 For some, that “four months pregnant” appearance can last for months to years. It is a common question that postpartum moms ask from an aesthetic standpoint, but as a pelvic floor therapist it can indicate the integrity of the abdominal wall. The timing at which this appearance can improve hinges on your genetics, daily posture, the degree of physical changes (and trauma) your body goes through, what your current health, nutrition and fitness levels are like. This blog will not go into how to lose that baby weight or achieve a flat tummy, rather how to rehabilitate the abdominal injury that is diastasis recti (DR). What is a diastasis recti? DR occurs when the rectus abdominis, your 6-pack muscles, separate in the front of the body. This commonly occurs during pregnancy affecting over 60% of childbearing women, but can also be found in persons with stomach obesity. As the abdomen increases in size, it stretches the front abdominal wall leaving the linea alba (connective tissue between your abdominal muscles) vulnerable to separation. The degree and severity of DR are unique to each individual and with each pregnancy, however, this can lead to a bulge or “pooch” in the abdomen. This is noticed more so when doing sit ups or crunches. Why should I care? Although it is normal having to have degrees of abdominal separation, if it is large enough and does not resolve on its own it can lead to recurring low back pain, pain during sex, constipation, pee leakage and other pelvic floor issues. This can spill over into your workouts, playing with your kids, etc. How do I check for DR? You can lay on your back with your knees bent. Place two fingers at your belly button pointing down toward your spine. Lift your head slightly to engage the abdominals like you are initiating a crunch. If more than two fingers can fit in the gap, then you likely have DR. Repeat this check two inches above the navel and 2 inches below. I have DR - What now? I would recommend pausing on activities that put undue stress on the abdominal wall like crunches, any plank variation, full push ups, toes to bar and pull ups. That does not mean that you will not be able to do these activities again, rather it will improve your capacity to load your body once the abdomen is working better. If not, the chances of experiencing the above symptoms are great. Based on your unique presentation, we will go over specific exercises to enhance the function of your entire core (bonus, it may aid in flattening the tummy!), breathing techniques, posture hacks, and ruling out related pelvic floor dysfunctions. We will build a plan together to not only get you to feel your best, but to move your best! Thanks for reading,
Dr. Krystal Fannin
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Breathing While structured breathing work may seem simple-even silly- to some, we know that it is a powerful tool for the pregnant and postpartum woman. Deep breaths have the ability to calm the nervous system which can affect muscle tension, heart rate, and blood pressure. Additionally, the respiratory diaphragm can mobilize muscles in the pelvis and back due to anatomical connections. Muscles, including those shown in the photo below, are big players in midline stabilization and support. A great place to start is the 90/90 breathing drill (seen below). Try this out for 10-15 breaths at the end of your day. Ask questions Many postpartum women do not know all of the details after birthing their baby. Some have told me they were not aware they had stitches down below until the 6-week check-up when the doctor wanted to make sure they were healing well! The check-up at 6 weeks can be quick so arrive with questions. It is helpful to know about any tearing, episiotomies, tools used during the birth, etc. These factors are all great to bear in mind as you return to exercise and daily functioning. Another question to ask-- “Is there a pelvic health PT that you would recommend?” They may know someone in the area or have worked with them prior. However, do not become discouraged if they don’t have a name to offer. A Google search for “women’s health PT” or “pelvic PT” should show professionals in the area. Compare websites and reviews to see if the PT would be a good fit for you and your goals! Pelvic Health Physical Therapy Once you have been cleared by the doctor for “usual exercise” and intercourse, I highly suggest visiting a pelvic health or women’s health PT. They will be able to further answer any questions about symptoms you may experience immediately postpartum and later. A pelvic PT is specialized on evaluation and treatment of the pelvic floor musculature. They can perform internal evaluations to test the strength and endurance of your pelvic floor, check for prolapse, address any soft tissue issues, etc. For the evaluation, the therapist will use a gloved