Pilates with Kierstin! Slingshot Lunges on the Reformer

Just in time for your New Year’s Resolutions, here’s another awesome exercise from Kierstin Elliot, Pilates Teacher at Beyond Basics Physical Therapy!

Goal: Strengthen the glutes and balance 

Exercise: Slingshot Lunges on the Reformer

Set Up: Standing on the floor with right foot near foot bar and left foot against the shoulder rest. Keep left knee straight and tilt upper body forward creating one long diagonal line from head to back toes. Use one blue spring as resistance. Belly button and chin are tucked in with neck lengthened and shoulders rounded back.

Execution: Inhale to send pelvis back into lunge bending the front knee 90 degrees while reaching arms forward and keeping the pelvis level and squared off to the front. Keep shoulders away from ears. Exhale to straighten the front knee, lower arms to sides, and return to your starting position.

Focus: Be sure to keep proper alignment throughout the spine. Lumbar spine should be elongated and supported throughout the entire exercise. Maintain core connection by dropping bottom ribs towards the top of your hips bones. Hips should also be level and squared off to the front- make sure there’s no pelvic rotation during lunges.

Importance: One of the best exercises for strengthening your glutes! This exercise also enhances your ability to stabilize the pelvis and lower back while connecting to the core for improved balance.

Modifications: Limit the range of motion in standard position, or drop back knee to the carriage. Dropping the back knee may draw more focus to the quad, making the exercise feel more like a stretch, however, the focus should still be held on standing glute. For an added challenge, grab a set of 3 pound free weights for your arms for added core control.

Pilates Move of The Month with Kierstin! Lat Pull and Triceps

Kierstin Elliot

kierstinbbpt_sm

Goal: To IMPROVE Posture!

Exercise: Lat Pulls and Triceps

Set up: Lie facedown on the box with naval pulled up towards the spine, chin tucked in with neck lengthened (as if you are holding a tangerine under your chin), glutes engaged, and legs extended. Pull yourself to back bars of the reformer and hold onto the poles with both hands. Use one blue spring for resistance.

Execution: Inhale to lengthen elbows, exhale to bend elbows.

Focus: The main muscle group targeted here are the lats. Think about pulling down from the armpits while the elbows bend and extend. This action will help stabilize the shoulders, keeping them out of the ears. Also, focus on releasing the upper traps and lengthening the back of the neck. The more work we can get from underneath the shoulder blades, rather than above, the better!

Importance: Improves posture! Strong back extensors lead to better posture, especially in this day in age where phones and computers are constantly pulling our shoulders forward and weakening our backs. Incorporate a few lat pulls into your routine and feel taller almost instantly!

Modifications: To make it easier, drop tension to one yellow spring. To make it harder, place a squishy ball between ankles and add hamstring curls or pulses between lat pull sets!

Here I am, demonstrating the lat pull!

A Holiday Gift for You! BBPT is Offering Free Consults for People Living in the Greater NYC Area!

Group Serious 2

Any persistent pain or chronic back or pelvic pain can be tough. It is tough to have and often times it can be extremely isolating. Many of our patients have to go through a number of clinicians before they even get a diagnosis of pelvic floor dysfunction. If you are reading this blog, you probably have some questions about pelvic floor dysfunction and if physical therapy is right for you.

We are here to help. If you are living in the Greater New York Area and have some questions about orthopedic, sports or pelvic floor dysfunction and if physical therapy is right for you, I encourage you to call our office. For a limited period of time, we are offering free 15-minute phone consults with our licensed physical therapists to patients in the greater New York Area. For those of you living outside this area, a fee may apply to the consult but can be applied towards payment for a PT visit if you chose to visit us. Don’t miss this opportunity to learn more about your pelvic floor and what PT can do for you.

The Physical Therapists at Beyond Basics also treat orthopedic (sport and joint injuries), pediatric pelvic floor dysfunction and orthopedic injury, and much more. Give us a call to discuss how PT can help with any one of these issues!

