I have had an enlightening few weeks studying Munira Hundani’s new course ‘Diastasis Rectus Abdominus and the Postpartum Core’ which for me, presented a fascinating new framework for both assessment and exercise prescription of the post partum core.
Diastasis Rectus Abdominus (DRA) is a widening of the linea alba (the midline of the abdominal wall) experienced by women during and after pregnancy. Whilst it is normal to experience some degree of separation it should generally resolve naturally postnatally however in approximately 1/3 of women the excessive and prolonged widening prevails adding to a sense of disconnection and dysfunctionality .
Commonly the protocol for fitness instructors, like myself, for dealing with DRA is to present a long list of things to avoid to prevent further widening of ‘the gap’. These might include lifting heavy weights (e.g children), sit-ups, plank, boat pose (Navasana) jack knives, russian twists etc for fear of causing too much Intra Abdominal Pressure (IAP) and worse still increasing the gap. The assessment of the DRA would usually be conducted primarily in supine using a head lift protocol and exercise prescription would typically be progressed dependant on the inter recti distance (or width of the gap)
Hudani’s work paints a much more positive picture for the treatment of DRA as well as a much bigger focus on the individualised journey that success should take accessed via the initial assessment. Crucially she demonstrates how clinical research shows that there is little to no correlation between the DRA itself and formally associated issues such as lower back pain or indeed the ‘type’ of exercise a woman should do. Rather than point the blame at ‘the gap’ she explains that the inter recti distance is just a another part of the abdominal wall that has widened as a whole, coupled with altered breathing and core connection strategies resulting in a mis-management of IAP. She goes on to emphasise the importance of IAP and how harnessing it using the diaphragm and the Transversus Abdominus (TVA) is the key to success.
So what does this mean for women with DRA? Well, by assessing the DRA in positions which prompt more IAP (i.e standing or sitting as opposed to supine – which, she explains, is particularly unproductive for those with increased circumferential laxity) it helps to illicit a better provocation of TVA’s true ability to activate and therefore a ‘way in’ to strategise a stepwise approach for that individual. The idea of using and creating IAP to strengthen the core automatically reduces the fear factor around creating too much IAP. Once the re-training of the diaphragm and TVA has successfully been achieved the list of formally avoided exercises are the very ones which need to be integrated in to optimise core and indeed whole body strength. This means your favourite yoga class, HIIT workouts or Pilates classes are once more back on the table.
If you have been affected by diastasis and are looking for ways to help progress do get in touch via the contacts page for more information.
In Pilates classes we give a lot of emphasis to using the pelvic floor muscles throughout all the exercises but I wanted to use this post to look a bit more specifically at some of the precursors to pelvic floor problems & signs you may be at risk or already have issues.
There are specific signs to look out for which can indicate that you may have a pelvic floor problem – these are all suboptimal issues that you do not have to live with, a trip to the women’s health physio (or men’s) will help get you on the road to recovery just like any other muscle injury. I’ll stress again, these are not just conditions of age or things that ‘just happen’ – you can do something about it, just because something is common does not mean it’s normal.
Peeing when you exercise, laugh, cough or sneeze
Needing to get to the toilet in a hurry or not making it there in time
Loss of control over your bladder or bowel
Accidentally passing wind
A prolapse – in women, this may be felt as a bulge in the vagina or a feeling of heaviness, discomfort, pulling, dragging or dropping. In men, this may be felt as a bulge in the rectum or a feeling of needing to use their bowels but not actually needing to go
Pain in your pelvic area, or painful sex
Being pregnant & childbirth
The pelvic floor is just like any other muscle so if it’s too tight or too weak or a combination problems can occur but there are certain events in life & lifestyle factors that can contribute to creating imbalances or dysfunction. Some people have pelvic floor muscles that are too tight (hypertonic) & cannot relax. This can be made worse by doing squeezing exercises & overworking the muscles without learning how to relax – this is why I always try to give time in the class to focus on actually relaxing & releasing the abdominals & pelvic floor.
The main precursors for pelvic floor problems will involve any type of unmanaged pressure within the abdominal canister or where there is poor load transfer .
History of back pain
Ongoing constipation & straining on the loo
Being overweight with a BMI over 25
Incorrect heavy lifting e.g using the Valsava maneover
Chronic cough or sneeze
Previous pelvic injury
Wearing high heels
With the right technique & exercise selection, Pilates is a great choice to help strengthen the pelvic floor – at any age, whether you’ve just had a baby or your babies are having babies!
After a bit of an end of pregnancy slow down (!) on the blog front I thought it would be an opportune time to write some post natal exercise posts to both remind myself & give some direction to anyone beginning the journey of reconnecting with their non-pregnant selves!
With any exercise programme, post natal or otherwise the ability to breathe correctly during exercise is essential to having a fully functioning core. Reconnecting with your breath will provide the foundation to both your core’s recovery rate & help you to progress with bigger more integrated core movement patterns (A.K.A sorting out the mummy tummy!). Whatever birthing experience you had or however fit you were/are post partum reconnecting with your breath is where you need to begin. The nature of pregnancy – with the baby in the tummy thing (!) – can create a disconnect with the way we breathe due to the expanding uterus squashing the diaphragm resulting in there being less room for your lungs to expand – so it is vital to relearn this essential function.
Try this – find a quiet space to practice lying down with a neutral spine & pelvis.