finger to palpate muscles internally. While a great deal of information can be gathered from an internal evaluation, it is not necessary for visiting a pelvic PT. The therapist can then prescribe exercises to help relieve the symptoms and provide hands-on work to hips, back, sacrum and other involved areas. Your PT should be a huge help in getting you back to fitness postpartum! Other areas they can treat and improve are bowel/bladder issues, painful sex, and pelvic pain. Focus on healing and strength rather than weight loss Social media and advertising may be all about “getting your body back” and fixing “mummy tummy,” but that is not the focus when you are postpartum. The first step in returning to fitness is addressing foundational strength and continuing to heal from the pregnancy and birth. Your body will go through so many changes in the months following your pregnancy and the timeline is different for every single woman. Steer clear of programs that say at week 8 you do blank. It should all be self-paced and based on symptoms, your birth story, and prior activity level. Do you need help starting out? This was the number one question I received from women in the clinic. “What can I do? Where do I start?” So I developed programming to recover and rebuild your core after having a baby. Check out the THRIVE: Rebuild Bundle programming HERE.  Find a community for support
Returning to group classes or running groups can be challenging because you will not be jumping right back into the level you were previously exercising. Having a group of women who understand your needs and have been or are currently at the same stage as you is tremendously beneficial. If this sounds like something you would be interested in, please join my Back to Fitness Postpartum Facebook page. We have posts nearly every day and a lot of great discussions- some serious and some silly! Once you return to group classes, be sure that the trainer knows you are postpartum and if there are any symptoms with movements. If they offer other movement suggestions that still do not feel great, then modify further! Symptoms (leaking, pain, heaviness in the vagina) are a signal to decrease the workload by resting or modifying or both! Getting back to fitness postpartum can be challenging but it is not impossible! With a holistic plan and support you will be able to recover and rebuild to get back to your favorite activities. If you are looking for help with learning more about postpartum fitness, the pelvic floor and how to reach your goals, then please reach out at Athletes’ Potential. Thanks for reading, Dr. Jackie, DPT Many people are willing to go the extra step to increase their efficiency and function when it comes to their sport: the latest and greatest running shoes, wrist wraps and weight belts to hit a PR or a personal trainer for the extra push. What if we could improve our function and decrease pain for free? I think I would have your attention. As we spend hours each week training, two very important muscle groups are ignored: the diaphragm and the pelvic floor. It is not for lack of use; every time you take a breath the diaphragm contracts and lowers to help fill your lungs. The pelvic floor works double time; these muscles are firing like crazy to keep you stabilized with each breath and during movements. If they work all day long, they should be strong - right? Not always the case. The “core”: Often times the “core” and “abs” are used interchangeably. The abdominal muscles that you see in a six pack are just the most superficial muscles of the core. The deep core is comprised of the diaphragm, pelvic floor, transverse abdominis and multifidi. These four muscles make up the “canister” of the inner core. As you see in the picture below, the glottis is also included in this as it has direct function with the diaphragm, and thus the pelvic floor. The transverse abdominis is a deep core muscle that is often referred to as a corset. It attaches to your pelvis and lower ribs and even has connections to the diaphragm through fascia. The multifidi are small back muscles that attach your vertebra and also connect to the pelvis at the lower levels. See how it is all connected? It is important to keep in mind that these are endurance muscles.  