All the best,

Beyond Basics Physical Therapy

212-354-2622 (42nd Street Location)

212-267-0240 (William Street Location)

PH101: Ladies Only Session

By: Fiona McMahon, DPT
Hey Ladies!!! In the next installment of our Pelvic Health 101 course, we are hosting a women’s only session to allow for a safe and non-threatening place to discuss many issues that can affect the health of your pelvic floor. This class one of Stephanie Stamas’s (the founder of PH101’s ) favorites and is definitely not to be missed. Hear more about it in her video below! Join us at 7pm on October 25th, 2018. Please register at pelvichealth101.eventbrite.com

 

 

Location

110 East 42nd Street, Suite 1504

New York, NY

10017

Pelvic Health 101 Fall 2018

Life After Giving Birth: Trying to Get Back to Competing After Pelvic Girdle Pain (PGP)

Note from Fiona McMahon PT, DPT

In this blog, our guest writer is talking about pelvic girdle pain (PGP), which can often get confused with pelvic floor dysfunction (PFD), although they are related, they are different conditions. For pelvic floor dysfunction, we often caution against just strengthening the pelvic floor. Often times the pelvic floor muscles are over tightened and tense and strengthening often can worsen the situation. Pelvic girdle pain refers to issues around the pelvic bones and sacrum. Both can occur during pregnancy but often require different treatment approaches. If you have pain, come see us at BBPT.

ball court design game
Photo by Pixabay on Pexels.com

 

Exclusively written for BeyondBasicsPTBlog.com

By: AvaFreya

Back in college, I used to be an avid tennis player and even had the chance of representing my school in intercollegiate tournaments. I would wake up at 5 am for three-hour training sessions all the while trying to balance my studies. But after college, the corporate life sucked me in, and I was lucky if I got to play for an hour every other week.

Then after childbirth, my life consisted of trying to raise a beautiful baby boy. I haven’t picked up my racket in months. It’s not because I don’t have time for things other than raising my child – I’ve been blessed with a husband who assumes his fair share of the responsibility. What’s holding me back is my physical state. The pelvic girdle pain (PGP) I experienced during pregnancy never really went away postpartum. In truth though, it is not uncommon. The American Physical Therapy Association notes that many women continue to have the symptoms of PGP after birth.

It’s a scary thought not to be able to do something you used to love so much. Compared to other stories I’ve heard, my case can be considered mild, but I had to seek help if I wanted to play again. Beyond Basics Physical Therapy led me to Pilates and I learned to channel my breathing in a way that it gently engages my pelvic floor [ remember this may be appropriate for PGP but not necessarily PFD]. It has been a great way to reintroduce strength to my core, considering that pregnancy has changed my body in more ways than one. When I get nostalgic and look at pictures from my glory days, I barely recognize myself. Where are the muscular legs, rock hard abs, and enviable arms? Not in this 34-year-old body of mine, that’s for sure. But I’m committed to gaining control over my body and getting back to the court.

But in the five months that I’ve been doing painstaking therapy, my sacroiliac joint feels a lot better, and I no longer feel stiff. During my recovery, Serena Williams was a great inspiration to me. For one, she’s a fantastic player, and Coral identified her as the highest paid female tennis player. More importantly, though, she’s a mom who never used her pregnancy as an excuse not to get a hold of her life. She probably even went through the same pain many other women, and I did. When I was bed-bound during my pregnancy, my idol was playing in the Australian Open while she was 8 weeks pregnant and even won the final.

Not all women’s bodies are the same or even experience pain similar to mine, but Williams continues to be my inspiration on and off the court. I have been playing tennis with my trainer—sometimes with my husband—and we sometimes play for as long as my stamina allows it. Torquing my hips doesn’t worry me anymore, in fear of a sudden crack of my bones anymore. On excellent days, I think that my backhand is even returning. Although I suspect that it will be a long time before I regain the level, I was playing at during college

Note from Fiona McMahon, PT, DPT at Beyond Basics Physical Therapy

We are so grateful to have AvaFreya share her experience of returning to tear up the court post baby! Everyone’s story evolves so differently with pregnancy and childbirth, which is what makes it both terrifying, exciting, and momentous, all the same time. The truth is some women bounce back on their own, (lucky duckies), others find it to be much more complicated. We recommend coming to visit a Pelvic Floor Physical Therapist during pregnancy and after you give birth to guide you to a program that is right for you. We often run into women, who with the very best of intentions, started down a path that actually made them worse! Often times we see this with women doing excessive Kegels when their pelvic floor is already too active secondary to weakness somewhere else in the body. Frankly, it’s a total bummer and delays getting back to the things you love. If you have recently had a baby or are currently preggers, you owe it to yourself to see a pelvic floor physical therapist who can advise you on exercises to do on your own or treat you more intensively if you need it. Your time and your health are way too precious.

