Harmonizing Health: The Voice to Pelvic Floor Connection
I have been speaking and teaching on the voice to pelvic floor connection in therapy to international audiences for well over a decade now; but a major gap still exists in pelvic healthcare: the exclusion of the voice as an integral part of pelvic health.
In 2020 Emerich and Gordon wrote:
In the literature on voicing, “there was no mention of the pelvic floor as part of the abdominal musculature involved in breathing or contributing to muscular support.” (Emerich Gordon and Reed 2020)
Emerich & Gordon 2020
Historically speaking, phonation & vocalization theory have STOPPED at the respiratory diaphragm. And pelvic floor therapy has also stopped at the respiratory diaphragm too.
There is a paucity of research on how the voice and pelvic floor are inter-related.
In spite of that, I’ve been integrating the voice into pelvic floor and trauma-informed care for over a decade. What does it look like to integrate the voice into pelvic physical therapy?
Integrating the voice into pelvic physical therapy includes evaluation of:
- History of trauma-informed and providing trauma-informed physical therapy care
- Orofacial soft tissue and bondy integrity and status
- The voice
- Neck
- Jaw
- Shoulder
- Thoracic, lumbar and sacroiliac spine
- Pelvic girdle and floor (including the hip)
Why must the voice be included in pelvic health care?
The voice is an essential part of pelvic health care because the voice is connected to the pelvic floor through both neural and fascial connections. Practically speaking, if you try holding your nose and blowing hard, what happens? Your pelvic floor will descend and stretch downward. See the ultrasound image below. Note that something similar happens when you take a belly breath.
In the image above – the individual was trying to recite a simple phrase, like Mary Had a Little Lamb. In doing so, this person was putting a great amount of descent on the bladder base. To orient you, the bladder is the dark square and the bladder base, where the measurements are taken, is a surrogate for the pelvic floor. So in this case, whenever this person spoke, especially forcefully, leaking occurred.
This is a case where the pressure created by the voice, internally, was so great, that it was overcoming the bladder’s ability to maintain continence. As a result, the bladder neck could not control the great amount of pressure it was under, so the bladder neck opened, and you can guess what happens next. Leaking.
But it does not always happen like this. Sometimes, it takes a person laughing, coughing, sneezing, jumping, running long distance, and/or lifting something heavy, to create this kind of leakage. The point is, the voice is the upper end of the pressure system, and if it isn’t controlled for, it can create pelvic, back, and breathing dysfunction and pain.
What’s more is it is not just the voice that creates the uppermost diaphragm (see the diagram below), the vocal area also includes the entire orofacial area, the neck, jaw, and all the bony and soft tissue there.
What does it look like to include the 3D approach in pelvic health?
The three diaphragm approach has been identified in the literature prior to my first mentioning it my book, Medical Therapeutic Yoga, nearly 10 years ago. In fact, more than 3 diaphragms have been identified by authors. Five, to be exact, diaphragms are listed. However, I choose to focus on the ones with solid scientific support, and this is where the “three diaphragm” approach to pelvic health was born. However, it isn’t just for pelvic health. The three diaphragm approach is also essential to managing stress and overall well-being.
The three diaphragm, or voice to pelvic floor, approach is requisite to be a primary care physical therapist. Further…
I believe the three diaphragm approach is a requirement to being a primary care physical therapist, mental health therapist, or to provide any healthcare where trauma to the pelvic, diaphragm, voice, or mental or emotional health is at play. The three diaphragm approach addresses the critical role of the vagus nerve and the deep front myofascial line in regulating the following:
Three diaphragm health depends on the health and integrity of the vagus nerve, which turn regulates:
- Mood
- Creating of sound
- Breathing
- Digestion
- Systemic Inflammation (that directly impacts joint health and pain perception, as well as immune function and digestion)
- Urination and defecation (bladder and bowel health)
- Cardiac output
- Sexual health
- Birth
The deep front line of the fascial system connects the three diaphragms through the following muscles (see the deep front line below, 2nd from the end):
- Jaw
- Neck/Orofacial area
- Chest
- Diaphragm
- Abdominal
- Pelvic Floor
- Inner Thigh
- Back of calf
- Soles of the feet
In an ideal world I would like to see everyone using a three diaphragm approach (I also call it a “voice to pelvic floor,” or V2PF approach) because it enables you to holistically and comprehensively connect the dots. If you are a provider, your patient’s jaw, neck, head, and voice issues can absolutely be caused by or worsened by not just poor breathing, but also pelvic and core dysfunction and pain. This means it is absolutely necessary to screen all three diaphragms if someone has pain anywhere between the head/neck and the knees. Even then, if you look at the deep front line, you will see that the soles of the feet are connected to voice and neck/head pain issues – through the fascia. So you cannot ignore even the feet if you want to be comprehensive and thorough in treating someone’s pain.
Who can voice to pelvic floor (V2PF) therapy help or benefit? Individuals with:
- Headaches
- Neck pain
- Jaw pain
- Vocal weakness, hoarseness, dystonia/dysphonia
- Swallowing issues
- Narrow airway, asthma, breathing dysfunction, COPD (chronic obstructive pulmonary disease)
- Long COVID
- Back pain
- Sacroiliac joint pain
- Pelvic pain
- Incontinence
- Painful sex/intercourse/penetration
- Pelvic organ prolapse
- Hip and knee pain or tightness
- Foot pain or tightness
What are the red flags for coexisting voice to pelvic floor dysfunction or lack of connection?
- Respiratory dysfunction
- Long COVID
- PFD
- POP
- SUI
- Hernias
- GERD
- Vocal dystonia
- Laryngitis
- Balance issues
- Postural control and poor posture
- Developmental delays
- Allostatic load/poor stress response or chronically high stress
- Vocal fatigue
- Poor vagal tone
- Poor digestion
- CV issues
- Persistent pain
- Apnea/OMB/Poor sleep
- PTSD or complex PTSD
What can you do to optimize your voice to pelvic floor connection?
The first thing you can do is be aware of the three diaphragms. Get started with this video series below:
Orofacial Release – Part 1
Orofacial Release – Part 2
