training is not going you know, in a linear way, it's like steps. So you end up in a step where you're in a higher step, and then, uh, you have to press and click. work hard to get up to the next step and up to the next step.

Uh, but this is the challenge and that's why we, we can also use different positions and they can choose a position where they feel is more difficult to do the contractions. Uh, we can, Also change, maybe trying to hold it for a longer period of time and then try to work on different ways of doing these muscles, but there is only, like the biceps, you can only do one thing and it's the same with the pelvic floor.

There is a mass contraction, so you are squeezing and lifting inward. That's, that's the whole thing, but you have to do it harder and harder. And again, the physiotherapist and the voice of the physiotherapist must encourage them to work hard. And because this is not relaxation training, it's strength training. 

Yeah. I think it's harder to do those exercises to make it harder on your own, right? That's something that most people can't do on their own. Once someone is finished with pelvic floor muscle training, how do they maintain the This is also a problem, and it's a problem in oral exercise science for other muscles as well, because we don't really have very strong evidence for how much and how long you should do maintenance training.

But a few studies we have in the general, uh, muscle training is that Again, it's important to reach maximal contractions to be as intensive as possible, and then one to two times per week, and then maybe only one set is necessary to maintain. But again, this differs on how high you have gone in your training before you are going to maintain, how well you were after the first training sessions, uh, but we have longterm studies, uh, also.

In peripheral muscle training, showing that between 40 to 70 percent are adhering to the program after five to up to 15 years. We had the longest follow up in 15 years and, and it was quite encouraging to see that women are able to continue to do this. And I think if they have really reached a level of where they can say that, well, I'm not Uh, incontinent anymore.

They understand that doing these exercises is going to help them. And some women said that they were doing it regularly every day, and they had a specific, uh, time of the day where they found it convenient to do it. While others say, well, I don't really do it. But after some month or weeks after I've stopped doing it, I can feel that it's really sort of sagging down, it's getting weaker.

And then I know exactly what to do because I've trained the muscles before. So then I do some really proper and hard strength training again for the peripheral for one week, and then I'm fine. So I, in my opinion, this is a very good way because they have control. Yeah, they know what to do. Yeah. It's all about giving people the tools, right?

So that they can do what they want. Um, when, when you see women who, um, want to do really intensive exercises like CrossFit and are doing, um, a lot of high impact, um, exercises, is that something that you think women with incontinence can do? Because so often they're told not to do anything like that.

That's so high impact. I'm a strong, uh, emphasizer of regular exercise. So I, I don't think I would ever tell anyone to stop exercising because, uh, it's so important for health, uh, in general. Uh, and also so very important, especially for mental health. So if you are on exercises and you were asked to stop exercising, it would really not be good for your health.

But, uh, we know that Really, very few of any sport women or exercises are also training the pelvic floor muscles. So I'm quite convinced that if they could add this to their other exercises, this would also help them. We have very few studies though. We just published one from my, um, Um, like latest PhD student, Christina Scav, uh, on, uh, CrossFit or functional training.

And we also show that they could be improved by doing peripheral muscle training. The results were not as convincing as we have seen before, but we think it's because we could not do supervised training because we had the COVID and it was difficult for them to, to do that. So that really influenced the results, but there was statistically significant.

So fine in that sense that we have shown that they can also improve. But I think they would have been improving even more if we could have followed them up or also if they could be a specific part of their exercise program. Because women who are exercising, they, are quite occupied because they are exercising in addition to something else.

And then we add pelvic floor muscle training on top of that. So it has to be included, I think, in their warmup program or as a general part of what else they are doing. So they are training the biceps and the quads and other muscles. Why not the pelvic floor? It's just because they don't, they are not aware that this muscle group is there and it needs to be trained just as the muscles.

And they need much more strength and much more function of the pelvic floor muscles compared to others, because if you just are in a sitting occupation and you have a cold once a year, and you cough, that's very little compared to everyday exercises with heavy weights. So these pelvic floors, they need to be much more, uh, functional than others. 

Yeah, I think that's such a great message. I mean, I really agree with you. Exercise is so important for so many things and anytime we recommend. Not exercising. That just doesn't make any sense. Right? Especially since so many women use exercise to maintain their mental health, right? As well as to age gracefully.

But I, I feel like that is a, um, a lot of women get that message, right? You should, you should stop doing these high impact things since these high impact things, um,  Cause you're leaking, but, but your advice is, you know, train smarter, train harder. So add pelvic floor muscle training to your regular program.

What do you think the average woman needs after a vaginal delivery for pelvic floor muscle function? It's very difficult to say in general, although I know that we are recommended that every woman should do it. But if you have, uh, uncomplicated pregnancy, you had a very easy birth. Uh, maybe not everyone needs to train the periflora because it gets back by itself, uh, into the shape.

