Benefits of Pilates with Pain Conditions

By: Amy Stein, PT, DPT & Denise Small, PT, DPT
deniseDenise Small, Physical Therapist and resident Pilates instructor spoke on the differences between Pilates’ practices, and what aspects are important for her patients with chronic pelvic pain. Denise is third generation instructor of Joseph Pilates’ technique. She has also taken supplemental training courses with Eric Frankel and Thomas Myers, both well-known body workers and movement therapy practitioners.

Denise explores movement patterns in her patients that may have caused pain in the past, and are now labeled as something to fear. Patients try to avoid these movements; however, they are necessary for healthy functional mobility. Denise uses the Pilates method to explore these movements, and to make them pain free and more familiar. Denise is guided by Pilates’ 8 movements principles, which are the staples of Joseph Pilates’ methodology.

They are:

1. Whole Body movement- all structures are involved, even if they are not moving.

2. Breathing- Pilates refers to this as an internal shower, or a massage for your internal organs. This also helps coordinate your movement, using breath as your internal rhythm.

3. Balanced muscle development: concentric and eccentric movements happen in synchronicity with the use of the Pilates’ springs.

4. Concentration and focus: Required for all of the above to be performed together

5. Control- Pilates is not about repetitions and muscle bulk. Pilates is about Form and coordination of all the movement principles. If all of the movement principles are being incorporated, one needs only to perform 8-10 repetitions of each exercise for maximum benefit.

6. Centering- Pilates heals the mind and body, by bringing your attention to your core. That is: the abdominal wall, the diaphragm, the pelvic floor, and the deep spinal extensors.

7. Precision- If the movement is specific, there is very little room for error

In addition to being guided by the movement principles, Denise has a few staples of her own, that she uses to frame her sessions. First, Denise believes that you need to have tissue mobility before stability. For example, one needs to be able to move their abdominal muscles before they can begin strengthening their abdominal muscles. If a patient’s abdominal wall is hard, then it is not necessarily strong. A strong abdomen is a part of a strong core. A strong core requires fluid coordination of the diaphragm, pelvic floor, the spinal extensors, and the abdominal wall with movement. This lack of coordination may be observed when a patient is performing an abdominal strengthening exercise. Does the patient hold their breath? Are they tucking in the tailbone and gripping their pelvic floor muscles? Does their abdomen bulge? Many of these compensations can be avoided with the use of breath while performing more subtle core exercises, like marching, before progressing to more advanced exercises.

Second, Denise always highly recommends rolling out your patient’s feet before doing any mat or reformer work. Studies have shown that the fascia of your feet is directly connected to the fascia of your core, pelvis, and spine. So, if you release your plantar fascia, you can release restrictions all the way through your legs and torso. Once the muscles and fascia of your feet are more pliable one can better align their skeleton, from the domes of their feet to the roof of their mouth.

Lastly, Denise likes to use as few cues as possible to not confuse or overwhelm the patient. In addition, her cues are oriented around the bones. Bones are easier for patients to visualize, and focusing on the bones alleviates the possibility of dysfunctional muscle recruitment; i.e. gripping. For example, for pelvic floor muscle tightness and pain conditions, Denise cues widening the sits bones with squatting and inhalation. The patient/client needs to work on letting go of the muscles and the sits bones, while we work on eccentric control. To learn more about Denise, visit her bio and our Pilates program .  Also see her recently published health tip to get started.

Prevention: Diastasis Recti, Part II

By Stephanie Stamas

So now that you’ve learned how a Diastasis Recti (DR) can be created during pregnancy, how can you prevent it from happening to you? There is currently a lot of available information on the positive benefits of aerobic exercise for the pregnant mother and the fetus, but little research focuses on the effects of exercises on abdominal muscle strength, function during pregnancy and exercises to prevent linea alba separation. While studying at Columbia University I had the privilege of conducting research with Dr. Cynthia Chiarello, who is a pioneer in examining the relationship between diastasis recti, exercise, function and prevention. A research article published by Dr. Chiarello, “The Effects of an Exercise Program on Diastasis Recti Abdominis on Pregnant Women” found a significant difference in the presence of a DR between women involved in an abdominal exercise program (12.5%) versus non-exercising women (90%)1. This conflicted with results reported in an article by Gillard & Brown that found no difference between the exercising and non-exercising groups2. Dr. Chiarello argues that the key difference between the two prescribed exercises protocols was the purposeful activation of the transversus abdominis (TA), a deep abdominal muscle that acts as the body’s natural corset (the circumference of the Coke can discussed in part I), and promotes continued linea alba approximation throughout pregnancy.

Activation of the TA is implicated in the prevention and resolution of a DR for several reasons. First, contraction of the TA acts like an internal splint, helping to stabilize your core and decrease the width of the linea alba from the inside out.  Secondly, because the linea alba is made of two fascial layers (deep & superficial), targeted strengthening for separation prevention of both layers is required. Typical abdominal exercises – crunches, curls, etc – target the rectus abdominis and oblique muscles which only strengthens the superficial fascial layer. The deep fascial layer and inner abdominal wall, which is mainly formed by the TA, is not addressed with these exercises and is under the most tensile stress with a growing uterus. The inclusion of rectus abdominis and oblique exercises should only be introduced once the TA has become adequately strengthened. In summary, strengthening the TA first should be the foundation of any pre-natal or post-natal exercise program (also, an added bonus – the TA aids in the pushing phase of labor!).

