A 12-week study shows that low-impact yoga and exercise can significantly reduce urinary incontinence episodes in older women, offering a safe, accessible alternative to medications
It’s more likely than not that personal trainers will work with female clients who deal with incontinence issues, which could be an obstacle on their path to the fitness and wellness goals. Recent research supports the belief that solutions are available, and exercise may be one of them.
A recent study led by Stanford Medicine and the University of California, San Francisco, has found that low-impact exercise programs, such as yoga and general stretching, significantly reduce urinary incontinence episodes in older women. The research, published in Annals of Internal Medicine on August 27, provides promising alternatives for women seeking non-pharmacological treatments.
A Underreported & Common Issue
Urinary incontinence affects more than half of middle-aged women and up to 80% of women over 80 and can interfere with daily activities and significantly impact quality of life. The study examined the effects of a 12-week low-impact yoga program and found a 65% reduction in incontinence episodes among participants.
“We were testing the kind of yoga that just about anyone can do, with modifications for different physical abilities,” said Dr. Leslee Subak, chair of obstetrics and gynecology at Stanford Medicine and the study’s senior author. “What I love about it is that it’s safe, inexpensive, doesn’t require a doctor and is accessible wherever you live.”
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The research set out to find cost-effective and accessible solutions for a problem that is often stigmatized and underreported. According to Subak, incontinence is mistakenly viewed as an inevitable part of aging, though treatments are available.
“Incontinence is not only common, but it also interferes with people’s lives,” Subak noted. “It takes away independence. Many women avoid staying with their children or grandchildren due to the fear and embarrassment of an accident.”
credit: MixMedia
Study Parameters
The study involved 240 women between the ages of 45 and 90, all experiencing daily incontinence. Participants were divided into two groups: one practicing 16 hatha yoga poses aimed at strengthening the pelvic floor, and the other group performing general stretching and strengthening exercises.
Both groups attended two 90-minute exercise sessions weekly and were asked to practice independently for at least an hour per week.
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Both the yoga and the control groups experienced significant improvements. Participants in the yoga group reported an average of 2.3 fewer daily incontinence episodes, while those in the general exercise group saw a reduction of 1.9 episodes per day. These results are comparable to the 30% to 70% improvement rates seen with medications for incontinence, according to the researchers.
Subak emphasized the importance of regular activity, which is good news for fitness professionals who work with this population.
“One of the take-home messages from this study is ‘Be active!’ I’m impressed that exercise did so well and that yoga did so well,” Subak added.
The benefits of physical activity, including yoga, extend beyond managing incontinence. As the study’s lead author, Dr. Alison Huang, professor at UCSF, pointed out, being physically active helps reduce the risk of other health issues, such as falls and bone fractures, which can be exacerbated by conditions like incontinence.
The study was funded by the National Institutes of Health, with contributions from researchers at Yale University and San Francisco State University.
While the bird dog exercise mainly works the core muscles, improving stability and strength, it also targets the lower back, shoulders, hamstrings, and glutes, making it one of the better full-body exercises you can do.
Over the years, I’ve done plank after plank and seen few benefits. It’s just not the exercise for me. I can hold the position for about a minute before everything starts shaking and my forehead starts sweating. Even with practice, it feels torturous.
At the end of a beginner’s Pilates class one day, I was talking to my teacher, and she recommended the bird dog exercise to me. She suggested it wouldn’t cause so much discomfort, but it could still help improve my fitness. As she also recommended the dead bug exercise to me (which I love), I knew I needed to try it.
How to do the bird dog exercise
This exercise starts on all fours, on a thick yoga mat for extra comfort if you want it. Sam Deville, a Pilates instructor and founder of a dynamic online platform of the same name, calls this exercise ‘swimming’ in her classes. She says: “It’s a brilliant move for strengthening the posterior chain (muscles on the back of your body). It looks simple, but when done with proper form, it fires up everything from your glutes and hamstrings to your core and shoulders.”
Here’s how to do it:
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Extend one arm forward and the opposite leg back, reaching long through both ends without collapsing into the shoulders or lower back.
Keep your core engaged and spine in a neutral position. Make sure your hips aren’t rocking or twisting.
Pause briefly at the top, then return your arm and leg to the centre.
