The third trimester of pregnancy—you’re fast approaching meeting your little one who may currently be treating your ribs as their own personal trampoline. That feeling of not being able to fully breathe or that you are getting drop-kicked in the ribs is pretty common. While it’s common, it doesn’t mean you are stuck with it for the next 12 weeks.
Diastasis Rectus- Navigating the Ins & Outs: Part 3 - Preventing & Treating a DRA
Now that we know what diastasis rectus abdominis (DRA) is and the causes of DRA, it’s important to understand how DRA affects us and what we need to know before returning to the gym, studio, or running.
What can I do to prevent or heal DRA?
The movements and activities that heal a DRA are the same activities that prevent them. Here is a list of ways that may naturally prevent or heal DRA.
- Creating appropriate intra-abdominal pressure (IAP) and using the diaphragm synergistically with abdominal musculature and the pelvic floor helps stabilize the body and decreases undue pressure on the abdomen that can cause DRA.
- It is through the breath and inhaling into all aspects of the abdomen including the lower pelvis, sides and low back that our core is stabilized. It is the stabilization with the breath and IAP and breathing into all aspects of the abdomen that creates a canister of stabilization.
- Another way to focus on the breath is to relax. Stop clinching your butt cheeks together, stop sucking in the abdomen and let the belly and butt relax and move freely with the breath.
Avoid movements that put undue stress on the abdominal musculature.
- This includes all exercises listed in the ineffective exercise section and it also includes any movement that causes tenting or coning of the abdomen (this is unique for each person)
- One thing that can cause unnecessary stress on the pelvic floor and abs is straining when you use the restroom. One way to avoid this stress is to avoid constipation. You may like to try the Squatty Potty to help ease the flow. If you are regularly constipated, please seek out medical advice.
Mind your posture
- Neutral spine is key! We don’t want to be pulled into anterior pelvic tilt or posterior tilt as both put strain on the body in different ways.
- The goal is to keep your pelvic floor and your diaphragm aligned!
SLOW IS FAST
- Postpartum is forever and deserves to be respected. It’s not only OK to go slow, it is better in the long run! Going too fast too soon can actually slow down the healing process.
- Postpartum gives you an opportunity to slow down and allow your body to recover, rehabilitate, and rebuild.
- ALL babies are born with a DRA and it is through their normal childhood development that they naturally begin to close and close their DRA through movement.
- This is where Dynamic Neuromuscular Stabilization (DNS) and BIRTHFIT come in as both are based on ontogenesis- the natural growth & development we go through as children. We do purposeful movements that can naturally help to heal a DRA.
See a pelvic floor physical therapist
- Sometimes pain and discomfort can come from weak muscles and sometimes it comes from tight muscles. The key is knowing what you are working with so it can be treated appropriately. One great way to know what needs work is to see a women’s health physical therapist in your area!
- If you are in the Chicagoland area, I highly recommend BodyGears (https://bodygears.com). They have three local locations - Wheaton, Oak Brook and Oak Park. It may be a little bit of a travel but they well worth the drive the support and knowledge you will receive!
The information by Dr. Lauren Keller of Elemental Chiropractic, Inc. is provided for general information only and should in no way be considered as a substitute for medical advice or information about any particular condition. While every effort has been made to ensure that the information is accurate, Dr. Lauren Keller nor Elemental Chiropractic, Inc. make no warranties or representations as to its accuracy and accept no responsibility and cannot guarantee the consequences if individuals choose to rely upon these contents as their sole source of information about a condition and its rehabilitation. If you have any specific questions about any medical matter or think you may be suffering from any medical conditions, you should consult your doctor or other professional healthcare provider. You should never delay seeking medical advice, disregard medical advice, or discontinue medical treatment because of information on this website.
“Breathing becomes dysfunctional when the person is unable to breathe efficiently or when breathing is inappropriate, unhelpful or inefficient in responding to environmental conditions and the changing needs of the individual.” (4) Dysfunctional breathing and it's effects can be found:
- For the love of all things good, stop sucking in
- Must I pee when I sneeze?
- Understanding the Different Breathing Options
But one thing in health that is sometimes over-looked is the why. Why do we have dysfunctional breathing or what are the causes? There are three main causes of dysfunctional breathing:
1. Developmental Adaptations
During the first year of life, our bodies should go through an ideal developmental pattern that helps create a stabilization system and helps form posture. Two studies (Vjota and Prechtl) both indicated that 69.7-72% of children develop normally while ~30% have abnormal development. (5)
This is one reason developmental kinesiology and the work of Dynamic Neuromuscular Stabilization (DNS) are important. Both address the ideal developmental pattern that can be adapted as an adult for the 30% of the population that may not have developed a strong stabilizing system in infancy.
