Hopefully you were able to read parts 1 and 2, where we discussed some of the reasons why proper breathing is important. Now the rubber meets the road. Time to do something about it! Let’s get into the “how”.
We discussed a pop can analogy in part 2, describing one opened pop can and one that was closed. If you stood on them, the closed pop can would withstand significantly more weight because the inside had more pressure. We want to keep this image in mind while breathing. When this is done you will have more core stability and overall strength, which results in less muscle compensation.
Another pop can analogy can be used to demonstrate core stability. Take the same two pop cans, but this time, they are both opened. Picture a dent in the side of one can and leave the other as perfectly cylindrical around the outside. If you stepped on these cans, the can with the dent would crush much sooner than the cylindrical can. Apply this to the “core canister” of our body, the abdominopelvic cavity: you want to maintain a cylindrical core without a dent to prevent any “energy leaks” and keep it optimally strong. This can be applied to breathing, or pretty much any movement. In most instances, you don’t want to arch your lower back posteriorly or tip your pelvis anteriorly. Just think of trying to prevent a dent in your pop can. Or, keep your diaphragm and pelvic floor parallel. Both of these pop can analogies translate to increased performance and a decreased likelihood for injury. Strive to create pressure and prevent a dent in your core and that alone will help you to make significant changes.
This may be foreign to you and can be very difficult at first. The easiest way to learn is to lay on the floor on your back with your feet up on a couch or chair. Your hips and knees should each be bent at a 90 degree angle. Take your fingers and place them on your lower abdominal or inguinal area. Try to breathe into your fingers when you inhale, while preventing your ribs and chest from moving up toward your head. Your ribs and chest should primarily only expand laterally. Sometimes it helps to cough and feel the intra-abdominal pressure push into your fingers to get some feedback on what it should feel like. Then, try to simulate that same pressure when you breathe.
You are off to a great start. Another visual is to think of your abdominopelvic cavity like a balloon that you are inflating. You don’t want to just inflate it to the front; it should expand out to the sides and back down into the floor equally, as well. Envision wearing a pair of sweatpants, and you want to expand the waistband equally a full 360 degrees around. If you feel an area that seems to be “dead” or not expanding equally, consciously try to breathe down and into that particular area when you inhale. Back to the balloon analogy: the apex, or fullest part, of the balloon should be about two inches below the belly button. This is sometimes a helpful visual to demonstrate how low the actual breathing should be. Once you start to improve, start working on maintaining that pressure while you exhale too, not just while you inhale. Ideally, you should feel the same pressure with your fingers when you exhale as you do when you inhale. This all takes work, but the benefits are profound.
It is best to work on this breathing on a consistent basis. Like any exercise, the more it is performed, the easier it becomes. Consciously work on this for five to ten minutes per day and you will eventually find yourself breathing in this manner unconsciously during your daily activities. That’s the goal! (Remember those motor patterns?)
In part 1, we discussed a few of the many ways breathing affects us systemically. Hopefully it answered some of the “why” breathing is important. Let’s dive into some more “why”, this time looking at the musculoskeletal side of things.
If you have ever paid attention to how a healthy baby breathes, you will have noticed that it is entirely with their abdomen. If they are laying on their back in just a diaper, you will only see their belly move with each breath, not their neck or shoulders or even chest. If you look closely, you will also realize that their belly doesn’t solely expand forward with each inhalation, it also moves out to the sides and down into the floor with each breath as well. It’s as if their abdominopelvic cavity is a balloon, and they are filling it evenly all the way around, 360 degrees. Fullest expansion should occur about two inches below the belly button
Try it. Lay on your back on the floor (preferably not in a diaper). Do you naturally breathe in this manner? Could you if you consciously tried? You should be able to. Believe it or not, we all started breathing in this way. However, we often develop improper motor patterns as we go through life. A motor pattern is the term that describes the order in which muscles are used to accomplish a particular task. For example, you want to take a drink of coffee. The brain sends the “drink coffee” message via the nerves to certain muscles in your arm to lift your cup of coffee to take a drink. Those muscles then respond by contracting in that particular sequence to lift the cup to your mouth. There are ideal and non-ideal muscles that get used for this pattern. The more we use a particular pattern, the more likely we are to use that pattern of muscles again in the future. This is why it is important to use the “proper” motor patterns, whether it be while drinking coffee or breathing or performing a back squat.
