By Sarah Russell MSc, certified clinical Pilates teacher, clinical exercise specialist and founder of The Ostomy Studio. Author of The Bowel Cancer Recovery Toolkit. Ostomy since 2010.
I’ve been practising Pilates for decades and teaching more specifically for the last few years. I’ve also had a stoma since 2010. I’m trained and certified with APPI in clinical Pilates and I believe that Pilates – done in an appropriate way – is fantastic for people who have had stoma surgery.
It’s important to develop a feeling of deep abdominal control and strength. A sense of being able to use our muscles to draw the stoma inwards, almost like we’re wearing an internal support garment. Your core needs to feel strong enough to cough, sneeze or laugh without fear of incontinence or hernia. And to have the sensation of the pelvic floor, abdominals and diaphragm all working in synergy and correctly when we exercise or just go about daily life, no bulging or undue pressure.
That’s what Pilates can give you.
What are the guidelines about exercise and stoma surgery?
Currently, there are no clear guidelines about exercise after stoma surgery, and nothing specific about Pilates. Which leaves people feeling unsure what to do and how to exercise safely. The biggest thing I hear from others in the ostomy community and from clients is a fear of abdominal exercises, fear of hernia and lack of information.
There are however a few general guidelines which do help to provide some reassurance. The ASCN (the Association of Stoma Care Nurses UK) published clinical care guidelines in 2016, in which they state patients should be encouraged to do ‘core abdominal’ exercises starting around 3-4 days post stoma-surgery and then to continue with these for life.
Exercises suggested in the guidelines are based on Pilates and involve knee rolls, pelvic tilting, one leg stretch and so on. These exercises are also illustrated in the me+recovery programme which I developed with ConvaTec in 2016.
The ASCN UK are leading the way globally with this advice and it’s great that this is a clinical guideline. However, there are a couple of issues:
1. Unfortunately, this advice is still not yet embedded into best practice or widespread in stoma care. Many patients are not getting information about abdominal exercises when they have surgery (if you did, then fantastic.. Your stoma team are on it!). But this leaves people feeling fearful about what they can safely do and confused about the recommendations.
2. Whilst it’s a great start, it’s really just the first step in what needs to happen in the rehab process. A few post op exercises are good… but are you doing them correctly? what happens next? How do you progress and get stronger? Are there any exercises which are better than others? can you get back to doing planks, sit ups and lifting weights?
And to address the question of this blog.. can you do Pilates with a stoma?
The answer – as with most things in exercise/fitness and rehab – is ‘it depends’.
What is Pilates?
Pilates is an exercise method which focuses on developing strength, control and movement in the whole body, with a particular focus on core/abdominal muscle control and strength.
It is low impact, often done on a mat with items of equipment, but can also be done in standing or seated and adapted for people with mobility issues. It is a mind-body form of exercise, requires concentration, co-ordination, mindfulness and precision of movement.
Pilates was developed by German-born Joseph Pilates in the 1920’s to aid the recovery of injured and sick soldiers in hospital. And it can be a fantastic form of rehabilitation after surgery, bringing awareness to the body and restoring movement quality, strength and body confidence.
Some Pilates exercises and classes can also be extremely challenging and require high levels of strength and stability. Pilates is often used with high performance athletes, and is definitely not an ‘easy option’.
There are also many different styles of teaching Pilates and there are areas where Pilates has fused with other methods combining with yoga, weights and even HIIT. My practice is based on the ‘physio led’ APPI clinical Pilates approach which is centred on modifications, adaptations and gentle progression.
An essential approach when exercising with a stoma.
What about Pilates and a stoma?
So when considering Pilates after stoma surgery, be aware of the varying approaches, methods and levels of difficulty. Don’t assume that one Pilates class is the same as another and be mindful and questioning about finding the right approach/class for you. Before ‘The Ostomy Studio’ I used to recommend people did a class suitable for post-natal women as this was the closest thing I could find.
Now I’ve developed a whole series of post-surgery classes, specifically for people with a stoma (find them at www.theostomystudio.co.uk).
One of the problems is that many ‘beginner’ level Pilates exercises/classes are still too challenging for someone just after surgery or indeed for anyone with a stoma. An understanding of ‘intra-abdominal pressure’ (more on that below) to reduce your risk of hernia should be at the centre of your Pilates practice and knowing how to modify and adapt exercises is essential.
Respect your stoma
Having a stoma makes people feel nervous about abdominal exercises. And I get that.