2. Physiological / Medical
Hyperinflation of the lungs causes air to get trapped in the lungs. This hyperinfalation, often seen in COPD, asthma or emphysema and severe pneumonia, and congestive heart failure causes the diaphragm to shorten and lose its power and efficiency. (3)
In 2001, Hodges et al stated that the coordinating function between the diaphragm and transverse abdominis are frequently reduced in respiratory disease. (2) When the diaphragm contracts it is unable to properly lift and expand the lower ribcage and instead the lower ribs are pulled inward during inspiration creating what's called a Hoover's sign.
2. Emotional / Psychological
Both psychological and emotional stress can alter the diaphragm’s control. Dysfunctional breathing has been shown to be present in 11% of the normal population, 30% of asthma sufferers and 83% in people suffering from anxiety. (4) It has been reported that voluntary breath modulation accounts for 40% of the variance in positive feelings such as joy and negative feelings such as fear, sadness and anger (7).
In 2001, Umezawa found that breathing modification is the most common self-regulation strategy for relaxation and stress management. (6) Chaitow stated that in “Overbreathing: A Mind-Body Vicious Circle” that over-breathing and anxiety go hand-in-hand as anxiety increases the sympathetic system which causes an increase in breathing rate which leads to excessive carbon dioxide loss and in the end lead to a decreased pain threshold and more anxiety and overbreathing. (9) In 2010, Meuret stated that reducing hyperventilation “has emerged as a potent mediator for reductions in panic symptom severity and treatment success.” (8) Furthermore, studies have shown that conscious control of ones breathing can improve anxiety, depression and panic disorders. (11)
- Hodges et al. Postural activity of the diaphragm is reduced in humans when respiratory demand increases. J. Physiol. 2001 Dec 15; 537(Pt3): 999-1008. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2278995/)
- Hoover CF. The diagnostic significance of inspiratory movements of the costal margin. J Am Clin Sci 1920: 633-46
- Courtney R. The function of breathing and its dysfunctions and their relationship to breathing therapy. Int J of Osteo Med. 2009;12:78-8
- H. F. R. Prechtl and B. Hopkins, “Developmental transformations of spontaneous movements in early infants,” Early Human Development, vol. 14, no. 3-4, pp. 233–238, 1986.
- Umezawa A. (2001) Facilitation and Inhibition of Breathing During Changes in Emotion. In: Haruki Y., Homma I., Umezawa A., Masaoka Y. (eds) Respiration and Emotion. Springer, Tokyo
- Respiratory feedback in the generation of emotion. Pierre Philippot, Gaëtane Chapelle & Sylvie Blairy. Cognition and Emotion. Vol. 16, lss. 5, 2002.
- Meuret AE, Ritz T. Hyperventilation in Panic Disorder and Asthma: Empirical Evidence and Clinical Strategies. International journal of psychophysiology : official journal of the International Organization of Psychophysiology. 2010;78(1):68-79. doi:10.1016/j.ijpsycho.2010.05.006.
- Chaitow L Gilbert C Bradley D. Recognizing and Treating Breathing Disorders. Elsevier Health Sciences; 2013.
- Ley R. The Modification of Breathing Behavior Pavlovian and Operant Control in Emotion and Cognition. Behav Modif. 1999;23(3):441-479.
Understanding the Different Breathing Options
When researching pregnancy and postpartum breathing as well as proper breathing when lifting, we run across three main types of breathing- abdominal hallowing, piston breathing, and diaphragmatic breathing. Each have their pros and cons and which is why understanding the different breathing options is an important aspect in knowing WHY we are doing something (#knowbetterdobetter).
Why the breath matters
Breathing matters because the breath is the key to a strong and stable core and body is the ability to create pressure, specifically intra-abdominal pressure (IAP), within the abdomen. IAP is fundamental in the initiation, control and prevention of movement.
Want the science on why Intra-Abdominal pressure is a GOOD thing, check the previous blog post, "For the love of all things good, stop sucking in."
Abdominal Hallowing / Sucking-In / Belly Button to Spine
Abdominal hallowing was previously mentioned in this blog but here's a quick breakdown...
