Which Core exercises are safe Postpartum for my Diastasis & Pelvic Floor?

Can I crunch again? 

• Is it okay to do a Plank?

These are common questions I get from my clients every day. The answers are different for everyone depending on the issues they have within their Deep Core System.

Some of the more common problems that can occur after having a baby are a weakening or stretching of the abdominal wall connective tissue causing a separation of the outermost abdominal muscle (Diastasis recti), urinary incontinence, pelvic organ prolapse, and other dysfunctions of the pelvic floor muscles from scarring, tightness, or lack of control and coordination.  All these problems can be managed, in part by learning how to properly control pressure placed on the abdominal wall or the pelvic floor muscles.


What is the Deep Core System anyway?  Let' start there.

The Deep Core System is a canister of muscles, connective tissue and organs between the rib cage and pelvic girdle.
It is a pressurized system that when works together helps to:

• stabilizes the spine
• supports the pelvic girdle and organs
• controls the forces (intra-abdominal pressure) on the connective tissue of your abdomen and pelvic floor 
• aids in continence and much more

What makes up this System?
Primarily for the purpose of this blog we will discuss the 4 deep core muscles and the skeletal structures to give you a simple understanding.

The Diaphragm which is a Dome shaped muscle sits up underneath the rib cage and aids in respiration and is the top of the canister.

• When you inhale the dome, shaped diaphragm descends down so the lungs can fill with air and flips like an umbrella taken by the wind.  This presses down on the abdominal contents and signals the pelvic floor to descend.
  
  
  

The Pelvic Floor muscles are in a shape of a bowl or hammock and made of superficial and deep layers and line the inside of the Pelvic Girdle creating the FLOOR.   When they contract they squeeze and lift.

• These muscles help control intra- abdominal pressure creating a sump pump motion moving down and up with the diaphragm, support the pelvic organs, control urination, movement of gas and bowel movements, squeezes the vaginal wall, nods the clitoris, stabilizes the pelvic bones, and is lymphatic creating fluids. 

The Transverse Abdominus starts at one side of your spine and wraps all the way around the front of your body creating a Corset and attaches on the other side of the spine.

• The TVA muscles job is to support the Lumbar spine and compress the abdominal organs.
  
  
  

The Multifidi are deep back muscles connecting one vertebra to the one above or below it and stabilize the Lumbar vertebrae. 

Neutral Alignment is Key

The Diaphragm is the top of this tube-shaped canister, the pelvic floor the bottom, the transverse and multifidus the front, sides and back. 
 
I personally like to think of it more like an Extra-large plastic Easter egg because lining up the top and bottom keeps all the good stuff inside.
These muscles connect the rib cage (top of the egg) to the pelvic girdle (bottom egg) deep inside underneath the exterior core or 6 pack muscles.

Traditional core exercises 

Traditional core work tends to focus on the exterior Core muscles like with crunching, bicycles and any exercise where you are in a flexed and flat backed position.   This can increase pressure down into the pelvic floor and increase intra-abdominal pressure. If the pelvic floor muscles are not strong enough to counter act the forces more dysfunction can occur. 

In addition, the Deep Core system becomes under trained, overlooked and forgotten with traditional fitness style core exercises.
Add having a baby or two, gaining weight around the middle and further stretching out that deep core system and making its job twice as hard and often times the hip muscles, exterior core and back muscles start to work overtime and create an imbalance in the system.   

In a front-loaded position like a plank, if the transverse abdominus muscle isn’t strong enough to compress and hold up the weight of the organs in the presence of a Diastasis recti then more stretching and weakening of the abdominal wall connective tissue can occur.   Again, the hips and exterior core may take over to compensate or one might hold their breath which again will increase pressure in the system. 


So HOW do you get these deep muscles working again?

• Exercising and doing functional day to day activities in Proper Alignment with the rib cage stacked on top of the pelvic girdle sets these muscles up to work in the optimal position by aligning the diaphragm on top of the pelvic floor muscles. 
• Retraining the diaphragm and pelvic floor to work together through proper breath control and coordination with the TVA muscle to help control intra-abdominal or pelvic floor pressure.
• Retraining the transverse abdominus to compress the abdominal organs, control the right amount of forces on the connective tissue and pelvic floor, and stabilize the spine.

How do I do all that?    Very simply by:

• Learning Proper Breathing to recruit these muscles.
• Learning strategies to control the pressure off the pelvic floor and connective tissue to promote healing during all your functional activities and fitness exercises. Start by not holding your breath with changes in position and continually breathing evenly during exercise.
• Temporarily avoiding front loaded planks, crunches, bicycles, full sit ups and other exercises if it is more difficult for you to control intra-abdominal pressure while retraining the deep core muscles might be recommended.  
• Gradually returning to these exercises with a progressive exercise program designed to do them safely without putting extra pressure in the system so the strategies taught can be applied. 
• Being evaluated by a Qualified and Experienced Women’s Pelvic Health Therapist who can give you an individualized prescription of exercises that are safe and appropriate for your specific condition and pressure management strategies and progress you accordingly.

In Summary
The overall answer is everyone is different in whether they will safely be able to return to these exercises and how long it will take them.   They may or may not be right for everyone and that is OK....
These are some of the concepts I teach to my patients.  Obviously each person’s ability to return to crunching, planks and other exercises that put pressure on the system will depend on their ability to control the pressure and together we find strategies that help you obtain that control, restore core strength and return to being functionally fit. ​

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​Author Nadine Adams, MSPT, CPT, is a Pelvic Health Physical Therapist at Peak Physical Therapy in Norwell. www.peaktherapy.com

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