Again, we all started breathing properly if we were a healthy-developing infant. Then life happens. We sit in desks at school for a good portion of our childhood, we sit in the car with our head and shoulders rounded forward while holding the steering wheel, we spend too much time on the computer or cell phone or in our desk, and then we throw daily stressors of money, kids, relationships, and our jobs in the mix, and we have a perfect recipe for changing our ideal breathing patterns. You can observe adults and even children that don’t use their diaphragm (the muscle that we use with abdominal breathing) to breathe, but instead use their chest, upper traps, and neck muscles. This leads to chronic tightness from the overuse, one of the reasons people love getting massaged here so much. They also carry all of this stress as tension in these muscles, which is a vicious cycle and perpetuates these improper motor patterns unless something is done to correct it. This also frequently attributes to many headaches, as well as neck, shoulder, and upper back pain or discomfort. All from breathing.
It doesn’t stop there. Take two pop cans. One is opened and the other is not. If you stood on these cans, the unopened can would withstand much more weight before crushing. The only difference between the two is the amount of pressure that’s inside. If you think of your abdominopelvic cavity like this pop can, you will want it filled with more pressure so your core is more stable. This helps protect your low back, creates more strength for every movement you can conceive, and stabilizes everything all the while. How do you fill your “pop can” with pressure? You guessed it, breathing. Well, breathing with your diaphragm along with activating the abdominal wall and pelvic floor.
So, you’re telling me that proper breathing can help with neck, shoulder, upper back AND lower back pain?? Yes! Actually, it can help with a host of other ailments in both the upper and lower extremities too (think core stability). Basically, if the core isn’t stable, nothing else can be either, which puts distal joints and tissues at risk for injury.
Many muscles in the body follow this pattern. The body is very good at compensating and if the entire core and body isn’t stabilized as described above, the brain recruits other muscles to contract to help stabilize instead. Think: “if you don’t do it, somebody else will!” This isn’t the worst thing in the world, because even though these other muscles being used for stabilization is “non-ideal”, it’s better than nothing. They help protect the joints and connective tissues from acute injury or help us get from point A to point B. However, if this occurs for long enough, these improper motor patterns will lead to chronic, overuse injury.
You may be wondering what the purpose of these “other, non-ideal” muscles is. They have a purpose and specific function, but the primary function is not stabilization. Typically, they are larger muscles that are used more for movement than stabilization.
Next up is part 3, where we bring it all home. We’ve touched on a few things that can be done, but part 3 will be specifically geared toward the “how to” of breathing.
This final post in the three part blog series will help you bring everything together and allow you to move forward with training.
With a strong core, you will be able to effectively and efficiently transfer load. Obviously when I mention “strong core” I am not talking about a six pack. As good as that may look, it screams dysfunction. Sit-ups and crunches should be banned in all 50 states. Yes, I am serious. When I say strong, I am talking about moving with activation of your diaphragm, pelvic floor, and all abdominal and lumbar musculature with proper movement patterns as mentioned in Part 1 and 2 of this series. During pregnancy, I work with women to train for the “big event.” This means assessing women in movements she is frequently doing and making sure they are being done well. Any movement that exacerbates an already present diastasis needs to be avoided. This applies to both pregnancy and postpartum. For any of you that have already trained for any event, you know that great training leads to better recovery. Birth is the biggest athletic event of a woman’s life, and – trust me – you will appreciate a quicker recovery.