 

For more reading on pregnancy and pregnancy-related conditions, please check out these blogs:

 

Stop Doing Kegels: Real Pelvic Floor Advice For Women (and Men)

Sacroiliac Joint Dysfunction

Lace up or Feet up? Running During Pregnancy

Why Do I Still Look Pregnant?!: Diastasis Recti, Part I

Why Do I Still Look Pregnant: Part II

Mind the Gap: Diastasis Recti Abdominis and What We Don’t Know: Part I

Mind the Gap Part II: Improving the Look and Function of the Mommy Tummy (Diastasis Recti)

 

 

 

We have offices in both midtown and downtown locations. If you recently have had a baby or are pregnant, please give us a call at

 

212-354-2622 (Midtown)

 

212-267-0240 (Downtown)

 

We are offering free phone consultations in both locations for a limited time!

 

 

Hypo-ed up? The use of Hypopressive Abdominal Exercise in Pelvic Floor Dysfunction

balloons

Joanna Hess, PT, DPT, PRC, WCS

I’m a recent transplant to NYC. For the last four years, I was living abroad and working at a interdisciplinary sports hospital. I loved learning about physiotherapy culture around the world. We each had different contributions – the Greek wheel, Scandinavian eccentrics, Australian pain science, and Spanish hypopressives. Hypopressive exercises were magic exercises that helped resolve low back pain, prolapse, incontinence, and diastasis recti abdominis. So of course, I wondered, “Are Americans missing the boat?”

What are hypopressive exercises? And how do they work?

Hypopressive abdominal exercises (HAE) were developed by Marciel Caufriez as a response to the obsession with “the core” and the corresponding exercises (primarily crunches) that would increase downward pressure. Hypopressive abdominal exercises use a pressure gradient between the thorax (the upper part of your trunk) and abdominal cavity to create a “vacuum” effect. By creating a vacuum that draws pressure upward, your body automatically recruits transverse abdominis (TrA) and pelvic floor muscles (PFM). Both the PFM and TrA are core muscles and are important in many functions. The HAE sequence begins with static positions and progresses to dynamic and difficult movements. The set up for the exercise is:

  1. Three breaths filling the ribs making sure the sides are expanding.
  2. Breathe in focused on expanding ribs out and lower ribs up while minimizing belly movement.
  3. Then, breathe out working on spinal elongation and keeping ribs up and out. Hold the exhale for creating the vacuum and relaxing the diaphragm. The belly button should start to move up.
  4. Close the throat as if you were at the end of a swallow to lift, expand, inflate rib cage further increasing the vacuum and pressure differential—like an inhale, but without taking in air.

In diaphragmatic breath, inhalation causes the diaphragm to descend which increases intra-abdominal pressure and a reflexive eccentric contraction of the pelvic floor and abdominal wall(an eccentric contraction occurs when the muscles lengthen). Exhalation is a passive return to the diaphragm’s resting position and if it is a complete exhalation, the PFM and TrA will also contribute some activity. For the hypopressive vacuum, inhalation relies on upper chest and neck muscles instead of the respiratory diaphragm and intercostals (rib muscles). The inhalation lifts the rib cage up and gives more volume. The exhalation activates the PFM and TrA to compress the abdomen which increases the pressure of the abdomen. The pressure difference between the diaphragm is augmented by the closed inspiration and creates the vacuum that creates this automatic response. With HAE, the abdominal cavity has the same increase in pressure, possibly more, than with diaphragmatic breath, but because of the suction upwards, it feels like a different pressure.

What’s the relationship between hypopressive exercises and core coordination?