Inhale (the expansion): Breathe wide into your ribs, try to do this 3 dimensionally so use the floor against your back as a reference, don’t just flare the ribs outward. Your abdominal wall will expand. Try to relax your shoulders, neck & jaw.
Exhale (the compression): As you breathe out feel your ribcage contract & lower, your abdominal wall & lumbar/thoracic muscles (see the pic) will tension. Think about connecting with your pelvic floor by drawing it up (think picking up a tissue with your vagina) from your vagina to your anus.
Once you feel you have the full core connection try this sitting & then standing making sure to integrate the pelvic floor contraction on each exhale & fully relax/release it on each inhale.
For some women, it will come as a relief knowing that all is required on the exercise front is a bit of breathing to get started but for others wanting to just get the running shoes back on & pick up where they left off, it may pose more of a frustration or perceived limitation to getting their bodies back. Understanding why we need to start with the breath is key to accepting your journey to hot mumness (technical term!) – safe in the knowledge that you’re going to reclaim (& maybe even improve on) the body you want both aesthetically & functionally without having to pee your way through a kettlebell workout because you haven’t addressed proper pelvic floor & core restoration!
So – at a glance list of ‘Why’s’:
Costal breath patterns (as directed above) will help take pressure away from healing abdominal & pelvic floor tissue.
Develops your MUCH NEEDED pelvic floor reconnection.
Increases your oxygenated blood to help healing abdominal & pelvic tissues.
Strengthens & supports your post partum abdominals, back & pelvis.
Helps aid valuable relaxation which in turn will help balance the hormone levels that control weight.
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You may need to strengthen your pelvic floor as part of some injury rehab, as part of your post partum recovery or for continence problems – one of the best ways to begin the road to recovery & full core restoration is by doing Kegels but how do we progress from there?
First let’s look at why the pelvic floor plays such an important role in our core restoration. Strengthening your pelvic floor will underpin any fitness goals you have, be they running, fat loss or just daily life. It’s worth noting that 48% of primiparous women & 85% of multiparous women experience some degree of incontinence also worth noting is that incontinence is the second most common reason after dementia for admission into assisted living. So pelvic floor exercise is crucial!
Initially & in fact after any injury the first place to start rehabbing a muscle is by being able to isolate the area in the first place. If your brain can’t access the neural pathway then moving on to a more complex movement will retard healing. So this is where a traditional Kegel (think, stopping flow of urine) is very helpful, a basic switching on & switching off of the muscle. Doing this will also help promote blood flow to the healing tissues & therefore aid the restoration process. If you find you can’t feel anything or you’re at all concerned get a proper exam by a women’s health physio who will be able to tell what’s going on.
This protocol will work well for that initial 6 week period post partum – you should feel the muscles getting stronger & easier to contract. Make sure you fully relax the pelvic floor between contractions as having a hypertonic or too tight muscle isn’t helpful either! Use your breath & visualisations to help you maximise the connection – so as you exhale, squeeze, as you inhale, relax. You can see from the diagram above how the pelvic floor muscles lie across the bottom of the pelvic cavities & this should give you an idea of what you are trying to access & also how important it is to have some muscle tension supporting the bladder, vagina & bowel.
Progress it by using pelvic floor activation as you lift & move, this is a key part of your on-going restoration. If you can protect the pelvic organs using the pelvic floor muscles as you add load (baby, laundry, you, buggies etc) you will prevent that added intra-abdominal pressure causing further stress on the pelvic floor leaving yourself vulnerable to pelvic organ prolapse or stress incontinence. This in turn will further strengthen the muscle’s function.
Note: Whilst I’m fully aware that men have pelvic floors too (!) this article is geared more toward women – hence the references to wombs & vaginas etc!
Tight necks, shoulders and back are par for the course with modern living leading to shortened chest, neck & anterior shoulder muscles & can result in and/or exacerbate a forward head posture as well as restrict correct breathing strategies.
This diagram shows how the fascia connects along the Arms Lines (pic A. Superficial Arm Lines on the left arm & Deep Arm Lines shown on the right arm) & the top of the Deep Front Line (pic B.) The posture of looking down whilst holding a baby will involve & place all these tissues into a shortened, tightened position – add this to our modern lives where most people have a forward head posture anyway from screen watching & it’s going to be a real pain in the neck (sorry)!!
Regularly stretching & de-fuzzing your neck will help relieve tension & prevent the build up of poor alignment adaptations. Head placement is key to having a tension free neck but tissues that are locked long or short will create pain & discomfort so try these 3 stretches to help stick your head back on top of your body where it belongs!
Lateral neck & arm lines stretch: Standing or sitting with a neutral pelvis, extend one arm with your palm up and then tip the opposite ear to shoulder. Try to keep your chin tucked and if you want to increase the stretch then place your palm flat against the wall (fingers back) as you do it.
Posterior neck stretch – head nods: Lying on your back with your knees bent, as you exhale nod your head and gently press the back of your head down into the floor to feel the stretch – then inhale to relax. Make sure that you don’t push down so much that you can’t maintain your chest position – if you notice your ribs lifting up then lessen the movement to control it. Also to optimise the stretch draw your shoulders down and away from your ears – think about reaching your fingers toward your toes throughout the nods. You should feel a lengthening on the back of the neck and remember this is just a small movement!
Try these 2 or 3 times a day to feel a difference.