18.1, Moms, and Toes to Bar???

Hey Cross Fit moms, happy 18.1!  Here are some modifications and considerations you might find helpful for the first workout of the open.  If you are early postpartum, I would highly suggest focusing your training on core and pelvic stability and strength before progressing to weighted dynamic movements, impact, or high rep/fast cycling style workouts.  Spending more time early postpartum focusing on strength, stability, and form will likely get you back in the game faster with less risk for set backs.  The Toes to Bar are the main culprit in this workout for mamas.  If they pose more of a risk, consider whether 18.1 unmodified is worth the setback.  With that, here are some modifications!

Advertisements

Mom needs her Transverse Abdominus

I’ve mentioned the Transverse Abdominis in some of my other posts, but I want to emphasize how important this muscle is to the abdomen, especially for postpartum women and still more important for postpartum women with Diastasis Recti.  The Transverse abdominis or TrA from now on, gets little love and attention from the fitness industry. Most folks want to work the outer, more visible 6 pack abs and obliques and rarely end up working the muscles of the “deep core” –the TrA.  Not working the TrA is especially problematic for women with Diastasis Recti who essentially have a malfunctioning layer of outer muscle because the linea alba is too stretched to anchor the muscles in place so they can do their job as designed.

To understand why the TrA is so stinking important, we’re going to have an anatomy lesson.

First, a piece of vocabulary: Fascia.  For our purposes, fascia is the tissue that connects muscles to other muscles or muscles to bone.  It is not muscular tissue.

Here is the TrA.  It is the deepest abdominal layer closest to your guts.  As you can see, it’s like a corset attaching your ribs to your pelvic bones in the front and all the way around

back.  It’s a stabilizer muscle meant to keep you upright.  Notice the muscular tissue does not extend all the way to your midline.  Instead, the muscle becomes fascia across the midline.

The next layer on the outside of your TrA is shared by the rectus abdominis musclesabdominal-muscles-diagram (6 pack) along the midline and the internal obliques further away from your midline.  It is important you know that these muscles are connected together in the same layer with facia, so remember it for later. This layer is the most problematic one for those with Diastasis Recti.  The problem lies in the linea alba, the fascia that connects the left and right recti sides in the middle.  The linea alba is too stretched out to hold the recti close together.   What’s more frustrating, tissues of the rectus abdominus run up and down–not side to side.  So no amount of working these muscles will pull them back together toward your midline.

The outermost layer is the external obliques.  They attach across the middle, again, with fascia.

Here’s where the anatomy gets a little complicated.  Somewhere just below your belly button there’s this area called the arcuate line where these 3 layers of fascia holding these muscles together switch their arrangement.  And it matters if you have Diastasis Recti, so stay with me.

Below the arcuate line, notice that the fascia (or sheath) that holds the sides of the deep TrA together connects over/outside the rectus abdominis?  This means, if you contract the TrA, it physically hugs the rectus abdominis together and in.  This is fantastically helpful for the rectus abdominis and the stretched linea alba.  Here it is quite literally a natural corset that squeezes your recti into you.  Yay!acurate line color

Above the arcuate line, notice that the fascia of the TrA no longer goes directly over/outside the rectus abdominis anymore.  Instead, its fascia connects underneath the rectus abdominis.  So the TrA and its fascia can no longer physically hug these muscles in.  However, contracting the TrA still holds back all the contents of the guts behind it, relieving that next layer of rectus abdominis and injured linea alba of some of the work its not currently capable of doing.

So remember that the internal obliques share fascia in the same layer as the rectus abdominis?   Take a look at the cross section above the arcurate line.  This is how most of your abdomen is organized.  See how the fascia of the internal obliques wrap around the rectus abdominis?  If you contract the internal obliques heavily or if you work them to the point that their resting tension is super tight, it actually pulls the left and right recti apart, which will further widen the damaged linea alba that we want to come back together.  The recti can’t fight this tension because they don’t have fibers that run left and right–only up and down.  So they can’t contract and pull against this tension.  Does this mean you shouldn’t ever work these muscles?  No.  That’s impossible.  You need to use these muscles, but you shouldn’t be focused on them in your exercise routine or you will likely make your Diastasis worse.  (This is why most people with Diastasis Recti are told to avoid sit ups, crunches, V-ups, Russian Twists, etc.)   Also, if you are doing any kind of abdominal work whether in daily activities or working out, the focus should be on engaging your TrA.