The diaphragm is the second largest muscle in the body! It attaches from the chest bone, to the ribs and down to the upper three lumbar vertebra. The pelvic floor is a group of smaller muscles that act as a hammock in the bottom on the pelvis. They attach from the sacrum to the inner ring of the pelvis. The diaphragm and pelvic floor have an intimate relationship of synergy during breathing. With inhalation, the diaphragm draws down and the pelvic floor drops simultaneously. It is essential that they have the endurance to move with each breath, but the pelvic floor must also have the strength to withhold increases in intraabdominal pressure. When the diaphragm and pelvic floor are stacked one on top of the other, you are able to more efficiently breathe and manage the pressure in your core. This is best achieved through optimal posture. When you are unable to manage the pressure, it will push towards the weakest area: often the pelvic floor. This leads to stress urinary incontinence, or peeing during jumping, running, laughing, sneezing, etc. This can be exacerbated by poor postures. Can you imagine how each of these poor postures affects your canister? Both sway back and increased lordosis move the core out of the optimal stacked position. Thoracic kyphosis, rounded upper back, puts your diaphragm in a shortened position, thus making it less efficient. Breaking or bending the canister is easily identifiable in poor overhead lifts and poor running form. The picture below shows that with a poor finish overhead, her diaphragm and pelvis are no longer stacked. This affects her breathing efficiency, the internal pressure and work of the pelvic floor. Not to mention, this puts her big movers, specifically the lats, at a disadvantage and can cause back pain. You have probably also observed runners moving their core out of the optimal position. Those who run bent over at the waist or those who lean their torso back as if running downhill are essentially bending the canister. When you lift something, the deep back and abdominal muscles will contract for stabilization and the pelvic floor should slightly lift to help secure the lower abdominal organs. However, if you hold your breath and bear down, the pressure pushes the pelvic floor down. This can make you more susceptible to leaking or pelvic pain. So I should never hold my breath? No, you absolutely must hold your breath or brace with certain athletic movements. Especially lifting heavy weights! How to Brace: Bracing or breath-holding is common for many athletes. Learning how to properly brace will ensure success in the movement and the proper distribution of tension throughout the body. Many times, tension is increased but only in the superior and inferior directions, or up and down. Remember the picture above: this means that the diaphragm and the pelvic floor are receiving most of the force. Luckily our diaphragm is big and smart, it knows that in order to live it must work. Unfortunately, the pelvic floor then becomes the weakest link and may be overtaken by the pressure. This results in SUI, or leaking during exercise. Focusing on sending the tension in 360 degrees will be helpful to reduce this downward pressure. Rather than just bearing down through your thorax, add tension to your hips and shoulder girdle. But what if you’re a runner? Obviously you do not want to hold your breath throughout a long run or even periodically. Then it is important to either down train or strengthen your pelvic floor, depending on your issue. If you experience problems with bounding or impact such as a box jump, exhaling on the landing will help to decrease the pressure in the thorax and load on the pelvic floor. Whether you have an underactive, overactive or normal pelvic floor, learning to properly brace with the diaphragm and pelvic floor engagement is important. By spreading the tension throughout your body, you are able to sustain more tension for greater loads. Pulling it all together: As you train, don’t neglect two important muscle groups: the diaphragm and the pelvic floor. They are often forgotten since you cannot see them in the mirror. But if you optimize their function, then your workouts will improve! Maintaining optimal posture is a great start; this applies to quiet standing, as well as during workouts. When you brace, be sure to spread tension throughout your body to avoid pushing it all to the pelvic floor. If you continue to experience issues or wish to have someone closely screen your movement with breathing and bracing, come by and see us at Athletes’ Potential. This is just the tip of the iceberg! Thanks for reading,
Dr. Jackie, PT, DPT Pictures https://samanthaeiblingyoga.com/tag/pelvic-floor-muscles/ Previously, we talked about safe exercise during your pregnancy. But how do you know when and where to start after having your baby? As always, consult your doctor before beginning an exercise program. Complications during labor or other factors, such as diastasis recti, can change your return-to-exercise timeline. Before I list a few suggestions for exercise, it’s important to review the guidelines: Protect your joints- effects of the hormone relaxin can last up to six months postpartum. Your ligaments will have more laxity and range of motion will be increased. It is important that you control your movement throughout the entire range and avoid loading your joints at the end range. An example that I use a lot is crashing into