- Activates the transverse abdominis
- Isolates the transverse abdominis through concentric contraction and separates the diaphragm and pelvic floor
- Inhibits activation of abdominal oblique musculature
- Sub-optimally strengthens the abdominal musculature through concentric contraction
- Creates oblique position of diaphragm and pelvic floor (see consequences of less than optimal breathing below)
- Not replicated in any functional movement
- Helps one connect with the pelvic floor
- A great start: more beneficial long-term than abdominal hallowing and chest breathing as it focuses on trying to connect the diaphragm and pelvic floor
- Focuses on proper posture/alignment as well as breathing
- Pulls the breath out of the chest and into the belly, which is where one wants/needs to breath
- Piston breathing implies unidirectional pressure with tight sides...when taught it typically includes something along the lines of "we quickly and forcefully draw the breath into the belly"
- This is not functional as one does not isometrically contract to breathe and move throughout the day
- The breath should never be "forceful"
- The pelvic floor and diaphragm should never be working separate of the abdominal musculature as this can create additional dysfunction
- One does not want to tighten the abdominal musculature in preparation of the inhalation as this separates the co-contraction activation that should occur
- The breath should create an eccentric activation of the abdominal muscles which then allows the muscles to tighten/loosen as they need in order to regulate the internal pressure
- The diaphragm, all abdominal musculature and the pelvic floor co-contract in coordination to create appropriate intra-abdominal pressure (IAP)
- IAP is what gives one strength and stabilizes the core to protect the spine from injury
- Coordinated co-contraction keeps the pelvic floor, diaphragm and musculature working in unison, which is the basis for optimal breathing (see below consequences of less than optimal breathing) (6, 7)
- Optimal movements - if you want to strengthen the glute med you would pick a single-leg deadlift over a clam shell, the diaphragm is no different
- Creates 360 degrees of expansion to stabilize the abdominal musculature, back musculature and pelvic floor
- Focuses on proper posture in both standing and seated position (4, 5, 13)
- Replicated in day-to-day function
- It may initially feel forced until the proper breathing patterns are learned
- The goal is to make the breath more automatic/reflexive and a habit...when initially learning to do diaphragmatic breathing, it may feel a little forced as one is not accustomed to breathing in this manner and it takes time to train the proper breathing mechanics
- It may be difficult to learn due to compensation that has been trained throughout the years
- One way to help learn the breathing easier is to utilize the Core360 belt which helps one activate their core correctly and consistently
Consequences of less than optimal breathing
Less than optimal breathing often leads to a functional cascade of complications/pain or faulty movement patterns. Some of those consequences include:
- Oblique position of diaphragm & pelvic floor which can create/may lead to:
- Increased lumbar lordosis and increased intra-fiscal pressure: more likely to ave back pain or disc injury, chronic back tightness and hyperactivity of lumbar erectors
- Lumbopelvic and hip instability : hamstring pain with bending and sitting, trigger points in low back, buttock and upper hamstring (14, 15, 16)
- Anteverted pelvis: can lead to butt-wink in squat (8, 9, 10)
- Poor thoracic extension and scapular stability: more likely to have shoulder and upper back/neck pain
- Non-coordinated co-contraction of diaphragm, pelvic floor and abdominal musculature:Weak abdominals: the abdominal wall does not offer resistance to the diaphragm contraction which does not allow for appropriate IAP
- Tight abdominals: the abdominal wall is too tight and the diaphragm and lower ribs cannot move downward to create ideal diaphragm activation and IAP
- Secondary effects:
- Pelvic organ prolapse and urinary/fecal incontinence (3, 11)
- Often caused by a lack of tonic support and muscular strength of the pelvic floor, core and surrounding pelvic girdle musculature (1)
- Increased risk of diastasis recti
- Increased risk of disc herniation (14, 15)
- Upper back and neck pain (18)
- Pelvic organ prolapse and urinary/fecal incontinence (3, 11)
Benefits of proper diaphragmatic breathing
- Improves core stability
- Coordinates and strengthens all components of the deep core musculature – pelvic floor muscles, transverse abdominals, multifidi, and diaphragm (2)
- Contracting the diaphragm increases intra-abdominal pressure and generates a co-contraction of the pelvic floor muscles (pubococcygeus, puborectalis, and iliococcygeus) and transverse abdomens (17)
- Decreased neck and shoulder pain (21)
- Improved function of Sternocleidomastoid muscle which may decrease ringing in the ear (19)
- Decreased use of pectoralis and scalenes which are commonly recruited in faulty breathing patterns (20)
- Improved ventilation of the lungs (22, 23)
- Increasing the inspiratory volume naturally increases the level of oxygen in the blood
- Maximize the diaphragm's efficiency in performing breathing activity
- Sapsford R. Rehabilitation of pelvic floor muscles utilizing trunk stabilization. Man Ther. 2004;9(1):3-12.