So the take away message here:  It is absolutely vital for the health of your abdomen to engage your TrA while doing abdominal activities. I hope you can quite literally see why now.

Ok, so it’s important.  Now what?

Focus on strengthening your TrA for the activities that you want to participate in.  If you’re reading this blog, I hope you’ve already taken my advice to go see a women’s health physical therapist (and if you are any sort of athlete who wants to pursue athletics, preferably you’ll see a therapist who has experience with athletes).  So I’m assuming you’ve done some rehabilitative exercises under the care of a physical therapist.  After doing quite possibly a trillion heel slides, marches, and toe taps lying on my back over the course of a year, my core was much stronger, but I was crazy bored and on a plateau of strength gains.  I was sick of doing an hour of rehab work then having to do my workout later because there was no full body challenge or real energy system challenge.  Let me be clear, rehab exercises are vital and make a huge difference.  I was just ready for more.  I needed to see how my rehab was directly linked to the physical activities I want to pursue.  The blow-before-you-go method helped me make rehab super applicable to my favorite movements.  Here’s a video I’ve already done to demonstrate how to engage the TrA before movement.

This blow-before-you-go method should be used before any movement if you want to locate and strengthen your TrA, even picking up baby, hauling in groceries, or getting something heavy off a high shelf.  There are some movements, however, that engage the TrA more than others.  These movements aren’t typically considered abdominal focused, but can really emphasize the TrA a workout when you focus on engaging it.  Learning to engage and strengthen the TrA might slow you down at first, but will likely lead to future strength gains in a variety of movements.  Some of my favorite movements to engage and strengthen the TrA are deadlift, sled pushes, uphill sled pushes, bench press, single arm (alternate your arms!) farmer’s carry, breaststroke in the pool, and ski erg or skiing-fashion pull downs from a cable machine.  The video below shows my current focus on strengthening the TrA enough to do a pull up safely.

And if you just want to focus on TrA strength with some supplemental movements (that are not heel slides or marches), here are 2 of the exercises I do on the regular now.

  1. Bridge plus double clam shell.I got this from Ashley at www.getmomstrong.com.  It ends up getting the TrA, hips, pelvic floor, and more.  Lay on your back with your feet elevated (start at lower elevation to make easier).  Exhale while pulling belly button to spine and pulling your pelvic floor muscles up and in.  Then start your bridge.  When you reach full height, push knees out.  As the knees go out, try to maintain the intensity of your pelvic floor contraction.  Knees go back together, lower yourself down.  Rest.  Do your reps slowly–there’s much to focus on in just one rep.  I started without a band and since have graduated to one of the lighter circular bands in my set.  If you notice the linea alba bulging, your TrA is probably not ready for this one.  Work on bridges from the ground and clam shells separately.

    2. TrA balance.  20170513_125001It doesn’t look like much, but it is.  Anchor a band on something and then back up.  The tighter the band becomes, the harder this is.  Engage the TrA.  Hold on to the band keeping a 90 degree angle at the elbow and keep elbows tightly at your sides Heels come off the ground as you shift your weight toward the balls of your feet.  Think about hovering your chest over the balls of your feet.  Do not hinge at the waist, but notice the bum does stick out a little bit.  Now hover in this position and focus on making your TrA keep you upright.  My glutes, quads, and hamstrings often want to take over the stabilizing work, so I have to purposefully relax them to force the TrA to do the  majority of the work.