the bottom of a squat—avoid that! Mobility exercises, specifically distraction, with bands should not be used directly after pregnancy and added conservatively after a few months. Ease into exercise- you may find that beginning with low impact exercise is more comfortable, such as swimming, biking, light weight training. Just as during your pregnancy, listen to your body and avoid going to exhaustion right out of the gates. Stay hydrated- especially if breast feeding, it is important to remain hydrated. The cardiovascular changes that took place during pregnancy will begin to level off. So drinking plenty of water and maintaining electrolyte levels is important for the health of you and your child! Mind your belly- diastasis recti is the separation of your abdominal muscles during pregnancy. Depending on the amount of separation, different exercises should be avoided. Not all women experience diastasis recti but it important that you communicate with your care provider to determine if it affects you. If so, abdominal crunches, planks and sit-up variations should be avoided until it is healing and closed to a certain degree. Pelvic floor health- many factors during the pregnancy will make your pelvic floor vulnerable to dysfunction: pressure from the baby, altered posture during the pregnancy, episiotomy or spontaneous laceration, vaginal delivery. It is important to check in with your pelvic floor and decide if it needs some attention before returning to exercise. Pelvic floor dysfunction can lead to a slew of issues; three very common issues are urinary stress incontinence (peeing when you sneeze, jump, etc), low back/hip pain and painful intercourse. If any of these issues persist, see a pelvic floor physical therapist and they can get you back on track. These are all common but not normal.  Keeping the guidelines in mind, work through these exercises and find your weaknesses. Hollow Rock Regression- this exercise is great to begin to regain midline control. Do not do this if you have diastasis recti. Air Squat- slow and steady, controlling your speed on the descent. If you are having hard time with control, squat to a box! Monster Walks- the deep rotators of the hip have fascial connections with the pelvic floor so they directly impact its function. Diaphragm Reset- it is important to practice breathing with proper posture- ribs over hips. In the later stages of pregnancy, the exaggerated lumbar lordosis (sway back) puts your diaphragm at a disadvantage. Starting with these foundational exercises will make your transition back to higher level exercise as seamless as possible. Keep those precautions in mind and communicate with your healthcare provider if you have any questions. If pelvic floor dysfunction seems to be sticking around, seek out a pelvic floor therapist. This is something that can be treated and resolved! Thanks for reading, Dr. Jackie, PT, DPT, CSCS Photos: http://www.someecards.com/usercards/viewcard/a2679791515bfaa20529fedf7844268414 Should women train differently than men? The answer to this question is far from black and white. There are some principles of strength and conditioning that remain constant whether training a male or female. However, the biological makeup of women causes some factors to be different than a man. First I will address the YES, or why women should train differently.
NO- Reasons why women should not train differently than men
So what do you do with this information? For most of you, continue to train as you were. However, it will behoove you to add some extra warm-up drills, “core” exercises and closely analyze your motor control. However, do not cut yourself short on the intensity. Remember, women can perform more reps at higher weight and yes you will maintain a feminine figure! Keep the intensity high for greater metabolic impact and don’t skip the weights. Thanks for reading! -Dr. Jackie, PT, DPT, CSCS References: Mata, John D et al. Sex Differences in Strength and Power Support the Use of a Mixed-Model Approach to Resistance Training Program. Strength and Conditioning Journal 38:2 April 2016. Tuttle, Lori J et al. The Role of the Obturator Internus Muscle in Pelvic Floor Function. Journal of Women’s Health Physical Therapy. 40:1 2016. Photos: http://onepercentchange.net/why-your-fitness-assessment-helps-with-weight-loss/ http://redefiningstrength.com/best-glute-exercises/ http://www.huffingtonpost.com/2015/01/13/running-effect-on-breasts_n_6460248.html http://sites.psu.edu/amberwaresticker/2015/09/16/rhetoric-and-rosie-the-riveter/ Many active women wish to continue their lifestyle even through pregnancy. Aerobic activity and resistance training are fantastic for maintaining fitness while keeping the baby healthy. Of course, always consult your doctor after becoming pregnant to make sure that it is safe to exercise at various intensities.