We must always respect the fact we have a stoma and that there is a certain (I use this word carefully) ‘vulnerability’ of the abdominal wall. However, no-one should ever feel vulnerable or fearful of exercise or that their stoma limits them in ANY WAY. I really believe that you can do almost anything you want when you have a stoma and you can (with the right approach) build up enough strength to do any kind of lifting or abdominal exercises.
So you have to find the balance. A balance between respecting your stoma but not letting it stop you from doing anything you want. It’s about becoming mindful of your body and exercising in an intuitive and safe way. The only way to do that is by learning movement, exercise, modification and experimenting safely with what works for you.
Intra-abdominal pressure (IAP)
The most important consideration during exercise/Pilates for anyone with a stoma, is to be aware of ‘Intra-abdominal pressure’ (IAP). This is where pressure increases inside your abdominal/pelvic cavities during an activity or movement. It’s that feeling of ‘pressure or bulging’ through your abdomen and pelvic floor when you cough, sneeze, push or pull something, jump or during exercise, especially core abdominal exercises or in heavy lifting. You may also experience incontinence and leakage of urine. Some people describe remembering a particular moment when they sneezed or lifted something heavy and they felt a parastomal hernia develop. This is basically where the pressure within exceeds the body’s ability to tolerate it.
The key for people with a stoma is to exercise in a way which doesn’t create excessive IAP, but ALSO at the same time to develop a resilient body which can withstand and moderate IAP, through good alignment, correct movement patterns and strength.
This comes from developing correct core function and learning how to use the breath (exhaling on exertion or effort) to moderate IAP. Having the deep ‘inner core’ working correctly and having good alignment will reduce IAP and enable you to tolerate higher load exercise and lifestyle movements.
So the starting point for anyone – regardless of whether your surgery was years ago or yesterday – is to ensure your deep core is switched on and you can connect and engage the deep transverse abdominis (TvA), pelvic floor and diaphragm. Get those muscles talking to each other! This doesn’t mean to head out and do planks or sit ups. It’s far more subtle and nuanced.
You need to be able to contract and connect with these deep muscles before doing anything else, and this is the first thing we do in clinical Pilates. You can find out how to do this at The Ostomy Studio in my Principles and Preparation video and then in either the ‘Post Surgery Series’ or the ‘Foundations 1’ programme or class.
Rebuild your foundations first
Imagine your body is a house, and it’s been knocked down through the process of surgery and illness. You want to rebuild it, and so you start with the foundations making sure they are put in place perfectly.
It’s painstaking and you need a lot of patience to make sure the bricks are aligned correctly, but you know it’s worth it as the house will then stand for longer and be a stronger house in the long run. If you rush the job and throw some bricks in too quickly, or you don’t wait for the cement to set, you run the risk of the roof not fitting properly or the chimney falling off.
Your body is exactly the same.
And THAT is the process of clinical Pilates and rehab after stoma surgery.
Foundations first, then progress and challenge. Do not jump into high level exercises too soon.
In the context of Pilates, this means building up in a way which is very gentle and progressive. Master the moves and exercises. Ensure you have control and perfect form. Only THEN do you progress to the next level. Exercising with a stoma requires patience.
This is what I love about clinical Pilates and the APPI method. It does exactly that. It is precise and highly modifiable.
So to answer the question ‘Can you do Pilates with a stoma’?
Yes.. But.
Pilates is a wonderful way to recover after surgery and to practice at any time with a stoma. It helps to restore strength and function to your whole body, to retrain your abdominal and core muscles. It brings awareness to the body (and your stoma) and may in fact help to adapt and accept our stomas more positively. Eventually, you may be able to work up to doing pretty much any Pilates exercise.
BUT...
1. Choose your class/video with care and start with a super-beginner level, post-natal Pilates (or similar), clinical Pilates (a back-pain class might also work) or find an instructor who is APPI trained. Work on your ‘inner core’ and the ability to connect with TVA and pelvic floor before you even think about progressing. Avoid high level exercises to soon and modify anything that makes you feel uncomfortable.
2. Be mindful of the concept of IAP and the feeling of bulging, doming or pressure around your stoma/abdominals and also your pelvic floor (especially if your surgery involved your pelvic floor). Never push through pressure. Always work to your own level and modify the exercises if you feel you don’t have control or you feel it’s too much for you.