As measured by surface electromyography (EMG) and dynamic ultrasound, HAE consistently have comparable or less activation of the pelvic floor muscle and transverse abdominis than isolated, well-cued exercises (1-4). However, to increase TrA contraction, HAE with pelvic floor muscle contraction recruits more fibers more than pelvic floor contraction alone (4). HAE biases activation of deeper stabilizers–transverse abdominis, internal obliques, and pelvic floor over the more superficial rectus abdominis and external obliques(6). No research has evaluated the HAE claims of decreased downward abdominal cavity pressure. While HAE are progressed with consideration for increasing challenge, they are not incorporated into everyday positions which has an impact on the body’s ability to integrate into a task.

So, will hypopressive exercises fix my problems?

The solution for downward pressure gone wrong is not forcing upward pressure, but addressing why the body lost its adaptability for life’s demands. I rarely use hypopressive abdominal exercises as treatment for problems of the pressure system–pelvic organ prolapse, stress incontinence, diastasis recti abdominis, lumbar disc herniations, and ventral hernias. Studies show that HAE do not have an advantage over conventional TrA and PFM exercises (8) in losing postpartum weight (9), improving pelvic organ prolapse symptoms (2,4,5), or correcting diastasis recti (10).

Besides being less effective than conventional exercises for strengthening and symptom relief, HAE exchange downward and outward pressure for upward pressure and compensatory muscle patterns. This could show up as gastroesophageal reflux disorder (GERD), hiatal hernias, hyperinflated lungs with increased sympathetic drive (and immediate lightheadedness), restricted diaphragm, forward neck posture, or thoracic outlet syndrome. The respiratory diaphragm has a mechanical advantage for respiration over upper chest and neck muscles which have other postural functions.

Escaping gravity is not yet sustainable which means, normal life—breathing, digestion, walking, and laughing—includes downward pressure. If the goal is to decrease pressure on the pelvic floor, lying down with hips elevated, headstand, downward dog, or inversion table—none of these translate into movements of everyday life, but they also do not alter the body’s normal respiration and stabilization patterns. “First do no harm.”

If someone is having difficulty isolating the PFM and TrA, I would connect with diaphragmatic breath, vary effort level, try different verbal and manual cues, and modify the relative position of the pelvis to the spine (7). After correcting the mechanical “pressure problem,” I would use HAE if an individual is still having great difficulty identifying the transverse abdominis and over-recruiting the rectus abdominis. But, I then would progress out of HAE to a isolated strengthening progression integrated into functional movements. HAE is also one of many tools that can help in decreasing acute low back pain associated with muscle spasm.

I nod at the centuries of wisdom of yoga that note benefit from hypopressive practices for posture, digestion, invigoration, and automatic recruitment of core stability. But let’s also remember the time-tried basics of a healthy movement-filled lifestyle. As more studies are published, I look forward to learning more about subgroups and larger functional goals for which HAE have benefit. For now, the magic bullet for pelvic floor dysfunction is not hypopressive abdominal exercises. Isolated pelvic floor and transverse abdominis activation may be old-school, but are well-researched with strong support and are overwhelmingly more beneficial than HAE at addressing symptom alleviation and muscle strengthening.

 

Thank you so much for reading our blog, if you think physical therapy can help you. Please give us a call at either our midtown location 212-354-2622 or our downtown location 212-267-0240. We are offering free phone consultations at both offices for a short period!

Joanna Hess is a treating therapist at our downtown location

Joanna Lee Hess

References

1. Brazalez BN, Lacomba MT, Mendez OS, Martin MA. The abdominal and pelvic floor muscular response during a hypopressive exercise: dynamic transabdominal ultrasound assessment. Br J Sports Med. 2018;52(Suppl 2):A22

2. Resende AP, Stüpp L, Bernardes BT, Oliveira E, Castro RA, Girão MJ, Sartori MG. Can hypopressive exercises provide additional benefits to pelvic floor muscle training in women with pelvic organ prolapse?. Neurourology and urodynamics. 2012 Jan;31(1):121-5.

3. Resende AP, Torelli L, Zanetti MR, Petricelli CD, Jármy-Di Bella ZI, Nakamura MU, Júnior EA, Moron AF, Girão MJ, Sartori MG. Can Abdominal Hypopressive Technique Change Levator Hiatus Area?: A 3-Dimensional Ultrasound Study. Ultrasound quarterly. 2016 Jun 1;32(2):175-9.

