Typically people go to pelvic floor physical therapy when they have incontinence, pelvic pain, pain during intercourse, and difficulty with bowel movement or urination. Pelvic Floor Dysfunction physical therapy is what a trained physical therapist who has gone beyond the normal training of a physical therapist does. Pelvic floor therapy typically involves the use of manual technique with the index finger inserted through the anus and/or vagina to work on the muscles inside the pelvic inlet. Sometimes they use devices internally and externally to assist in relaxing the muscles of the pelvic floor.

Some pelvic floor physical therapists evaluate the patient’s posture and walking (gait) to evaluate the impact of the outside muscles on the muscles of the inside of the pelvis. Unfortunately, pelvic floor dysfunction is on the rise and the number of trained physical therapists for pelvic floor dysfunction is not enough to support the need the pelvic floor therapists who are physical therapists who do internal work as the focus of their work. The question then is, is the internal manual work a complete treatment and are physical therapists the only therapists that deal with pelvic floor dysfunction!!

Pelvic Floor Manual Therapy Limitations

Internal manual therapy of the pelvic floor has its limitations for obvious reasons. For instance, the depth of the area that is approached using the index finger is highly limited!! This is a big problem because there are many muscles, connective tissue, and soft tissue inside the pelvis that cannot be reached through the two access holes (one in men).

pelvic floor dysfunction

Pelvis ligaments front side

Let’s face it, while women are used to internal manual work because of their gynecological exams, no one looks forward to this invasion of privacy in the name of treatment. We should chase the whys behind the involvement of the internal muscles of the pelvis that are either tight or weak. Why are they tight, weak, or both? Does going inside to massage or practice contracting those muscles help? How does nature relax and strengthen those muscles?

Benefits Of Pelvic Floor Physical Therapy

When in conjunction with other modalities such as biofeedback and lifestyle modifications, manual work that is done internally will go a long way. The question to ask is if that is the first step toward the correction of the muscular imbalance of the muscles inside the pelvis!

Why Internal Manual Work May Not Be The Right First Step

The muscles inside the pelvis provide support for the pelvis because your pelvis is the base of your trunk and the foundation of your movement. Remember, you can live without arms and legs but you cannot live without your torso! Your pelvis is the base of your torso and has a huge responsibility; its support and stability are crucial and the inside of the pelvis works with the outside of the pelvis to provide a double layer of support and reinforcement.

The muscles of the inside don’t randomly become tight or weak but as a response to what is happening on the outside. When it comes to the treatment, we not only need to look at the movement and support of the outside of the body but to finish the solution by looking at the inside of the pelvis as well. That is why using internal manual work as the main approach to pelvic floor dysfunction in my opinion is wrong!

How Does Nature Strengthen And Relax The Muscles Of The Pelvic Floor?

Believe it or not, when you breathe in correctly and biologically, you relax the muscles of the floor and when you breathe out biologically, you strengthen the same muscles. Walking and sexual intercourse also do the same thing. Squatting down and pinching the urine flow only messes up the neural action and is something that stirs my patients away but what is biological breathing?

The video below will tell you all about it but do know that this is how we all as babies breathed and all babies do automatically. No wonder it is the right way to breathe after all, nature knows best and if all babies on this planet breathe the same way, then we must be meant to breathe that way.

What Does A Comprehensive Pelvic Floor Dysfunction Treatment Look Like?

At my clinic, after a detailed functional movement and postural neurology assessment, I can see if there is pelvic instability that is the root cause of pelvic floor dysfunction. I do not need to do internal manual work to make that assessment and do focus on the fact that we need to first stabilize the “house” (pelvis) that the pelvic floor is the “floor” of.

  • The treatment outline is as follows:
    • Biological breathing


    • Developmental Kinesiology (DNS) exercises are inspired by studying babies! You see, no babies use any bands, weights, or gyms, have a physical therapist, chiropractor, or personal trainers to guide their exercises and yet all go from helpless infants to running toddlers. These are the right exercises to follow because we are born with the ‘software’ that dictates those moves and they are compatible with our body’s design and abilities. These are the same exercises I use with my joint hypermobile patients who have one of the most unstable joints due to their connective tissue disorder. 


  • At some junction along the way, when enough proper movement functionality is built, I use the Emsella Chair which is an FDA-approved machine that provides 400 Kegels a minute. I use this machine for what it is capable of doing but apply my protocol. You see, if my patients know how to breathe biologically, they are using the diaphragm muscle correctly. If they sit on the chair, myself or my team monitor how they are sitting, and how they are engaging the key body parts, then as the machine stimulates the muscles to contract, because of the positioning and the monitoring that we are doing, those contractions are more uniform and intentional. That is like gluing two pieces of wood to each other at a 90-degree angle; we glue the 2 pieces, put screws in, and then put a bracket to hold the pieces together while the glue dries. If we position and engage the body and muscles correctly, when the Emsella Chair contracts, the inside of the pelvis muscles can do the contraction correctly. With biological breathing in place, we are influencing the inside just as effectively as we influence the outside during the process.


  • From my experience, every pelvic floor dysfunction case is resolved when the steps outlined above are performed. It makes sense because we can address pelvic instability by doing comprehensive work and the bonus is that our patients can understand, prevent, and predict what may lead to their dysfunction before it is too late.

Two mitered pieces of wood glued and reinforced with a bracket

If you have pelvic floor dysfunction, are receiving care, and are not happy with the results or have any questions, do not hesitate to contact me.

Dr. Shakib

Recommended Reading:

Pelvic Floor Dysfunction Symptoms

Can I Do Pelvic Floor Therapy On Myself?