- Lee DG. The Pelvic Girdle: An integration of clinical expertise and research, 4e. Churchill Livingstone; 2010.
- Wei, J.T. and DeLancey, J.O. Functional anatomy of the pelvic floor and lower urinary tract. Clin Obstet Gynecol. 2004; 47: 3–17
- Sapsford RR, Richardson CA, Maher CF, Hodges PW. Pelvic floor muscle activity in different sitting postures in continent and incontinent women. Arch Phys Med Rehabil. 2008;89(9):1741-1747.15.
- Sapsford R. R., Hodges P. W., Richardson C. A., et al. Co-activation of the abdominal and pelvic floor muscles during voluntary exercises. Neurourology and Urodynamics. 2001;20(1):31–42.
- Bø K. Urinary incontinence, pelvic floor dysfunction, exercise and sport. Sports Medicine. 2004;34(7):451–464. doi: 10.2165/00007256-200434070-00004.
- Pereira L. C., Botelho S., Marques J., et al. Are transversus abdominis/oblique internal and pelvic floor muscles coactivated during pregnancy and postpartum? Neurourology and Urodynamics. 2013;32(5):416–419. doi: 10.1002/nau.22315.
- Soljanik I., Janssen U., May F., et al. Functional interactions between the fossa ischioanalis, levator ani and gluteus maximus muscles of the female pelvic floor: a prospective study in nulliparous women. Archives of Gynecology and Obstetrics. 2012;286(4):931–938. doi: 10.1007/s00404-012-2377-4.
- Capson A. C., Nashed J., Mclean L. The role of lumbopelvic posture in pelvic floor muscle activation in continent women. Journal of Electromyography and Kinesiology. 2011;21(1):166–177. doi: 10.1016/j.jelekin.2010.07.017.
- Cerruto M. A., Vedovi E., Mantovani W., D'Elia C., Artibani W. Effects of ankle position on pelvic floor muscle electromyographic activity in female stress urinary incontinence: preliminary results from a pilot study. Archivio Italiano di Urologia e Andrologia. 2012;84(4):184–188.
- Halski T., Słupska L., Dymarek R., et al. Evaluation of bioelectrical activity of pelvic floor muscles and synergistic muscles depending on orientation of pelvis in menopausal women with symptoms of stress urinary incontinence: a preliminary observational study. BioMed Research International. 2014;2014:8. doi: 10.1155/2014/274938.274938
- Devreese A., Staes F., Janssens L., Penninckx F., Vereecken R., de Weerdt W. Incontinent women have altered pelvic floor muscle contraction patterns. The Journal of Urology. 2007;178(2):558–562. doi: 10.1016/j.juro.2007.03.097.
- Chmielewska D, Stania M, Sobota G, et al. Impact of Different Body Positions on Bioelectrical Activity of the Pelvic Floor Muscles in Nulliparous Continent Women. BioMed Research International. 2015;2015:905897. doi:10.1155/2015/905897.
- Hebert JJ, Koppenhaver SL, Magel JS, Fritz JM. The relationship of transversus abdominis and lumbar multifidus activation and prognostic factors for clinical success with a stabilization exercise program: a cross-sectional study. Arch Phys Med Rehabil. 2010;91(1):78-85
- Cholewicki J, Silfies SP, Shah RA, et al. Delayed trunk muscle reflex responses increase the risk of low back injuries. Spine (Phila Pa 1976). 2005;30:2614-2620
- Holmich P, Larsen K, Krogsgaard K, Gluud C. Exercise program for prevention of groin pain in football players: a cluster-randomized trial. Scand J Med Sci Sports. 2010;20:814-821
- Akuthota V, Nadler SF. Core strengthening. Arch Phys Med Rehabil. 2004;85(3)(suppl 1):S86-S92
- Ingraham, Paul. The Respiration Connection: How breathing might be a root cause of a variety of common upper body pain problems and injuries. PainScience.com. updated September 13, 2016 (published 2005).
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- Kolar P, Neuwirth J, Sanda J, Suchanek V, Svata Z, Volejnik J, Pivec M. Analysis of diaphragm movement during tidal breathing and its during activation while breath holding using MRI synchronized with Spirometry. Physiol Res 2009;58:383-92
- Kolar P, Sulc J, Kyncl M, Sanda J, Neuwirth J, Bokarius AV, Kriz J, Kobesova A. J Applied Physiol Aug 2010
To Tuck the Pelvis or Extend the Spine - That is the Question
Whether you are sitting in a chair all day long, lifting weights or pregnant, the position of your spine matters. In fact, in all three instances we want the same thing - a neutral spine. To tuck the pelvis or extend the spine - that is the question, but really, the answer is neither...we want a happy medium of both and here is why:
What is a neutral spine?