4. Stüpp L, Resende AP, Petricelli CD, Nakamura MU, Alexandre SM, Zanetti MR. Pelvic floor muscle and transversus abdominis activation in abdominal hypopressive technique through surface electromyography. Neurourology and urodynamics. 2011 Nov;30(8):1518-21.

5. Bernardes BT, Resende AP, Stüpp L, Oliveira E, Castro RA, Jármy di Bella ZI, Girão MJ, Sartori MG. Efficacy of pelvic floor muscle training and hypopressive exercises for treating pelvic organ prolapse in women: randomized controlled trial. Sao Paulo Medical Journal. 2012;130(1):5-9.

6. Ithamar L, de Moura Filho AG, Rodrigues MA, Cortez KC, Machado VG, de Paiva Lima CR, Moretti E, Lemos A. Abdominal and pelvic floor electromyographic analysis during abdominal hypopressive gymnastics. Journal of bodywork and movement therapies. 2018 Jan 1;22(1):159-65.

7. Sapsford R. Rehabilitation of pelvic floor muscles utilizing trunk stabilization. Manual therapy. 2004 Feb 1;9(1):3-12

8. Martín-Rodríguez S, Bø K. Is abdominal hypopressive technique effective in the prevention and treatment of pelvic floor dysfunction? Marketing or evidence from high-quality clinical trials?. Br J Sports Med. 2017 Sep 4:bjsports-2017.

9. Sanchez-Garcia JC, Rodriguez-Blanque R, Sanchez-Lopez AM, et al. Hypopressive abdominal physical activity and its includence on postpartum weight recovery: a randomized control trial. JONNPR. 2017; 2 (10): 473-483.

10. Gomez FR, Senin-Camargo FJ, Cancela-Cores A, et al. Effect of a hypopressive abdominal exercise program on the inter-rectus abdominis muscle distance in postpartum. Br J Sports Med 2018;52(Suppl 2):A21

Mind the Gap: Diastasis Recti Abdominis and What We Don’t Know: Part I

asphalt-communication-commuter-221310

Joanna Hess, PT, DPT, PRC, WCS

Summer holidays are approaching. You’re lounging at the beach and feeling quite proud of the ruffled swimsuit that guards the battle marks of the mom bod—the wrinkly and poochy belly. On the horizon, a woman in string bikini framing her flat tummy joins the four children sitting next to you. She must be their nanny, or maybe the children were adopted, or she probably had a surrogate. But after a short conversation, she reveals that in fact is the biological mother of these children and that she carried to full term. And when you awkwardly compliment her on the restoration of her college-era body, she nonchalantly shrugs and says, “Genetics? Maybe the coconut oil that we brought back from Bali?”

As the power of airbrushed social media images expand, the Cinderella stories of mummy tummy to model abs give hope to the many moms scrolling mindlessly on our phones passing the wee hours of childcare. These stories are powerful and inspiring, but do not reflect most of our situations, nor answer many elusive questions about diastasis recti abdominus.

What is Diastasis recti abdominis and why do we care?

Diastais recti abominis (DRA) is the excessive separation between the two sides of the rectus abdominis (the six pack muscle), which creates a pooching of the belly, particularly with difficult tasks. For this blog, the background information focuses on pregnancy related DRA while the application of the information can be used for any one with DRA. During the third trimester 100% of women have a DRA, defined as a separation >2 cm below the umbilicus (1). One answer to why we care about DRA is that we want our stomachs to look normal if not flat. The wrinkly skin stomach has not reached mass popularity on the runways. Another reason we care is because DRA has been assumed to predispose a long term sequelae of breakdown in the body. The cosmetic appearance associated with DRA improves as the inter-recti distance (IRD), the width between the bellies of the rectus abdominis, decreases.

As physical therapists, we screen for DRA in order to gain a larger understanding of how the body is working together. Many of us assume that the lack of stability in the front of the body will lead to compensations in other parts of the body—primarily the diaphragm, pelvic floor, and back. Dysfunction in these areas have been documented to be higher during pregnancy and the post-partum period (2). Physical therapists regularly address DRA when patients present with low back pain (LBP), pelvic floor dysfunction, pelvic pain, and urinary incontinence (3). A couple of studies looking at post-partum women seeking medical care for abdominal pain and pelvic floor dysfunction show a higher incidence of DRA in this populations (4,5). However, this is not to say that the DRA causes or predicts these conditions.