3. Look out for an obvious ‘doming’ of the abdominals – you can see it yourself. Especially on exercises where you lift your head and shoulders (this should be one of the last things you do in the rehab phase and even then not too often). If you notice it or feel it then take things back to the previous level or take a rest. This is a sign that you’re not quite strong enough for that exercise just yet or you need to modify.
4. Breathing is super important. Rib and diaphragm breathing should be part of your ‘foundations’ work. And then always exhale on the effort part of an exercise or where you extend a leg or arm away from your body. This helps to engage the diaphragm. Breathing correctly also has the added benefit of stimulating the parasympathetic nervous system and reducing stress.
5. Build up super slowly (I literally cannot stress that enough) and work on correct form and technique. Be aware of maintaining a neutral spine/abdominal control during your practice. If you feel you’ve lost control during an exercise or there’s too much pressure, then stop, modify or take a rest.
6. There are some Pilates exercises you might always want to modify. I’m personally cautious with any exercises where you have both legs lifted AND head/shoulders up at the same time, particularly in static positions (and I’ve had my stoma 10 years). The most challenging would be having BOTH legs extended and arms extended overhead at the same time. For me these just feels like too much pressure around my stoma. I don’t do these myself or with clients.
Exercises I generally modify, adapt or avoid are:
· Hundreds (with legs in table-top or extended legs to ceiling)
· Criss cross
· Double leg stretch (with both arms and legs extended)
· Teaser with both legs extended
That said, everyone is different, and you have to work out what feels right for you. Some people will feel comfortable doing those exercises. Just always be mindful of excessive pressure and always be respectful of your stoma.
I personally do high level exercises such as scissors and leg pull in prone, BUT it’s literally taken me years to build up to them. You have to be patient and work up to things super slowly.
A note on a few other exercises:
Planking (or leg pull in prone) is possible when you have a stoma, BUT you do need good inner core control and shoulder strength before working up to it. I always prefer to do it on a long arm (rather than elbows) and I find ‘moving’ through it (rather than a static hold) feels more comfortable. I also always do a ‘hover’ preparation (leg pull prep) on my knees to get into position first, which creates an activation of the inner core. I always avoid the classic ‘fitness’ plank on elbows and holding static for a set time.
Planks/leg pull in prone is an advanced exercise and creates high IAP/places a lot of pressure through the stoma, so work up to it slowly and ideally with supervision and be sure you're strong enough before you try.
Many people think that it’s not advisable to lie on your stomach when you have a stoma. I’d urge you to try and see if you feel comfortable. It is possible to lie prone and it won't do your stoma any harm! You absolutely can do Pilates exercises such as swimming, breast-stroke, cobra and swan dive – all lying on your tummy. Your stoma is way more resilient than you realise and doesn’t mind being squashed. Just be sure your bag is empty (a full bag is never nice to lie on!). Some people try to use a rolled towel under their hips to take the pressure off the stoma, but I’ve never found this necessary and actually find it affects pelvic alignment. So try it without if you can and see if you can manage it.
Summary
A long blog to answer a short question. I do however hope this has been helpful, perhaps not just for people with stomas, but also for Pilates teachers and other fitness instructors. As I said at the start, there are no guidelines about stomas and exercise/Pilates and very little research. Clinical trials are happening, but it’ll be while before anything starts to come through into practice.
We are all different, will recover at different rates and find different exercises easier than others. Pilates in general is fantastic. I love it. I practice daily and bring it into my work with almost every client, fusing it into workouts and sessions as part of rehab and ongoing strength work.
But the key issue for anyone with a stoma is to find the balance between abdominal strength, whilst respecting the stoma and moderating intra-abdominal pressure. This may mean learning to modify and adapt certain exercises – possibly forever. This helps to reduce the risk of hernia around the stoma, which is the biggest problem for most ostomates. This shouldn’t stop people exercising however and we need to become as strong and fit as we can and not stop doing the things we love.
I launched The Ostomy Studio in 2020 to meet this need. To bring specific clinical Pilates to the ostomy community where people could exercise safely from the comfort of their own homes from anywhere in the world.
But I don’t want people to stay doing ‘ostomy Pilates’ forever. I want people to get back to their usual fitness or Pilates class with the knowledge of how to modify and adapt if needed. To rebuild their confidence and to feel empowered with the skills and ability to exercise intuitively and safely. Getting people back to normal and the life they love.
Find out more at www.theostomystudio.co.uk