The general guidelines are to accumulate at least 20 minutes of moderate intensity almost every day of the week. For those of you who look for more intense activity, 3-5 days of vigorous activity is suggested for 20-60 minutes per bout. Baby Bumps & Barbells guidelines:
Targeted Strengthening As the baby bump grows and the center of mass is moved forward, your posture will be affected. The lumbar lordosis, or curve of the low back, will increase drastically throughout the pregnancy. Often times, your thoracic spine will flatten. Although postural changes are expected and normal, it is important to continue to maintain the best posture possible. Continuing upper body strength training and focusing on proper posture are key. Another group of muscles that is greatly affected during pregnancy is the posterior chain. I’m talking specifically about the glutes and the hamstrings. Any barbell work to strengthen these areas should be continued throughout, keeping the baby bumps and barbells guidelines in mind. Lunges and squats remain some of the best and most simple workouts to target the posterior chain with little risk. Birddog- if achieving this position proves to be too difficult, you can keep your knees down and extended just one arm at a time. Then you can progress to extending just one leg at a time before combining for an arm and a leg simultaneously. Safe Stretching As mentioned earlier, pregnant women are inherently more bendy than they were pre-pregnancy so stretching may seem unwarranted. However, most of these stretches are aimed at relieving areas of pain or tension from the growing bump and new posture. Child’s pose- as the baby bump grows, this can be modified by having your arms and hands out-stretched on a workout ball, chair, or any other elevated surface. A large ball will give you the option of small rotations right and left with your arms to feel the stretch intensified along your sides. Seated Hamstring Stretch- as the bump grows it may be necessary to use a bed sheet wrapped across the bottom of the foot and held with the hands. Hip flexor stretch- while standing at the bottom of a staircase, place the lead foot two or three steps up. Keeping the back leg on the bottom with a slight bend in the knee, shift the weight forward to the lead foot to the point that you feel a comfortable stretch in the front of you trailing hip. Cat Cow- a great way to stretch the lower back and get the thoracic spine moving throughout the entire pregnancy. Pigeon- if you are unable to achieve or maintain this position, adding a firm pillow under the upper thigh of the back leg and buttock area of the front leg may be more comfortable. Deep Squat- a great stretch for your hips and pelvic floor during the pregnancy. **Caution – in the third trimester, ask your doctor before trying this stretch as it may induce labor ** Remaining active will lead to a healthier and happier pregnancy. Keeping the posterior chain strong can ward off back pain for mom while exercise activity increases blood flow for the baby. Remember, it is important to always listen to your body and consult healthcare professionals when questions arise.
Thanks for reading! -Dr. Jackie, PT, DPT, CSCS References R Artal, M O’Toole. Guidelines of the American College of Obstetricians and Gynecologists for exercise during pregnancy and the postpartum period. Photos: FitPregnancy.com, tfwropestone.com, fusionwellness.com, themusicmommy.com, alimcwilliams.com, momjunction.com Midline stabilization is heralded as the foundation of safe and successful weightlifting. But have we been ignoring a part of the “core”? The pelvic floor is a topic that tends to be avoided. Most people do not casually discuss urinary frequency over coffee or admit to their coach that they pee every time they perform double-unders. Men- if you think this one is just for the women, stick around! I only realized the prevalence of leakage after CrossFit HQ posted a video following regionals. All of these women were saying “It’s ok, I pee during workouts too. It’s normal!” Please do not confuse normal and common. Urinary incontinence may be common in certain populations, especially of heavy lifters, but it is absolutely not normal. The pelvic floor includes a group of muscles that attach from your coccyx (tail bone) and sacrum to your pelvic ring.  These muscles are important for bowel and bladder function, organ support, and stability of the pelvis. Although pelvic floor dysfunction (PFD) was thought to be largely a problem of women, it is becoming apparent that men have similar issues. The pelvic floor may seem very foreign and uncomfortable to discuss, but when it properly functions it can improve your workouts. Here’s how: I like Mary Massery’s description of the core as a “soda-pop can”. The front of the can is the abs, the back is the multifidi, the pop top is the glottis and the bottom of the can is the pelvic floor. The core pressure is maintained by a functioning glottis and pelvic floor, with the diaphragm acting as a pressure regulator.   