In recent prospective studies using ultrasound assessment, the assumption that DRA correlates to pelvic floor dysfunction and low back pain (LBP) is challenged. The findings suggest no relationship but even a possible protective mechanism of DRA during pregnancy, with no difference in LBP symptoms at one year postpartum regardless of DRA status. Of course, this is a statement of generalization to a study population and does not reflect the outliers, individual predispositions and presentation.

DRA During Pregnancy

No differences were found in pelvic floor function or in urinary incontinence between women regardless of DRA status, during or after pregnancy. Women presenting with DRA in their 2nd trimester were more likely to have higher vaginal resting pressures, strong pelvic floor muscles strength, and better endurance of pelvic floor muscles. The set of women with 2nd trimester DRA had lower BMI before pregnancy and during pregnancy with trend increased general physical activity (6)

DRA Post-Partum

Interestingly, women who at 6 weeks postpartum did not have a DRA were more likely to have a pelvic organ prolapse > Stage 2 (6). DRA status (none or mild) had no relationship with low back pain at 6 months (1) and 12 months postpartum (7). This corroborates another study showing no difference for DRA in women reporting LBP and that severity of DRA does not predict intensity of LBP when present (5). Heavy lifting >20x/week was shown to be a risk factor for postpartum DRA, but not age, pre-pregnancy BMI, 2nd trimester BMI, weight gain, caesarean or vaginal delivery, abdominal circumference at 35 weeks, hypermobility (p – 0.06), cardio and strength exercise, general abdominal and pelvic floor exercise (1). From the research available, we cannot predict from a group of postpartum women with DRA who will have symptoms that affect their daily living.

Looking a Little Deeper at Diastasis Recti Abdominis

As assumptions about DRA and its relationship to long term dysfunction start to shift, what is important to identify in a DRA presentation is also changing. The literature and clinical practice related to DRA mainly looks at the IRD, or the separation between the right and left muscle bellies of the rectus abdominis However, the focus on the widening of the linea alba may be less important than the ability of the linea alba to transfer forces and contribute to the stability of the abdominal muscles (8). A wide linea alba that holds tension and stabilizes the front of the abdomen with increased intra-abdominal pressures through functional task may be more desirable than a narrow linea alba with distortions that loses force and allows abdominal pressure to push forward through functional task. A pulled-apart and taut rubber band hold tension better than a relaxed and crumpled band. The width and depth of the linea alba need to be contextualized within the individual’s posture, daily movement, and functional core adaptability. The literature has yet to identify subgroups that would likely explain why some people have DRA that self-resolve and among those who don’t, why it impacts cosmetics and function in some people and not in others, why it seems to be a protective mechanism for some pelvic floor and low back conditions and exacerbating in others.

The linea alba is often connected to the rectus abdominis because of the focus of the IRD as a marker of DRA. However, the linea alba actually is the anatomical and functional intersection of all the abdominal muscles—the rectus abdominis, the internal and external obliques, and transverse abdominis, which is seen at a microscopic level with different angles of fibers in the linea alba. In a cadaver study looking at the collagen of the linea alba without DRA, previously pregnant women had thinner linea alba, but greater widths. Females who were previously pregnant had higher ratio transverse to oblique fibers—60% for females and 37.5% for males. The female cadaver that had never been pregnant had infraumbilical fibers more similar to males (9). The small size of this study limits its application, but perhaps an increase of transverse abdominis muscle activity in the lower abdominals is represented in the higher number fibers, and that this adapted activity resolved the DRA for these women.

Hormones may possibly play a role of the development of DRA for some women, but because DRA persist well after post-partum hormones return to normal. In men, hormones are unlikely to be the primary driving cause of persistent DRAs. Women who are breastfeeding do have a higher relationship with unresolved DRA until breastfeeding is concluded (5). However, no research has been conducted on this relationship and may add to another subgroup to explain the variance of women who spontaneously resolve and others who never resolved their DRAs.

 

Joanna is a treating therapist at our downtown location. Stay tuned for the next installment on this topic, Mind the Gap Part II: Diastasis Recti Abdominis: What we Can do About it.