Repeat the exercise for 10 slow reps, says Deville, focusing on control and alignment.
Expert tip for the bird dog exercise: “A great form-check tip is to place a soft, half-deflated ball on your lower back,” says Deville. “If it rolls off, you’ll know your hips or core need more control. It’s a really nice, simple but effective way to get instant feedback.”
Benefits of the bird dog exercise
Boosts core strength: In the bird dog, you have to keep your core strong to stop yourself from leaning to one side or sinking, much like in the plank. When done correctly, this exercise “gently works the abdominal muscles, says Susie Martin, a Pilates instructor and physiotherapist who works with Complete Pilates.
Improves stability: “You might think you’re fit and strong, but get into the bird dog, and you’ll find out. You might be wobbling all over the place,” says Martin. The exercise challenges your full-body stability, which can help in other activities where you have to “transfer power from your legs to your upper body”, she notes, such as racquet sports or strength training.
Good stretch: It felt like a lovely way to stretch out and unwind at the end of the day after sitting hunched over my computer, and it’s a good way to start the day and get my blood pumping.
Increases upper-body strength: The bird dog puts us in an unusual position, which means muscle groups are used differently. “It encourages weight bearing through the upper body, which is good for shoulder strength and function,” she says. Plus, you don’t need any weights to do it, making it suitable for a Pilates workout at home or a gym session.
Aids spinal alignment: Deville says the exercise is also a good option for those with lower back issues as it “builds strength through the back and core without putting too much pressure on the spine”. Always consult your doctor before trying a new exercise if you have these issues, however.
Can you do a weighted bird dog?
Adding weights can make a bird dog harder, helping beginners improve core strength and stability even more, says Deville. You can use dumbbells or ankle weights for this exercise, but an easier way is to incorporate a set of the best resistance bands. These rubber bands are cheap to buy, easy to store at home, and can spread the resistance out from arm to foot, unlike other weight types.
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How to do a weighted bird dog with bands
Set up in the regular bird dog position on all fours.
Wrap a resistance band around the ankle of the leg that’s stretching out first, bringing it forward and looping it through your fingers of the opposite hand.
Keeping your core tight and in a controlled way, extend the weighted arm forward and the opposite weighted leg away from each other.
Vexloria
Resistance Bands, 5 Levels
These resistance bands come in five different levels, from light to extra-heavy. As shown in the video, you wrap one end around your hand and the other around your foot, making the regular bird dog exercise feel harder, and so improving your strength.
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Is the bird dog better than a plank?
The bird dog and the plank have a place in a Pilates abs workout, the experts say. However, beginners may find more benefits with the bird dog exercise, at least to begin with, since it’s more adaptable. You can make it harder or easier with variations or even ankle weights.
However, they are different. “A plank is more intense on the anterior (front) core, while bird dog targets the back body and really challenges the deep stabilisers,” says Deville.
Just like how a squat and the clamshell exercise are equally great at building lower-body strength, but work slightly differently.
Martin recommends learning the proper form for a plank and incorporating both exercises into your workouts, if you can. “The plank is more challenging in terms of higher load for the abdominal and back muscles, which makes it good for those who want to challenge absolute levels of strength,” she says, adding that the bird dog is good for challenging your stability and balance.
How long should you hold the bird dog pose for?
You don’t need to hold the bird dog pose for long for it to be effective. If you want to work on your endurance and balance, Deville recommends holding at the top for five to 10 seconds. But she adds that control, extending and returning your arms and legs with precision, is most important.
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In January 2025, I attended my first bootcamp class.
I had spent the day hunched over my laptop, anxious and craving an intense workout that would dispel my worries. I booked the class at a nearby gym, and the five-star reviews promised the all-consuming exercise I wanted: “Militant style instructor, but very motivating,” read one. Another: “Hardest workout of my life; extremely rewarding.”
The gym was no-frills – just a room with a mirror. After a standard warm-up, we did four sets of lateral shuffle push-ups across the floor, interspersed with standing, weight-bearing exercises.
When my turn came, I dropped to plank position and started doing steady, shallow reps, focusing on my form.
