Separated Abdominals After Childbirth

Question:

My client is a mother of two children. Her abdominals have separated pretty far apart and need to be brought closer together. There is a back problem as the spine is in a straight position and causes problems when performing abdominal work. Are there any exercises I can use to overcome this problem?

Answer:

It sounds like you may have two separate issues to address. Before you do anything with this client, you may want to get full medical clearance to make sure your client is ready for exercise. Next, you need to identify the cause of the “straight spine.” Is the loss of curvature in the lumbar spine? Is it in the thoracic spine? Both? Does she have a posteriorly tilted pelvis? Are her hip flexors “lax?” Does she appear to have very tight hamstrings? When she stands, does it look like her hips sit forward (as though they are resting on the Y ligament, and she stands with her weight on the front of her feet)?

“Straight Spine” is a very general description, and you are going to need to know what the underling causes are so you can progress appropriately. If you are not familiar with pelvic repositioning, especially with someone with diastasis recti (separation of the rectus abdominis), I highly suggest you refer the client to a physical therapist who specializes in post partum reconditioning.

Regarding the abdominal separation, I am assuming that the separation is due to child birth. If so, you will want to find out how far she is postpartum. Depending on the extent of the stretch, it can take several months (seven to nine) to start to see the rectus abdominis returning to their original position. What happens during the latter stages of pregnancy is a twofold attack on the fascia attaching the rectus abdominis to the midline. Globally, the body is releasing hormones to decrease the elasticity of the body’s connective tissues as the uterus is applying a stretching pressure from within. This decrease in elasticity means less resistance to elongation, which results in easier elongation. This can also mean that the original homeostasis of the connective tissue length may actually lengthen. Structurally, connective tissue is stronger than muscle, but it also is more prone to plastic changes. It also means there is a potential for the fascia to tear away from the muscle, which can take several months to heal. Some women may experience enough structural damage to the connective tissue that they need surgical intervention to shorten and tighten the fascia, regardless of what happens with the rectus abdominis muscle fibers.

You can start by performing an abdominal separation test to quantify the separation and to help you track progress. Have your client lie on her back with her knees bent to approximately 90 degrees and her heels flat on the floor. Have her place her fingertips on the vertical midline of her belly just below the belly button. While relaxed, have her press into her abdominals. She can use her other hand to support her head as she performs a “crunching” motion (lifting her head and shoulders while moving her ribcage closer to her pelvis). It is important that she maintain a neutral neck and shoulder alignment and is not curling up into a fetal position. While holding the “crunch” position, have her palpate, feeling for the sides of her rectus abdominis. Measure in finger widths to quantify the amount of separation.

Once you know where you are starting, you can start outlining your game plan. Think about working from the inside out, focusing first on the inner unit (transversus abdominis, diaphragm, pelvic floor muscles, posterior fibers of the obliques, internus abdominis, multifidus and lumbar portions of the longissimus and iliocostalis) and foremost on the transversus abdominis to provide needed control and stability. Absolutely avoid exercises such sit ups, curl ups, rotational exercises, leg lifts or any other exercise that causes the rectus abdominis to bulge out during exertion, which may actually perpetuate the separation.

The following exercises from Paul Chek's Scientific Back Training and Scientific Core Conditioning programs are a great place to start.

Draw Ins

You should have her do approximately one to three sets of 10x10 second intervals on each side. As soon as technique waivers, stop the exercise and rest or desist. Have her assume a supine position on the floor with her knees bent and feet flat on the floor. She should draw her navel in toward her spine while maintaining a neutral spinal alignment. Have her hold the position for 10 seconds, relax and repeat. Once she masters this, she can move on to the next two drills.

Single Leg Lifts

You should have her do approximately one to three sets of 10x10 second intervals on each side. As soon as technique waivers, stop the exercise and rest or desist. Have her assume a supine position on the floor with her knees bent and feet flat on the floor. She should draw her navel in toward her spine while maintaining a neutral spinal alignment. Next have her lift one foot off of the ground approximately one inch and hold for 10 seconds. Lower the foot and repeat on the other side. It is important that she maintain her neutral spinal alignment and drawn in abdominal position throughout the duration of the exercises.

4-Point Transversus Abdominis Trainer

You should have her do approximately one to three sets of 10x10 second intervals. As soon as technique waivers, stop the exercise and rest or desist. Start on all fours with the hands directly under the shoulders and the knees directly under the hips. The spine should be in a neutral alignment and the scapula should be bedded correctly (avoid winging). Have her take a deep breath in expanding her belly to slightly towards the floor. As she exhales, she should draw her belly button in toward her spine and hold for 10 seconds. Once again, the spine should remain in a neutral/static position during the exercise.

Horse Stance

Once she masters the Single Leg Lifts and the 4-Point Transversus Abdominis Trainer, you can progress to the horse stance. You should have her do approximately one to three sets of 10x10 second intervals on each side. As soon as technique waivers, stop the exercise and rest or desist. Start on all fours with the hands directly under the shoulders with the elbows pointed back, the fingers forward and the knees directly under the hips. The spine should be in a neutral alignment and the scapula should be bedded correctly (avoid winging). You can place a dowel rod down the length of her back as a tool to help maintain correct posture (the dowel should remain horizontal.) While maintaining an approximate one inch gap between the lower back and the dowel, draw the belly button in toward the spine. As she holds this position, have her lift one hand and its contralateral knee about 1/16th-1/8th of an inch off of the ground. She should hold this position for 10 seconds before returning them to the ground and switching to the other hand and knee. Once again, it is important that she maintain a neutral spinal alignment and the dowel stays horizontal. Once the position can no longer be maintained, stop the exercise.

Once she can perform three sets of 10x10 seconds one each side, you can progress the exercise by lifting the arm and leg to the same horizontal plane and the body. The arm should approximate 45 degrees from the midline and the thumb should point toward the ceiling. The leg should be straight back as though driving the heel back through the wall. She should maintain a neutral spinal alignment and the dowel should stay horizontal. Once the position can no longer be maintained, stop the exercise.