    One of the most helpful tools for TrA engagement is a mirror.  Complete these movements in front of a mirror, especially when starting the blow-before-you-go method.  Sometimes it’s hard to tell from feel if the TrA is fully engaged, but I can always tell when I see my abdomen.  If your gym doesn’t have mirrors, go buy a cheap full-length mirror, store it in the restroom, and use it during workouts.

Alright, now go make your TrA totally B.A.

Pull up progression for Diastasis Recti

After seeing Diana Fasset at Success Physical Therapy, I was directed to Ashley’s resources at www.getmomstrong.com.  One post that caught my eye was about pull ups.  I often feel bored and frustrated with my movement restrictions, so I was very interested in working toward getting my pull ups back safely.  I also suspect that there are some postpartum ladies out there who need to ensure that they are doing pull ups in a way that is safe for their abdomen.  Knowing that Ashley struggled with Diastasis Recti after her twins, I was excited to see what she had to teach with our physical therapist.  Check out the video.

After receiving some supervised practice from Diana, I was given the ok to start this progression, and I thought it might be helpful to see what it looks like a beginner with a noticeable gap tries this safely.  So here I am.

The safest way to do this is under the supervision of a physical therapist.  My body doesn’t look or operate exactly like yours.  And to reiterate, if your ribs flare, your back arches, or your linea alba bulges, stop!  You can injure your linea alba further.  I like to work with a mirror in front of me almost always to ensure what I’m doing is not provoking a bulge.  Sometimes it’s hard to be aware of the bulge, especially if you’re not familiar with what your abdomen should look and feel like when safely engaged.   Go get a mirror or train a gym buddy to check you properly during movements.

So while my Transversus abdominus tries to catch up with the strength of the rest of my body, one thing I don’t want to loose is Latissimus dorsi strength.  One of the exercises I use to engage my TA and Lats are pull downs using a band.  Hopping on a SkiErg or cable machine would give about the same stimulation.  This is also a great exercise to practice the blow-before-you-go method.  If you missed that post, it’s right here.

I’ve also done a lot of freestyle in the pool with a buoy between my legs (often available at pools).  I don’t kick during laps to put all the work of propulsion on my upper body.  It’s quite a Lat blaster.  Be careful to keep your TA engaged (especially as you exhale under water) and prevent your back from arching.

I like these 2 exercises because unlike ring rows, they involve an overhead (or nearly overhead) pull without unhealthy stress to the abdominal wall. If I’m attempting a CrossFit workout that prescribes pull ups, I often sub a mixture of ring rows and pull downs to keep my Lats in the game until I get my pull up back.

Good luck mamas!

The Abdominal Pressure System

I was told once by a doctor that the symptoms I was experiencing from Diastasis Recti had nothing to do with my pelvic floor issues.  My abdomen and pelvic floor together were trying to contain my guts and failing.  How is that unrelated?  I have since found new doctors and physical therapists who have acknowledged and emphasized the entire abdomen as a pressure system.  The pelvic floor, abdominal wall, and diaphragm should all be working together to contain innards and maintain stability.  Here’s an introduction to the abdominal pressure system using a weird model I constructed using items around my house.

If you suspect that your pelvic floor and abdomen is not working in conjunction with your diaphragm when you breathe, go see a women’s health physical therapist who will be able to asses what your pelvic floor is doing when you breathe.  Until then, try laying on your side with a pillow under your head and knees comfortably bent.  Put one hand on your abdomen.  Take a deep breath as you relax your pelvic floor and allow your abdominal wall to expand out.  As you exhale, think about bringing the muscles surrounding your vagina and anus into a gentle squeeze as your abdominal wall retreats back toward you.  As you practice this breathing drill, it should become more natural and automatic.

Please check out these related videos for more information.