But caution soon fell away. Upbeat music was booming and someone was always advancing beside me. When the instructor encouraged us to lower all the way down, I obeyed, even though my form suffered. I had rarely done more than a handful of pushups at a time, and in the final set, I was exhausted, collapsing on every rep and barely prying my torso off the floor.
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The rest of class was a blur. I became nauseated, told the instructor I needed to pause, and stepped outside to suck cold winter air into my lungs.
Back in the studio, I sat on the sidelines and waited for the dizziness to recede before slinking to my spot for the core section and cooldown.
Later that night, I felt what I thought was typical post-workout muscle soreness. I was satisfied; the ache was proof of a successful workout.
But the next day, lifting my arms to wash my face was exhausting. Searing pain kept me awake that night. Two days after the class, my arms were so stiff I couldn’t raise them more than a few inches, even to brush my teeth.
When I Googled my symptoms – pain, weakness and a new one, dark urine – something frightening came up: exertional rhabdomyolysis, a condition wherein extreme exercise causes muscle cell contents to flood the bloodstream, potentially overwhelming the kidneys. One article warned that debilitating pain after a new, intense activity was a sign to visit the emergency room.
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I went to the ER but suspected I was overreacting. After all, the internet always offers the worst possibility.
Doctors use bloodwork to test for exertional rhabdomyolysis; typically, they diagnose it if a patient has too much of a muscle enzyme called creatine kinase (CK) in their blood – at least 1,000 units per liter, or five times the normal range. However, there is little consensus on this number, says Dr Barry Boden, an orthopaedic surgeon at The Orthopaedic Center in Maryland, who specializes in sports medicine. Some recent guidelines suggest that only higher amounts – as much as 10,000 units – warrant diagnosis and inpatient treatment.
My CK count was so high the machine in the emergency room couldn’t measure it; a nurse had to do a second blood draw and send it to a more precise lab. They put me on an IV drip and eventually reported the exact number: 57,000.
Thus began my seven-day hospital stay. My mom and sister traded shifts, acting as my arms for the week – scrubbing my teeth, feeding me, washing my face. I had never felt so helpless and irresponsible. What had I done to myself?
What is exertional rhabdomyolysis?
Normally, during exercise, muscles tear a little and then rebuild. There may be a little extra CK in a person’s blood as a result, which healthy kidneys can filter out.
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But excessive exercise can harm muscle cells so much that their contents – including CK and a protein called myoglobin – overload the system. “When the cell membrane starts to break down, the chemicals within the muscle cells start to get released, which can cause damage to other organs around the body,” said Boden. “ If there’s enough of those chemicals from the muscle that reach the kidney, it can cause damage to the kidney.”
The symptoms are muscle pain (even while at rest), weakness and dark urine, though few people experience all three. Treatment involves early and aggressive administration of IV fluids to help the kidneys filter the toxins. It’s possible to manage a mild case with at-home oral hydration, but it’s always important to consult a doctor because mild symptoms don’t always mean low CK elevation, said Dr Petr Schlegel, a CrossFit trainer and professor at the department of physical education and sports at the University of Hradec Králové in the Czech Republic.
Exertional rhabdomyolysis is dangerous and fatal in very rare cases; researchers estimate that 10% of patients develop acute kidney injury (AKI), and some suffer other serious complications.
How common is exertional rhabdomyolysis?
Before I had rhabdomyolysis, I had never heard of it; I thought the worst that could come from a workout was a broken bone or a regurgitated lunch. I now know it can happen to anyone, although people with certain conditions, such as sickle-cell trait and hypokalemia, are predisposed. Despite the common misconception that only unfit people can get it, even elite athletes are susceptible.
“Anybody can get it – anybody that’s pushed to an extreme, taking a big jump in their exercise level, or doing something they’re not used to doing,” said Boden. “Everybody has muscles, and if the muscles are damaged enough, you can develop rhabdomyolysis.”
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Boden authored a study estimating there were over 40,000 exertional rhabdomyolysis cases in US hospitals from 2000 to 2019. But he said it’s impossible to get a precise count, as no organization collects the data.
This number is likely an underestimate, as the condition is probably under-reported, said Schlegel. Since the symptoms closely resemble those of delayed onset muscle soreness – the normal ache people expect after a workout – individuals may not seek care.