While the exercises demonstrated in the functional progression video seem simple, I guarantee you will find the challenge in actually performing these clean movements; especially as you are just starting. It is crucial to focus on the movement itself and not how many repetitions or sets you are getting in. Once this foundation is solid, resistance and weight can be added to the extremities. (Watch for videos coming soon.)
Focused core work should be done on a regular basis and I recommend adding at least one of the functional progression steps into each warm-up as well as spending 2-3 days per week moving through the entire progression. This may be body weight only or with resistance and or added weight.
Why should you continue to work through this progression and what will this help? Other than the obvious benefits listed in the previous blogs, it will be helping you literally all of the time. To prove this to you all you need to do is answer one question for me: How often do you breathe? Okay, point proven. Really though, it is that important. Yes, I could go on about the benefits of strength training and the benefits of hiking or biking or even running and how your core function is DIRECTLY related to each of these, but I will not. I will not because when it comes to core health, it does not matter what form of activity you choose. You need this stability to walk to your car. Hell, you need this stability to sit at your desk all day.
As chiropractors, my husband and I work with all levels of athletes (females and males), from amateurs to world champions. It can be humbling when the weights are taken away to perfect these basic movements. But time and time again, we see the benefit. Performance gains are made faster and injuries are reduced. Gaining this stability and strength can help to reach performance levels that may even be beyond what our athletes expected. And truly, we are all athletes; the variation is to what degree we utilize our athletic capability. Again, birth is the biggest athletic event of a woman’s life! Improving “performance gains” in birth means improved labor outcomes and “reduced injury” translates to faster healing postpartum!
Your body is incredibly intelligent and you will move from point A to point B if needed. The question is whether you are both effective and efficient. If you are moving with compensation (or birthing with compensation) instead of function you are setting yourself up for injury. You may not see the side effects of compensation immediately, but I guarantee you will eventually. The side effects show up in numerous ways: shoulder injuries, knee injuries, low back pain, neck pain, pelvic floor dysfunction, DIASTASIS!
Compensations, also known as poor movement patterns, lead to what I call “energy leaks.” This is a forced (instead of smooth) transfer of load, taking more energy and causing decreased performance. If you are healing a diastasis postpartum, know that leaving this untreated is not without further issues. DRA not only causes troubles for mom but can potentially affect future pregnancies, including positioning of baby and labor. When we apply this idea of forced transfer of load instead of smooth transfer of load, we’re talking about physically transferring the load (weight) of your baby from internal to external.
Please look at the big picture. Your body moves as a whole unit. Train it that way. Whether you want to move heavy weight, run a mile, walk up a flight of stairs to work, or give birth, you need your entire core to be stable! An injury will cause you to realize how much your core is needed in EVERY. SINGLE. MOVEMENT. As you return to or start activity, this is work you should continue to improve for the rest of your life. Implement these changes. Pay attention to the form you are perfecting during your core work and make sure it is as clean when you deadlift that weight from the ground. It is going to take being mindful to make this habitual, but you will reap the rewards.
Ideally, you won’t know the full extent of these rewards because ideally, years from now you will still be implementing these functional movements and making time for this habit instead of worrying about bathroom stops on your one hour drive, peeing your pants at the bottom of a snatch, and last but not least, your “gap” will be filled.
Share this information with others. Be part of this paradigm shift by exposing others to information that can truly be life changing.
Remember, postpartum lasts a lifetime and movement is life. Do not settle or own dysfunction because you are female, age X and/or have had children. You deserve a quality life and this is certainly going to help you achieve that!
QUICK TIPS REFERENCE LIST
Top 3 Exercises for Pregnancy:
Top 3 Exercises for Postpartum:
Avoid: (During pregnancy and postpartum)
Poor Posture & Prolonged Sitting
ANY exercise that aggravates DRA (this may include, but not limited to, planks, push-ups, and pullups)
Please, if you have any questions at all, then I encourage you to set-up a phone consultation with me, or we can schedule a consultation in person at Coulee Health. I’m super eager to discuss all things pelvic floor and core related. And, I’m even more motivated to help you get moving again. After all, MOVEMENT IS LIFE!