 

How to deal with diastasis recti

 

 

Before motherhood, I’d never heard of Diastasis Recti.  Knowing what I know now, I can look back at pictures of myself in my first trimester and recognize the separation.  I had a large belly and continued to work out with little restriction throughout most of my pregnancy.  I raised concerns with my doctors and midwife, and they said that everything was normal and that I could keep doing whatever physical activity I had been doing before pregnant.  After a rather terrifying labor, I was left with a prolapsed bladder and a belly that looked like it still contained a baby.  At 3 months postpartum, I still looked more pregnant than some full-term moms.  I went to the doctor and received reluctant help for my pelvic issues and a shrug/“you’re a new mom, be patient” in response to my concerns about my abdomen.  After some fights with a few doctors and research of my own, I wound up simply demanding a referral to see a physical therapist.  I’m currently 16 months postpartum, and a lot has improved since then, but I’m still trying to recover.  I’d love to share what I’ve learned.

 

First, let me define and explain Diastasis Recti, or from here on out, DR.  Between those elusive 6-pack muscles running in 2 vertical lines down your abdomen (aka rectus abdominus) is a structure called the linea alba.  This structure is not muscular.  Instead, it is made out of fascia that holds the 6 pack together and attaches to the pelvis and ribcage.  Sometimes the pressure of your abdominal cavity–in many cases caused by a baby or two–overwhelms the stretchiness of this poor structure; and after baby is out, it does not recoil back into position.  Because the linea alba is thinned and stretched out, it no longer holds the rectus abdominus together or internal organs back.  This is a big problem that contributes to back pain, incontinence, weakness, a general lack of control and protection, and a huge blow to self-confidence.  Some moms just need a little time and normal activity for the linea alba to snap back into position.  For others, it doesn’t happen on it’s own. No amount of crunches can fix this–it’s not muscle.  (If you’re doing crunches, stop!)

Before my pregnancy, I thought that because I was very athletic and active, that I would “bounce back” quickly. Others confirmed this, as if “bouncing back” is some sort of badge that only hard-working mamas attain.  F*ck “bouncing back” and all the pressure this idea poses for moms!  Athleticism and hard work are important factors in returning to whatever a normal or new normal state is, but it’s not the only thing at play when recovering from pregnancy.  Body frame size, hormones, birth weights, multiples, number of pregnancies, genetics, hypermobility are all at play.  Many of those factors are out of any mom’s control.  However, there is hope.  You can rehab your DR.  I’m not saying every woman will see her pre-pregnancy abdomen again, but you can get better.

1. Find a healthcare professional who can recognize, diagnose (the test isn’t complicated or invasive…in fact, you can do it yourself or get help from a friend https://www.youtube.com/watch?v=Y7l82ZXNhSE), and make treatment plan.  If you have a great Doctor, Midwife, or PA, they will probably refer you to see multiple other professionals.  Go and see them all.  It’s very helpful to know all of your options and also ensure that you don’t have multiple conditions to contend with (broken bones, hernia, torn tendons/muscles, unbalanced hormones, pelvic floor issues).  At the very least, you should see a surgeon (abdominoplasty discussed below) and–pretty pretty please–a physical therapist.  When diagnosing DR, most doctors and PTs will give you a measurement which will be the number of fingers that fit into “the gap”.  If this sounds wildly unscientific, you’re right.  If your doctor has fatso fingers or twig fingers, those numbers could be incredibly unhelpful in describing your condition accurately.  Also, various bodies function differently under various DR widths.  I know women with much wider DRs than mine who don’t struggle with half the symptoms I do.  So, please don’t let this number draw too many immediate conclusions for you because, scientifically, it just can’t.  If you have a healthcare provider who is dismissive, unsympathetic, or ignorant; find a new one.  You must be your own advocate.