A neutral spine is when the position of the diaphragm is aligned with the pelvic floor. The spine is not flexed, extended, tilted or twisted.
Benefits of a neutral spine
The following is a list explaining why a neutral spine is beneficial:
- Maintains good posture
- Prevents or decreases muscular imbalances and strain on joints (3)
- Supports and protects the spine
- Improved lung capacity
- Increased strength and mobility (4)
- Maintains integrity of stabilizing complex (diaphragm, abdominal muscles, pelvic floor)
- Antagonistic trunk flexor‐extensor muscle coactivation was present around the neutral spine posture in healthy individuals. (1)
- Decreases risk of pregnancy-related pain, including sciatica and low back pain (3)
- Distributes load evenly through discs (3)
- Relieves pelvic floor dysfunction including urinary incontinence (3)
The Mechanics of Tucking the Pelvis vs. Lumbar Extension
Tilting the pelvis too far forward or tucking it too far backward can exaggerate or minimize the natural curve of the spine and cause pain, discomfort, or instability through the following mechanics:
Pelvic tucking is called a posterior pelvic tilt and is created when the pelvis rotates backwards (posteriorly). When this happens the coccyx (aka tailbone) moves down and forward. At the same time the pubic symphysis which is in the front of the pelvis moves forward and up towards the navel. By tucking, the lumbar spine actually moves into flexion and can pull the ribs down in a shearing motion that puts the abdominals almost into a crunch position by shortening the musculature. This movement also shortens the hamstrings while lengthening the quadriceps and back musculature. One reason people will tuck the spine is to activate the glutes, but this movement actually causes chronic tightening of the gluteal muscles and external hip rotators but this movement can pull the femur head back and externally rotate it causing widening of the pelvic floor and weakening the pelvic floor muscles.
Lumbar flexion creates an anterior pelvic tilt and is created when the pelvis rotates forward (anteriorly). When this happens, the lumbar spine (low back) goes into hyper lordosis and the hamstrings and abdominals are lengthened while the quadriceps and back musculature are shortened causing the psoas and spinal erectors to be hyperactive. This position can also elevate the ribs and create a concentric abdominal wall while creating an oblique position of the diaphragm and pelvic floor, causing pelvic floor instability and an inability to optimally use the diaphragm.
How do I get to neutral?
Here are a few tips to help you achieve a neutral spine:
- Toes/feet are pointed straight ahead or at a slightly outward direction (11 o’clock & 1 o’clock position) and feet are hip-width apart
- You should feel equal pressure on the three points of your foot (see diagram) creating a tripod
- Stacking is the key to stability: your head should be above your shoulders, your shoulders should be above your pelvis, your pelvis should be above your knees and your knees should be above your feet
- Make sure your diaphragm and pelvic floor are on top of each other
- Avoid “rib flare” by gently lowering your ribs down until the lower ribs move into the abdominal skin and musculature
- Don’t tilt the pelvis forwards or backwards: the pelvis should be neutral and not tilted forward or tucked. To do this, think of a cup, you don’t want the pelvis tilted forward or backwards causing water to drip out of the cup
- Make sure your chin isn’t jutted out and your head is squarely on your shoulders
- To do this you tuck the chin straight back while also elongating the neck
- Sure, you may feel like you have a double chin but we almost all do and that’s ok because it helps maintain that neutral, stacked spine
What does a neutral spine look like?
A neutral spine/ pelvis is when the ASIS (aka the hip bones) is in line with the pubic crest and the lumbar spine is balanced atop the sacrum, the rib cage will be lifted and supported by both the abdominal and back musculature and the pelvic floor and the diaphragm should be stacked upon one another.
To Tuck or Extend: Is it black-and-white?
Nope. First off, not everyone is created equal so there will naturally be some variance in what is best for each person. Constantly arching the spine is not healthy just as constantly tucking the spine is not healthy. The key is to systematically move the spine through its full range of motion with load. Therefore, we need to focus on a neutral spine for both weight-bearing and non-weight-bearing movements to help build strength and create a strong stabilizing system.
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- Panjabi, Manohar. (1993). The Stabilizing System of the Spine. Part II. Neutral Zone and Instability Hypothesis. Journal of spinal disorders. 5. 390-6; discussion 397. 10.1097/00002517-199212000-00002.
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