-Dr. Erica Boland, DC
Mother of 4
As discussed in Part 1 of the DRA blog series, in order to understand how to heal diastasis and properly train the core, we need to understand how our bodies were made to function in the first place. Babies are born with immature motor patterns. You will notice newborns tend to have knees tucked and hands and arms often flexed close to body and even near the face. Development begins with the drive to learn more and explore the surrounding environment. As babies are exposed to lights, sounds, and touch, they have the desire to discover more of this world and begin to integrate different parts of their body into learning.
Babies are not taught to roll, hold or grasp objects, sit up, crawl, or walk. Movements do, however, occur in a typical sequence and it is crucial that each milestone is met. Our movement patterns in the first year of life are the basis for function in movement as adults. As we watch the movements of babies and toddlers we can teach ourselves. If milestones are not met, the area is not used properly with movement patterns and can lead to problems later on. For example if support on elbow during tummy time, rolling or crawling does not happen, the scapula (shoulder blade) is not secure within movement and can eventually lead to impingement issues or even tears in the rotator cuff, etc. This is also one reason a patient can have surgery on that same shoulder and end up with the same problem. If the movement pattern is not addressed, the problem remains. Meeting milestones seems exciting as the little ones progress but the saying holds true “let them be little.” Let them do it on their own and do not push before they are ready.
Thumbs move from inside closed fist to outside closed fists
Eye contact begins
Support on elbows
Can rotate head without moving trunk
Spine starts to upright from mid to upper back
Start support on opposite knee and elbow (helping to begin closure of DRA)
Diaphragm flattens and mature breathing patterns begin
Free hand grabs objects but cannot cross midline
Hands can touch hips and groin
Oblique muscle activation occurs
Able to roll from back to belly
Can grab feet with hands
Can bring toes to mouth
Rocking from base of support on hands up to all fours: video example
Start to creep forward with use of upper body
Oblique sit occurs (first elbow and down thigh, eventual open hand and down thigh)
Further crawling development
Stepping forward to standing
Side walking along furniture
Stand freely after standing with support
Walking between objects (side to side)
Walking in sagittal (forward) plane
Stand independently from “bear” position
The movements attained in the first year of life are the foundation of all basic human movements. Following a major event like childbirth (or surgery or other major trauma), re-learning these movements IN ORDER helps heal the body as well as establish a solid foundation to build strength on. The diaphragm is used for both breathing and postural support. At 4.5 months as the diaphragm flattens and a more mature breathing pattern begins. When addressing the core, especially postpartum, the first step is establishing a strong breathing pattern. (Check out Dr. Mumma’s video here.) This is key in reconnecting to your core. After creating a human in that space for the the majority of a year, a woman needs to discover her new normal. Working on diaphragm activation can and should be done in the first day after birth while bonding with baby. This does not mean you need to start exercise but just focusing on what you are already doing, BREATHE!
12-16 times per minute: BREATHE.
In through your nose, out through your nose or mouth, filling your entire abdomen with air. When you inhale, your chest should not rise, but rather your belly should expand 360 degrees. This begins the healing process of the postpartum period internally.
Healing of the core needs to come from within. This occurs only after proper diaphragm activation which is a movement downward of the diaphragm during inhalation and upward during exhalation. From the outside, there will be expansion of the chest and abdomen in an outward direction as opposed to a dysfunctional upward motion of the chest and shoulders, as you saw in Dr. Mumma’s video above. As diaphragm moves downward, abdominal and lumbar musculature are contracted eccentrically (bracing outward, NOT SUCKING IN) and simultaneously counteracted by pressure of the pelvic floor. How awesome is it that we can gain a strong core by doing exactly what the baby just born will be doing?! Start with diaphragm activation, gaining proper intra-abdominal pressure, and move through the sequence of developmental movements, and the core will be strong enough to support day to day movements and eventually more vigorous exercise.