To help you begin strengthening your TA, I have created a two-phase abdominal exercise program. The first phase focuses on isolated TA activation (week 1-2) and the second phase begins to add dynamic activities on top of TA stabilization exercises (week 2-6). Click on the links below and then enter the corresponding codes to gain access to the exercise programs.

Phase 1TA activationCODE: W9KNTZK

Phase 2TA activation with dynamic activitiesCODE: HDQ7JN2

Adaptions for Pregnant Mothers
For those in their second trimester – It is recommended that you don’t lie onto your back more than 5 minutes at a time as there is a (low) chance of decreased blood flow to the uterus. So either do the exercises with your back elevated on a wedge, in modified squat position against a wall or take breaks lying on your back by switching to another exercise in a different position. If you notice that you are starting to develop a diastasis recti, be sure to splint your rectus abdominals during all exercises – cross your arms around your waist as if you were hugging yourself and pull the muscles towards midline in sync with the TA contractions.

Adaption for post-natal mothers with DR
Start with the phase I exercises all supine (lying on your back), making sure to splint your abdominals with either the sheet wrapped around your abdomen (See Part I), using your hands to manually bring the edges of the muscle bellies together or while wearing an abdominal binder. These are by no means the only exercises out there, but are foundational stepping stones required to return to crunches, planks, bicycles, etc diastasis-free and pain-free!

I’ve had great feedback from Part 1 and a lot of excited expectation for this post on prevention. I knew a lot of my friends would benefit from this series, but I couldn’t not have imagined how hungry people were for this information. I have received some excellent questions that I was not able to address in these two posts, therefore you can now look forward to Part 3! I will be answering questions that I have received and have not been able to address. Feel free to reach out to me if also you have any questions: stephanie@beyondbasicspt.com

*While abdominal exercises are generally safe during normal pregnancies, it is important to observe the ACOG precautions for exercise & consult with your physician prior to starting a new exercise program.

References
Gilleard WL, Brown J Mark M. Structure and function of the abdominal muscles in primigravid subjects during pregnancy and the immediate post-birth period. Phys Ther. 1996; 76(7):750-762

Chiarello CM, et al. The Effects of an Exercise Program on Diastasis Recti Abdominis on Pregnant Women. J Women Health Phy Ther. 2005; 29(1):19-24

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

By Stephanie Stamas

Is it just me, or does it seem like everyone is having a baby this summer? My Facebook feed is filled with pregnant belly time lapses and newborn pictures. I’m at the age where a lot of my friends are starting families and knowing that I am a pelvic floor therapist, I have been getting a lot of phone calls. One of the top questions that I have been asked is – I’ve had my baby, so why do I still look pregnant?

Here is the scoop – When you are pregnant, your abdominal muscles expand in length by the addition of more muscle fibers (sarcomeres) to accommodate your growing belly. After birth, it typically takes 6-8 weeks for the muscles to re-organize and shrink in length to a size that best supports your abdominal contents. This is how the body is designed to adjust to the changing abdominal circumference. Some women, however, grow very quickly and the muscles are not able to expand quick enough. When this occurs, the linea alba (the vertical line of the much-desired six-pack) stretches and the abdominal muscles move away from the midline. This is a more common occurrence in women with more than one pregnancy, multiples (twins, triplets, etc) or a non-exercising lifestyle prior to pregnancy. The stretched linea alba does not typically return to its previous length in a 6-8 week time frame and can allow the abdominal contents (your organs) to bulge through the thin tendonous structure, leading to the look of being pregnant.

Having a diastasis recti may not only result in the mother continuing to look pregnant, but it can also lead to low back pain, pelvic pain, constipation and pelvic organ prolapse. I like to compare the core to a closed canister (you can think of a Coke can) – The diaphragm is on top, the pelvic floor muscles are the bottom and the abdominal musculature – specifically the transversus abdominus and multifidi – are the circumference of the can. These muscles create a tight-knit closed environment that allow for proper support of the viscera (organs), stabilization of the spine with functional activities, and normal function of the bowel, bladder and sexual systems. Having a diastasis recti is similar to having a split along the side of the coke can, and therefore can compromise all systems that rely on that closed environment.

Great, so I think I have a diastasis recti – now what do I do?
Most separations can return to normal with progressive exercises. First off – stop all crunches and abdominal exercises you are doing.  If you have a separation, doing crunches will actually contribute to the muscles being pulled away from the midline and worsen the diastasis. We need to promote approximation, not separation. Some women benefit from wearing an abdominal binder to counteract distraction forces across the linea alba with physical activity. This is helpful for active mothers who are required to use their abdominal muscles, specifically the rectus abdominus, throughout the day (lifting, carrying, etc). The abdominal binder often gives mothers immediate abdominal support, but should not take the place of strengthening. Below is a basic foundational exercise that will begin to allow the rectus abdominus muscle to return to midline.

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If the muscles are not coming together within 4-6 weeks of starting the exercises, see your local women’s health physical therapist (like us!). Sometimes abdominal scars, muscle tightness (especially internal & external oblique) and thoracolumbar fascia tightness can prevent the muscles coming together in the front because of adhesions elsewhere in the core. Also, if you are experiencing low back pain, pelvic pain or dysfunction with bowel, bladder or sexual function, then seeing a women’s health physical therapist is highly recommended.

Just found out you were pregnant or trying to get pregnant soon? Stay tuned for Part 2, where we will discuss preventative measures to prevent a diastasis recti!