So the levator hiatus is closing. It is lifting up and then you can start and do some easy exercises. So, uh, I'm not sure really that everyone needs it, but we. Cannot say who needs it and who does not need it. That that's why we are giving general advice. And then, uh, also we know that many women have now, uh, it's been shown that they have, uh, injuries to the pelvic floor muscles, to the fascias.

And so, so then they need much more, um, knowledge and, uh, awareness on how to exercise. So, so the General exercise recommendations now is that everyone actually shouldn't train after, uh, pregnancy and childbirth and especially during pregnancy because, uh, It has been really strong evidence now that it's prevented in women who do not leak, uh, and they start exercise the periflora during pregnancy, it's really preventive, both during pregnancy and after childbirth, but after childbirth, we also now have a level one evidence that they should train the periflora to then improve urinary incontinence.

Yeah, we need to really get that message out there, right? Because I don't think most women who are pregnant or looking to conceive are thinking about their pelvic floor, right? And thinking about exercising. That's the time to start thinking about it. And I think it's a, it's also a time where women will be motivated because they know that something is going to happen to the pelvic floor.

The, the child is going through the two sides of the pelvic floor. So it's, It is bound to be opened up and it's bound to be stretched. Uh, and also, fortunately, we now have a systematic review with 12 RADMOS controlled trials showing that you have actually no problems with vaginal birth after peripheral muscle training during pregnancy.

I think that's also a very important message because they have shorter, Uh, labor than others. And it has been some reluctance among midwives, obstetricians, and also physiotherapists because they think you can get in a way too tight by doing peripheral muscle training during pregnancy. This is a myth.

It's not true. They have easier birth. Uh, and we should also have that message out. Yeah, I agree with that, right? There is that theory that you're, you're bulking everything up and it, it would be harder to deliver. Um, You may bulk the muscles because it's been shown, uh, that we can bulk the muscles, but it's, it's actually, uh, in pregnancy, when you do pericardial muscle training, there is a wider, uh, elevator hiatus area. 

Okay. Um, so I, I read in one of your bios that you teach your own exercise class every week. And do you incorporate pelvic floor strengthening into your, into the exercise class that you teach? Yes, I started this 34 years ago, so I've done it ever since. Uh, yes, I have always done that because it was at the same time when I started to do my research on peripheral muscle training and it was actually, um, why I was interested in peripheral muscle training, uh, at the very beginning because I heard that women stopped exercising because they had urinary incontinence.

And to me, that was really bad thing. So I really wanted to incorporate it into my class. So then I also trained the pelvic floor in the same way as I trained the abdominals and the gluteal muscles and doing squats and doing biceps and you know, all this other thing. We always do it. And I must say, It's been very interesting because, uh, the women that have been also training with me for many years, if we, if I have a locum, if I'm away, so somebody else is there, they are very annoyed if they are not doing the peripheral muscle training because they're so used to it.

This is a natural part for them and they really appreciate it. So if someone's looking for an exercise class and they want to do pelvic floor training, what, what did they look for? Well, no, because I, I, I've been striving with this for many years and trying, I'm teaching at my university, which is a sport university.

They, I always taught my students to do it. I know that they will probably most of them do, but I, very seldom see it. If I go to an exercise class, it's so seldom that they also mention or do any peripheral muscle contractions. And also many instructors and also some of the physios who are teaching this in the class, they try to incorporated in other exercises.

So they are doing a seat lift or they are doing a squat, and then they try to do peripheral muscle training at the same time. The Pilates is also like this, like contract the peripheral, breathe in, do this and do that. And there's so many things at the same time. So instead of, because they don't do that if they're doing abdominal training, then they are doing the sit ups or the crunch, but for the peripheral, they think differently, which I think is very strange.

So you have to do proper peripheral muscle training it. Just as you do proper back training. It's the same, same, they are striated muscles and should be trained in the same way. But I know that many Pilates classes now, they also have an emphasis on the pelvic floor, which I think is good. But again, in most of the classes I have seen, they have just.

Done what I just said. So breathe in, compact your pelvic floor and do this crunch or do that. So that's not enough. Uh, you have to do it properly. I, yeah, I don't think I've ever been to an exercise class where they did pelvic floor strengthening separately. Right. You're right. It is always incorporated as, as something as part of another exercise.

And, and then it, it's a lot. Yeah. It's very difficult because, uh, dual tasks, uh, are much more difficult than single tasks when we are doing exercises. It all sounds so simple in talking to you. And I, I just wonder why we don't do it a little bit differently and why we aren't a little bit smarter. I mean, I think we're all just, we like to ignore the pelvic floor, right.

And just pretend like it's going to be fine without, um, directly working with it. Yeah. Yeah. Yeah, it's very strange. And I also find that, uh, some of my physiotherapist colleagues around the world that they, they think it's too simple just to do peripheral muscle contraction, but it's not simple because you can't see the muscles and they may be injured.