To call and make an appointment with our expert PTs call:

212- 354- 2622 (Midtown)

212-267-0240 ( Downtown)

 

References:

1. da Mota PG, Pascoal AG, Carita AI, Bø K. Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Manual therapy. 2015 Feb 1; 20(1):200-5.

2. Lee DG, Lee LJ, McLaughlin L. Stability, continence and breathing: the role of fascia following pregnancy and delivery. Journal of bodywork and movement therapies. 2008 Oct 1; 12(4):333-48.

3. Keeler J, Albrecht M, Eberhardt L, Horn L, Donnelly C, Lowe D. Diastasis recti abdominis: a survey of women’s health specialists for current physical therapy clinical practice for postpartum women. Journal of Women’s Health Physical Therapy. 2012 Sep 1; 36

4. Spitznagle TM, Leong FC, Van Dillen LR. Prevalence of diastasis recti abdominis in a urogynecological patient population. International Urogynecology Journal. 2007 Mar 1; 18(3):321-8

5. Parker MA, Millar LA, Dugan SA. Diastasis Rectus Abdominis and Lumbo‐Pelvic Pain and Dysfunction‐Are They Related?. Journal of Women’s Health Physical Therapy. 2009 Jul 1; 33(2):15-22.

6. Bø K, Hilde G, Tennfjord MK, Sperstad JB, Engh ME. Pelvic floor muscle function, pelvic floor dysfunction and diastasis recti abdominis: Prospective cohort study. Neurourology and urodynamics. 2017 Mar 1; 36(3):716-21.

7. Sperstad JB, Tennfjord MK, Hilde G, Ellström-Engh M, Bø K. Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. Br J Sports Med. 2016 Jun 20:bjsports-2016.

8. Lee D, Hodges PW. Behavior of the linea alba during a curl-up task in diastasis rectus abdominis: an observational study. journal of orthopaedic & sports physical therapy. 2016 Jul; 46(7):580-9.

9. Axer H, Keyserlingk DG, Prescher A. Collagen fibers in linea alba and rectus sheaths: II. Variability and biomechanical aspects. Journal of Surgical Research. 2001 Apr 1; 96(2):239-45.

10. Liaw LJ, Hsu MJ, Liao CF, Liu MF, Hsu AT. The relationships between inter-recti distance measured by ultrasound imaging and abdominal muscle function in postpartum women: a 6-month follow-up study. journal of orthopaedic & sports physical therapy. 2011 July.

11. Coldron Y, Stokes MJ, Newham DJ, Cook K. Postpartum characteristics of rectus abdominis on ultrasound imaging. Manual therapy. 2008 Apr 1;13(2):112-21.

12. Boissonnault JS, Blaschak MJ. Incidence of diastasis recti abdominis during the childbearing year. Physical therapy. 1988; 68(7):1082-6

13. Chiarello CM, Falzone LA, McCaslin KE, Patel MN, Ulery KR. The effects of an exercise program on diastasis recti abdominis in pregnant women. Journal of Women’s Health Physical Therapy. 2005 Apr 1; 29(1):11-6.

14. Benjamin DR, Van de Water AT, Peiris CL. Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy. 2014 Mar 1; 100(1):1-8.

15. Pascoal AG, Dionisio S, Cordeiro F, Mota P. Inter-rectus distance in postpartum women can be reduced by isometric contraction of the abdominal muscles: a preliminary case–control study. Physiotherapy. 2014 Dec 1; 100(4):344-8.

16. Sancho MF, Pascoal AG, Mota P, Bø K. Abdominal exercises affect inter-rectus distance in postpartum women: a two-dimensional ultrasound study. Physiotherapy. 2015 Sep 1; 101(3):286-91.

17. Litos K. Progressive therapeutic exercise program for successful treatment of a postpartum woman with a severe diastasis recti abdominis. Journal of Women’s Health Physical Therapy. 2014; 38(2):58-73.

18. Gillard S, Ryan CG, Stokes M, Warner M, Dixon J. Effects of posture and anatomical location on inter-recti distance measured using ultrasound imaging in parous women. Musculoskeletal Science and Practice. 2018 Apr 1; 34:1-7.

19. Kirk B, Elliott-Burke T. The Effect of Visceral Manipulation on Diastasis Recti Abdominis (DRA): A Case Series.