2.Go see a physical therapist to make a plan to regain coordination, control, and strength.  Some states have direct access, meaning you don’t have to get a referral from a doctor to see a PT.  Find a women’s health or pelvic floor certified one if at all possible.  Ask around for recommendations.  Here’s a finder link http://www.womenshealthapta.org/pt-locator/  In my experience, a physical therapist was the first health professional with a sympathetic and science-driven mind who looked at the whole of me and spoke into the treatment of all my major injuries and related issues.  This is incredibly valuable.  I was focused on DR and pelvic issues, but would never have gotten treatment for my mangled and weak hips had I not seen her.  You might be wondering “Why do I need to go to a PT if there is a wealth of information on the internet, even physical therapy exercises?”  Here are some reasons: 1.There are some great resources on the internet; there is also a ton of crap.  If you pick the crap, you could make your condition worse. 2. I am an athlete, Cross Fit coach, and fairly knowledgeable about how to do exercises; and I had to be corrected multiple times while doing exercises.  If you don’t do exercises correctly, they may be ineffective or harmful.  3. You simply may not be ready for the cool exercise you found on the internet.  It might be safe for some moms but not you.  Internet resources can’t see your body or tailor a program to fit your needs.

3. Learn to breathe, stand, sit, and move in ways that protect your linea alba and coordinate your diaphragm and pelvic floor.  I hope this is an integral part of your physical therapy, but it might not be emphasized.  Regaining strength through a set of exercises for 20-60 minutes/day is great, but the way you stand, move, and breathe for the other 23ish hours has an incredibly significant impact on your recovery.  For a few folks, running through a series of typically assigned rehab exercises will be enough to rehab DR to a satisfying degree.  Others will gain stronger abdominal and supporting muscles, but the linea alba will refuse to bounce back.   Before I thought of the core as a pressure system, I never considered how much of an impact my breathing and posture had on my healing.  My first 9 months of physical therapy strengthened my abs and narrowed my waist, but my linea alba didn’t change enough for me to notice differences.  I hit a plateau.  Within a few weeks of correcting my posture and breathing habits, the gap between my rectus abdominus has slowly started to make some noticeable narrowing!   For example, I have learned that I stand with my pelvis shifting forward, tucking my bootie under, but this actually defers the work of support to my poor linea alba which is forced to compensate in its injured state.

Julie Wiebe, one of my physical therapists and a well-respected expert in the field of women’s health physical therapy, has amazing resources online to dig into.  Get started with these videos/articles.  Or if you have the time, just go see her!https://www.youtube.com/watch?v=cW9mwfy-6-I

https://www.youtube.com/watch?v=FYOuh2-Hqmk

http://www.juliewiebept.com/alignment/the-junkless-trunk-and-not-in-a-good-way/

https://www.youtube.com/watch?v=4-3FlJAMKxE

4. Lose some body fat (if you’re carrying extra).  Before I hurt your feelings or make you angry, let me clarify.  If a belly protrudes because of DR, the bulk of the protrusion in most cases is not fat but internal organs refusing to be contained by your weakened and thinned abdominal wall.  However, some folks carry around fat under their abdominal wall, which means the muscles and the linea alba have to fight to contain internal organs and extra fat in their already stretched state.  Give your abdominal wall less to contain while it heals.

Some folks carry subcutaneous fat (fat on top of muscle).  After my pregnancy, I was one of those people.  Getting rid of some of that fat did not directly help heal my DR, but once a lot of that fat was gone I could see with clarity what was happening to my muscles.  This helped direct my training, breathing, and posture.  And although it did not get rid of the entire belly protrusion, losing a few pounds of fat did reduce my overall midsection circumference–which helped with comfort and confidence.  I know this is really hard to do (especially if you’re breastfeeding), but there are nutritional coaches who can help you do this without going hungry.  I started tracking my macros, meaning I had a daily amount in grams of carbohydrates, protein, and lipids to eat. It was tedious at first, but easy once I got the hang of it.  I still got to eat some chocolate and pizza, and never went hungry.  I highly recommend this method and finding a coach to help you through it.  There are many other ways to eat healthier.  Find one!

As far as working out goes, please communicate with your physical therapist about what you’re ready for.  If you’re less experienced at planning and modifying workouts, I recommend trying to find a pilates instructor who is familiar with DR and pelvic floor issues.  Many of them are quite knowledgeable and can help you find some safe movements.  If you want to go back to running, speak with a physical therapist who has experience in this area.  Also, check out Julie Wiebe’s website.  She has many tips for runners.  If you are headed back into something like Cross Fit, I advise working with a physical therapist and also finding a female coach who knows how and why to modify movements and breathing for pregnant and postpartum women.  Ashley from the getmomstrong website listed below under resources also posts workouts that are safer for most moms.