Data indicate exertional rhabdomyolysis is on the rise. In Norway, Australia and the US, researchers have observed an increase in hospital records between the 2000s and 2010s. This year, hospitals in a Canadian province reported a surge in cases.
Researchers suspect the popularity of high-intensity workouts is behind the rise. They are efficient and produce measurable progress, but are risky if misused, said Schlegel: “Evidence suggests that high-intensity exercise, especially when combining strength and endurance elements, carries the greatest potential to induce [exertional rhabdomyolysis].”
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Can you prevent exertional rhabdomyolysis?
Prevention guidance has been pretty consistent since the earliest studies from the 1960s: vary exercises to avoid overloading one muscle group, incorporate rest, and gradually build intensity when starting something new or after time off.
Starting low is especially important when targeting large muscle groups – such as biceps, triceps and quads. “It’s that hyperintense going from zero to 100, really intense workouts of large muscle groups, that puts people at risk,” said Dr Bryant Walrod, a sports medicine physician and the head team physician for the Ohio State Buckeyes. Weight matters, but so do reps; an outrageous number of low-weight exercises or calisthenics – hundreds of pushups or squats, for example – is the trigger in many cases. Walrod also advises doing a different kind of workout from one day to the next.
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Eccentric exercises like push-ups – where muscles lengthen – are particularly likely to cause injury. In a 2024 article about how to prevent rhabdomyolysis in student athletes, the National Federation of State High School Associations called push-ups the “No 1 cause” of rhabdomyolysis. In April, Texas families filed a lawsuit against a charter school after 20 children were hospitalized after hundreds of pushups.
Walrod said collegiate sports professionals became more vigilant about prevention after University of Iowa football players were hospitalized with exertional rhabdomyolysis in 2011. “That case spurred better control of workouts, better monitoring, and better input from the trainers and strength coaches.”
“Where we see most of the cases is that athletes are being pushed or threatened or punished [contrary to industry standards],” said Dr Rebecca Stearns, COO at the Korey Stringer Institute for preventing sudden death in sports. Coaches are not exercise physiologists, and even when well-intentioned may not have adequate training to prevent overexertion, said Boden.
Similarly, there’s no guarantee fitness instructors understand the risk. “People may be going in unconditioned and doing too much too soon,” said Walrod of these classes. CrossFit incorporated prevention into its trainer curriculum after reports of severe cases among participants, but in general, class participants should self-monitor.
How do you identify overexertion?
I was discharged from the hospital with a firm instruction: no exercise except walking for a month. I had to learn what an appropriate challenge felt like – how to self-monitor, discern between safe discomfort and overexertion, and advocate for myself. But when is hard too hard?
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Unfortunately, sensing that something is wrong is a subjective measure; there is no universal metric.
“I never have a very satisfying answer to that, but I do think it’s a line we need to be vigilant about always, and it changes from day to day,” said Dr Natalia Petrzela, author of Fit Nation: The Gains and Pains of America’s Exercise Obsession, longtime fitness instructor, and professor of history at The New School.
“You know your body the best, and if you feel like something isn’t right, it’s time to speak up,” said Walrod. Sports medicine physicians advise people to stop exercise immediately if unusual pain occurs; in the event that there is excessive muscle breakdown, it’s critical to stop the movement right away.
Speaking up in a class setting can be difficult. Many feel self-conscious about pausing or modifying activity, especially if an instructor is singling them out. Petrzela said that she motivates participants in her class but also expresses a key caveat: “Only you know what you can do today.” She said this language “helps [them] find that very important and difficult-to-discern line”, adding that this nuance might get lost in classes with less experienced instructors who give inflexible instructions.
During that fateful class, I ignored the alarm bells. Maybe I was desperately chasing endorphins or wanted to prove to myself that I wasn’t weak. Ironically, my arms atrophied to below baseline as a result.
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Over a year later, I’m still building my strength back – but not at bootcamp. I opt for low-impact methods such as barre and pilates where I can modify if needed, and there is no need to keep pace with others.
Sometimes I tell instructors about my medical history, so they understand what’s happening if I pause. Verbalizing it also reminds me to be careful. Finally, I avoid anything new or especially difficult when I’m having a hard day.
Fitness culture taught me that pain is gain – but now I know that’s not always true.