Functional Progression Demonstration Video
Breathing and movement patterns need to be discussed before birth and definitely assessed postpartum. Change is needed. It starts NOW.
As a practitioner, my work with pregnant and postpartum women continues to grow. This is where I not only see the literal gap in the body’s system (DRA) but also see the figurative gap in our system.
Consider this scenario: mom has baby, mom and baby are both healthy, mom presents for postpartum check up and pending no major issues is “cleared” for exercise. The evaluation being done of the core function at the postpartum visit is minimal at best and often completely overlooked. In fact, full movement patterns are never assessed. There is occasionally a check for diastasis rectus abdominis but not the entire core function. This leads to mom turning to online forums for help with a “gap” in her stomach or she may have been told to do crunches and sit-ups to help. The fact that our society has made “mommy tummy” a marketing ploy is an entirely different topic.
Let’s think about this though. In a hospital setting, as most births in our country are, practitioners are allowed limited time with patients as it is. For them to take on a thorough, functional physical would not only add appointment length but also require further education. My opinion is this is the point that collaboration in postpartum care must occur. Furthermore, my experience has proven time and time again that restoring core function in the immediate postpartum period launches moms into better recovery postpartum and overall better movement patterns. Long term, this leads to everything from less leaking when she sneezes (or runs, or laughs) to reduction in neck and back issues.
Beyond that, when assessing and treating the DRA, we must recognize that this is related to the entire movement patterns of the mother and not the diastasis alone. Sit-ups, crunches, holding the belly together during a contraction of the abs, and “zipping” the waist are not exercises that will be relatable to true movement. These are exercises towards strengthening single muscle groups and while they may seem to be beneficial temporarily, long term problems are likely to remain. We do not decide to get up from the chair and use transverse abdominus to walk to the yard. We also don’t consciously think about using our pelvic floor to stand at the park and watch our kids play. We need these muscles to be working together without conscious thought and in order for the muscles to work together they need to be trained through movement patterns we will use. Often that means taking it back to the basics of moving like a three or four month old infant. Trust me, even athletes moving heavy weights are humbled by this training and while they may be frustrated at the idea of dropping their weights, they are happy with the eventual improved strength and reduced risk of injury.
How does this all relate to your pelvic floor? Your core function is directly related to your pelvic floor function (fun fact: your pelvic floor is part of your core). It is actually directly related to ALL movement. Your core is your powerhouse. Without stability in your core, your foundation is off and eventually the pieces will crumble.
BIRTHFIT is education! We refer to the postpartum period as Queen in Training, and expect this specific healing time to last 9-12 months. Postpartum lasts a lifetime, but we want you to focus on the movement milestones to meet as a mother and hold yourself accountable to this. Approach your immediate postpartum period with intention and purpose. Know your body and understand how it functions as one unit. You will heal in less than a year and you will function better than before. If you can grasp this concept and share this with others, together we will create the shift in care that we need.
Dr. Erica Boland, DC
PART THREE… next week, relating core function to training
DIASTASIS RECTUS ABDOMINIS: FILLING THE GAP
Part 1 What and Why of Diastasis Recti
As I search the Internet and question colleagues, hungry for more information, what I actually learn is that we have a problem. The problem is the large gap; both figuratively and literally speaking. The gap in our postpartum healthcare is directly related to the gap in your abdomen.
It is beyond frustrating to see the misinformation marketed to new moms: “lose that mommy pouch” or “get your belly bikini ready” and “simple steps to a six pack.” (Unfortunately, “move well and quit screwing shit up” doesn’t sell as well.)
What is even more frustrating is many of the trusted resources, even the “experts” in the field, are still missing the boat. The consequences remain: misinformation and what I consider an epidemic of dysfunction.
I am sure by now you have heard the term Diastasis Recti or Diastasis Rectus Abdominis (DRA). For the sake of this post series I am going to refer to women. Just don’t forget, men have a core (and pelvic floor) too.