When you take a breath in, the diaphragm descends. This requires the pelvic floor muscles to descend and lengthen. When you exhale the diaphragm rises and the pelvic floor rises and tightens. In fit individuals, (notice I said individuals and not just women), a common pelvic floor problem is overactive muscles. Very strong back or abdominal muscles can cause increased inward pressure. It’s been shown that when your deep abdominals contract, so does your pelvic floor. Imagine squeezing the can from both sides with the pressure maintained. The bottom and top will have to withstand more pressure and bulge. If your abdominals are always squeezing in then your pelvic floor is always pushing up to withstand the pressure. It’s overworked! The diaphragm is pretty darn good at its job. If it does not work, we have a bigger issue on our hands. So often, when something’s ‘gotta give’- it’s the pelvic floor. When all of these muscles work in concert, your canister and the force it can produce is maximized. Thus, your workout improves. A conversation about breathing techniques regarding the glottis and diaphragm is essential to training the entire core. Here I am simply touching on one contribution but remember it does not work alone. Keep in mind, PFD can also manifest in ways such as pelvic pain, painful intercourse, low back pain, urinary frequency or even the dreaded butt wink. It is not just urinary incontinence. “ Pelvic floor pain is only caused by pregnancy, right?” Wrong. There has been no correlation shown between PFD and post-partum women. Sure, some moms experience issues but again, it is not normal for any population. Weakness and/or tightness of the pelvic floor can be caused by poor postural habits, extended periods of sitting, over training of the abdominals and pregnancy. Excluding pregnancy of course, men are susceptible to all of the other risk factors. “Ok, so I pee on myself at the gym and it’s not normal. What do I do to stop it?”
Thanks for reading! Dr. Jackie, PT, DPT, CSCS References: Sapsford, Ruth R, Hodges, Paul W. Contraction of the Pelvic Floor Muscles during Abdominal Maneuvers. Physical Medicine and Rehabilitation, 2001, Vol.82(8), pp.1081-1088. Healthyplace.com Presentation at CSM 2016 by Mary Massery: referencing Massery 2005 & 2006. So you learned how to hold your kids in Part 1 and then learned how to pick your kids up in Part 2. Now that you fine physical specimens have that stuff under control it's time to learn how to fix yourself! The reality is sometimes we can't help but be in a bad position with our kids. Sometimes you have to round your back to get your toddler out of the tub. Sometimes you have to keep you neck in a flexed position for a long time when you are giving a baby a bottle or breast feeding. Shit, sometimes you even have to sit for long periods of time in chairs designed for people that are 3 feet tall and you may be 6'2, like me. In these situations it's up to us to correct some of the damage we may be doing to ourselves. Today is about correcting the upper back and neck. A nice little addition to this is that it will also do wonders for your overhead position. It's a win win! Minimize the effect of crappy positions while chasing your kids around and snatch more! Good luck and thanks for all the positive feedback about the parents series. Kids are awesome but so is a pain free back! Dr. Danny, PT, DPT  So you learned how to hold a baby in Part 1 but that's the easy part. Now we have to go over how to pick these little suckers up off the ground! It's my honest opinion that kids often times intentionally try and make it as hard as possible to pick them up. When my son doesn't want bath time to end but I'm tired of dodging wet foam alphabet letters, it's time to pick him up. Picking up a 28 lbs toddler may not sound very difficult but if you think that, you obviously don't have kids. Try this to get a better understanding of what it's like. Go to a fish market and buy a 28 lbs live salmon. Now fill the bath tub up and put the fish in the water after you cover it in soap. Now bend over and try and pick up the fish and wrap it in a towel. Let me know how that works out for you. Today's video is designed to help you save your back while you perform your parenting activities. Whether it be getting a kid out of the tub, putting them in a car seat or getting them in and out of a crib. Parenthood is basically performing high volumes of deficit deadlifts in really awkward positions. Best of luck with the kids! Dr. Danny, PT, DPT  Everyone's happy except my son, let the fun begin! Hey guys, being a parent is freaking hard! If you have kids you know what I'm talking about. If you don't have kids, enjoy your free time and sleep while it lasts. Over the course of the next few weeks we'll be releasing some videos on how to stay pain free as a parent. From holding your kids, to picking them up and everything in between. We can apply some of the Movement and Mobility principles to every situation. Enjoy the videos and apply the concepts to your daily lives. Don't worry guys, we can survive parenthood together! Dr. Danny, PT, DPT |
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