Uh, so it's difficult for the participants to do this. So why should we make it so more difficult by doing all this breathing and doing all this other stuff instead of thinking just on strength training principles? I think it's because it feels different than a different contraction, right? I mean, when I.

When I'm lifting, I can feel muscle fatigue. And when you're just focusing on the pelvic floor, I think it's harder to feel that muscle fatigue. Don't you think? Yeah, but if you're doing really  close to maximum contractions and you do 8 to 12, I, I feel that I'm tired also. You can feel the fatigue also then.

Yeah, I, I, I guess you're right. I mean, I think that probably is the problem, right? Where we're not doing, um, we're not so close to maximal fatigue, um, and, and not challenging ourselves enough. My last question for you is what is your best advice for aging gracefully for women? You mean in general, not on the lapel floor?

You can answer it any way you want. Um, yeah, I, I. I think there are many factors that, uh, make, uh, aging better than others, uh, because you need to have a good life to also be aging gracefully. So hopefully to have a good social life and to have friends and to have, people around you that you love and you can be with.

Uh, that's also a very important part of, of aging and to trying to, to, to, to keep your friends. I think it's very important and have also spend time with your friends. But, uh, uh, in addition to that, of course, there is this about, uh, uh, to continue to be exercising, uh, and to be physically active. It's very important.

We know this is so important to prevent so many different diseases. Exercise is medicine and it's something that we should do at a regular basis and even more, uh, when we age, because we need, we need more because aging is, you know, going. taking us the other way. So we need to exercise more and most people exercise less, unfortunately.

So it's just to, to, and to find things that you like to do when you're exercising. It shouldn't be something that you hate and then you just force yourself to do it, but fine. I mean, if you like badminton, play badminton. If you like to dance, uh, Brazilian dances, uh, do that. It's something that you like to do.

And of course, uh, non smoking it's obvious. And then, but also nutrition that we have to think about what we are eating and less alcohol. Uh, it's also important, I, at least I experienced in Norway, we didn't used to drink a lot of wine in Norway before, now it's a more of a wine culture and we are drinking much more than what we should.

Uh, I, I'm not a very, I, I don't drink a lot of alcohol, I thought, but when I'm thinking about it, when I'm going to conferences and when I'm with friends, some weeks I can have alcohol like four or five days a week. Which is too much. So we should try to reduce, uh, some of the alcohol consumption, although some alcohol may be okay, or some wine may be okay, but try to reduce that, but, and then not eat too much.

And  I'm amazed about the American culture, I must say, because when I'm in the U. S., the portions  They're so big. So for me, one third would be a big portion. And then if you eat too much, this, this is a big problem. And I think it's also spreading all around the world. Also in Norway, we can see now, for instance, popcorn in the US, you have this big basket of popcorn.

We used to have very small portions in Norway. Now it's the same here. And this is not good. We have to, to really think about, uh, how, how we are eating, uh, not only that it should be more vegetables and fruit and, uh, you know, fish, uh, to eat that, but the portions, I think it's, it's a big problem and it's, uh, unfortunately spreading around the world.

Yeah. And I think it's something when you're in the U S a lot of people don't realize because it is so part of the culture and it's not until you travel to other countries that you realize how very. How very different it is. Um, uh, cause our portion size is awfully big. And I don't, I don't know how it, I don't know why that is.

I don't know how it got to be that way, why that's considered to be a, a, a good thing. Um, but yeah, that, that's a amazing difference, right. That you would consider a third of a U S portion size to be a big portion. Yeah. And it's really true. I've seen this so many times and I'm wondering, I've been asking my American colleagues and they say, well, we don't, as you said, we don't know why this has come and habit, but maybe it's also that you, you want to have good service to the people and that they should have a good thing for the money they pay.

And therefore you don't want to. Take it away, but it's not good for health. No, I mean, when you look at the effects of all of that, right? Because we are very obese nation. Um, it, it, it is not great, right? I mean, we are a sedentary and obese nation right now, which is definitely the opposite of what we want to be.

I like what you said. And, and I definitely agree with you in, in my clinical practice. I think some of the patients that I see that age the best are women who golf. Yeah. Right. Because they're out, they're social, they're walking, and it's a sport that you can do your entire life. And it really meets that, that social, um, as well as physical component and people that do it, love it.

And so I think it's important for everybody to, to find whatever that is, if it's Brazilian dance or, or badminton or golf. So thank you for everything that you're doing to help women age more gracefully, right. And to figure out how to use our bodies in the best way. So much for doing this and spreading it.

I think it's excellent that you really have you spend your time in, in spreading the message. So thank you so much for inviting me. I'm trying. Thank you so much. Bye bye.