In my time as a chiropractor, doula, BIRTHFIT affiliate, coach, and mother of four I see firsthand the many issues that lead to and come from core dysfunction. It is time we start looking at the system as a whole and healing it that way. I am thankful for having studied Janda, Lewitt, and Kolar’s work. Their work has paved the way for an in depth understanding of how our bodies were born to move.
Within these innate movement patterns lies our answer.
I hope to help you understand this as simply as it actually is. Think about this for a minute: when is the last time you witnessed a baby doing a sit-up? How about “zipping” in his or her transversus abdominis? Nope. Me either. Want another fun fact? Babies are BORN with diastasis. Yes, that’s right. YOU were born with a diastasis and immature movement patterns. Guess what else? Babies heal that diastasis on their own through functional movement patterns. By four and a half months the diastasis should approximate or come together. This is also around the time that baby starts to roll to both sides. Not a coincidence.
No one teaches baby to roll or sit up on his or her own or crawl or squat or walk. We should not be putting them in these positions before this occurs naturally (Stop Interfering with Your Child’s Development). All of these movements are formed as neurological stimulation occurs in the environment. That simply means that baby’s brain is intrigued and wants to learn more about surroundings, hence baby is motivated to movies the most instinctive, natural way. Again, movement is life.
Why then, are we still attempting to look for treatment of DRA and core dysfunction by singling out muscle groups? We are not made to function that way, so hoping to return to full function by rehabbing or training that way is setting ourselves up for failure in the form of continuous injuries or dysfunction.
DRA does not have to occur. It is a separation in the rectus abdominus muscle due to immature movement patterns. Basically, this happens when movement reverts back to that of a newborn infant and can happen for a number of reasons. The simplicity of this concept is actually great news. If we return to what our bodies were born to do, we fix the problem at its roots and avoid simply making the surface look better.
The Functional Progression that I pieced together is not new. It is simply taking the work that I have studied into a fluid movement pattern that is more functional than a Turkish Get-up. The progression addresses the entire core and allows for resistance or weight to be added as normal movement patterns are solidified.
Dysfunction of the core and pelvic floor is much more than DRA and is so common that even upon questioning patients, it is often not mentioned. As founder of BIRTHFIT, Lindsey Mathews states, common does not always mean normal. Peeing in your pants when you are 50 (or younger) because you are “getting older and have had children” is NOT a rite of passage. Yes, it is common. No, it is not normal. And until we start filling our gaps, women will continue to suffer from these issues.
Stay tuned for Part 2!
-Dr. Erica Boland, DC
“Can I be BirthFIT?”
This is a question I recently received from a patient that is a few years, instead of few months postpartum. The answer to that question is, “YES!”
Ideally, women start preparing to be BirthFIT before conception and pregnancy by staying active, eating healthy, hydrating and working on mindfulness and emotional well being. The postpartum series is targeted at women 2 weeks-6 months postpartum. This is simply because this is also the ideal time to heal your body and mind after birth. However, there is no time limit on when that can occur! The fitness portion of the postpartum series emphasizes the strength and improvement of the core. This includes the diaphragm, all abdominal musculature and the pelvic floor. Your core is your powerhouse and proper function sets you up for proper movement patterns and easier transition into or back to fitness. It is never too late to address this!
As women there are many things thought of as some sort of “right of passage” coming with giving birth and aging. This is absurd! Below is a list of just a few issues that are “common but not normal” (and certainly not a badge of honor as a woman) that may develop with improper core function (and can be helped).
Diastasis of rectus abdominis (a split in centerline of abdomen)
Decreased diaphragm breathing
Stress or urge urinary/bowel incontinence
Abdominal trigger points/pain
Frequent or recurring injury during exercise due to decreased activation of the core in unison
As stated previously, it is NEVER too late to become BirthFIT! Do not accept these issues as something normal to deal with. Seek assessment from your local chiropractor and contact your local BirthFIT affiliate!
Please watch for corresponding video to come on Coulee Health’s Facebook page.
Follow Dr. Erica on Twitter and Instagram: @EMomDC