Splints and abdominoplasty

Splints–very controversial in case your research has not yet revealed this.  In short, my experience with trying splinting on my own was short-lived and unsuccessful.  Because it was an artificial tightening of my abdomen, it overwhelmed my weak pelvic floor which made me pee my pants more.  Also, it did nothing for my abdominal muscles or linea alba.  As humans, our support systems are internal from the musculoskeletal system, not external.  Anything that trains your body to rely on external, artificial support likely does train your internal system to return to its job.  There are some individual, specific reasons to splint. Please only utilize splinting under the direction of a smart, problem-solving health care professional who is working alongside you, otherwise, you might just be out $50-200.  I could not find one splint that could show research revealing the positive impact on splinting alone in the healing of DR.  Some programs advise splinting along with rehab exercises.  Why not just train your body to do the work of movement without external help?  If your body can’t do a particular movement correctly without the splint, is it a good idea to do it?

Abdominoplasty–very expensive if you can’t get insurance to cover it.  Among the frustrating aspects of DR, are the ways that DR is defined.  Sometimes definitions and medical attention is driven by insurance companies and their willingness to reimburse for various therapies rather than medical science.  For example, under Tricare North (Health Net), I was required to sign a document that stated emphatically that DR is most definitely not a hernia, but rather a cosmetic issue.  Therefore, abdominoplasty would not be covered by insurance.  I met recently with an OBGYN under Tricare West (United Health Care) who informed me that my DR is a type of hernia, and he has successfully seen patients receive covered abdominoplasties as treatment.  What the hell?  Is it or isn’t it a hernia, doctors?  I decided against the abdominoplasty, but was floored by the general lack of consensus and scienciness of the medical community. I highly recommend going to see at least one plastic surgeon to discuss your situation.  When I first considered abdominoplasty, I was immediately dissuaded by my plastic surgeon and his description of the surgery, the risks involved, and the lack of research about the athletic capabilities of moms afterward.  I couldn’t find a woman in person or on the internet who could speak into what it looks like to participate in sports like triathlons or Cross Fit after an abdominoplasty.  And even if I could find a few folks with successful stories of continuing in athletics, that does not guarantee that my DR surgery and rehab will be the same or that I’d be able to find physical therapists and coaches with experience helping post-abdominoplasty moms return to high intensity sports without literally bursting at the seams.  My goals, however, may not be your goals.  If you have great insurance or a pile of cash, can find a brilliant plastic surgeon, and don’t care about running fast or lifting heavy stuff, then explore this option.

There is hope for your recovery.  I hope you have a few more tools to help you along the way.  I’m not yet where I want to be, but I’m so much better off diastasis3than I was a year ago.

Recommended resources.  (Nerd out ladies.  You may have to teach health care providers about DR.)

Julie Wiebe is the mother of women’s health physical therapy.  She has tons of free resources including a blog and videos.  She also has online courses for purchase.  Glean as much as you can. http://www.juliewiebept.com/

Tracy Sher, another women’s health physical therapist founded the site Pelvic Guru.  It focuses a lot on research-based mama rehab. https://pelvicguru.com/

Katy Bowman is a mom who had DR and also works in the field of biomechanics.  Although I disagree with some of her methods of healing and her theories about what causes DR, her description of the anatomy of DR and the abdomen as a pressure system is valuable in her book Diastasis Recti: The Whole Body Solution to Abdominal Weakness and Separation

If you are an athletic mama, check out these helpful blogs.

http://everyday-battles.com/ Articles are by an experienced strength and conditioning coach who struggled with DR

http://www.mamalionstrong.com/ Another athletic mama who struggled with postpartum rehab.

http://www.getmomstrong.com/ A health coach and her recovery after twins.  She posts workouts and dietary advice as well as mama recovery articles.