The pregnant belly.
Ironically, for something that so many people ask to touch, the baby bump is something few personal trainers want to lay their hands on in the fitness studio. In fact, it is often relegated to a third world of outdated and inadequate core conditioning.
The other kicker here (yes, blatant pun intended) is: what is good for mama is in many cases good for the rest of us, too.
In this article, we will examine the importance of pre- and postnatal core conditioning, and how critical core-related training principles can benefit new mothers as well as the general population.
Who’s Paying Attention to Mom?
When I developed Core for the Sport of Motherhood™, it was in response to a gaping hole in the fitness market. Moms were performing very high demand activities – pregnancy, delivery and raising children – and then after receiving their postpartum clearance (or not), they turned to mass-market concepts such as “Ab-Blast” to try to regain their core conditioning. This presented a big problem because these programs did not account for the special issues of pregnancy and postpartum. Specifically, these programs did not consider this population’s unique need to maintain core integrity and mitigate the risk of excessive intra-abdominal pressure. And while it’s true that there have been postpartum-targeted core fitness classes in the marketplace for years, many have not comprehensively addressed the full demands on a mother’s core.
Where’s the Science?
Given that the only constant is change, adjusting fitness programming to address principles arising from new research is essential to achieving optimal results with our clients. Research on the core – largely designed around a rehab setting rather than a fitness program – has to be realistically interpreted based on what that research indicates about the type of work we do in fitness.
Fortunately we have the work of many to consider, including Raul Artal, James Clapp III, Janet Hulme, each of whom are known in part for their research of pregnant women. There is also much practical information on the female pelvis and its mechanics from Jill Schiff Boissonnault, Mary Jo Blaschak, Irene Dowd, Eric Franklin, Blandine Calais Germain, Michelle Kenway, Joanna Landreth-Smith, Elizabeth Noble, and Kathe Wallace. In addition, we have excellent research on related subjects including pelvic floor recruitment, continence, spinal stabilization and back pain, as well as smaller-scale research on postpartum diastasis recti reversal by Julie Tupler (2005) and anecdotal evidence from many practitioners working with this clientele.
Although good, relevant scientific findings do exist, it is important to bear in mind that there is still far less research on the core for the prenatal and postpartum population than there is for the general or low back pain populations. Imagine how many expectant mothers who fit the necessary criteria would volunteer for studies and have their medical professional’s approval to do so. Imagine how many mothers with a new baby at home have compatible postpartum conditions, the time and energy to devote to a study. It is easy to understand why these studies are scarce compared to other populations. As the body of research grows and its applicability to prenatal and postpartum fitness improves, however, our evolving protocols will be more substantiated.
Listen to Your Mother
The scarcity of research and history implementing the findings mean that for the time being, studies on other demographics as well as less formal studies and anecdotal experience with the prenatal/postpartum population play a larger role than usual in process of determining the appropriateness and effectiveness of a suggested protocol.
First we'll look at what we’ve learned about core conditioning for prenatal and postpartum women, then we'll draw connections to the value these best practices pose to other populations.
The Sport of Motherhood Endgame
As fitness professionals, our goal is to create varied programming for expectant mothers that address the many ways their cores need to function, and to strategize for core-related challenges that will present later in the pregnancy – including:
- postural endurance
- pressure on the abdominal fascia
- increased intrinsic load on the pelvic floor
- impact of the intrinsic load on continence during and (extrinsically) after the pregnancy
- stamina for delivery
And for postpartum clients, we need to consider:
- recovery post-pregnancy and delivery
- postural control and stability in the event of an extrinsic load being reached to, lifted or carried to or from beyond the base of support
- core control given a dynamic extrinsic load
Our programming choices can help prevent core performance issues from arising. (Caveat: we are not physical therapists and when practitioners do not know how to spot issues such as compromised tissue integrity or timing delay, or try to treat the client instead of refer them out, they place the mother at risk for significant injury.)
The Core Crossover
What surprised me as I developed my own program for moms was how many of the best practices for prenatal or postpartum core training are largely applicable to the rest of our personal training clientele. We’ve been doing many other populations a disservice by not incorporating many of these principles into our core programming.
For example, most of the core-related goals noted earlier are relevant to other populations we train every day. Besides the obvious common need for postural endurance, consider the effects excess weight in the form of pressure places on the abdominal and pelvic floor fascia.
- the challenge spinal stabilization presents for our clients
- the vulnerability our older and/or obese clients have to low back pain, umbilical hernias and incontinence
- the items or children we maneuver in positions and ranges of motion where the load is outside of our base of support (i.e. pulling luggage off a baggage carousel)
- the times we handle a dynamic load under those same conditions (i.e. using a pet carrier with pet inside or a bucket of water or placing a child in a car seat)
The cross-relevance between the populations is pervasive.
What Mom is Teaching Us
Let’s look at specific core-related issues for mothers and how they also apply to other populations.
The Importance of Abdominal Fascia Integrity
The biggest core-related risk that mothers face is compromised core integrity. This includes tissue integrity (quality and structure) as well as functional integrity (recruitment and release capability).
The risk of compromising the integrity of the linea alba – the fascial tissue connecting the right and left sides of rectus abdominis – by overwidening and possibly even tearing it completely is well known. The widening or tear can occur anywhere along the linea alba, but the umbilical area is the most vulnerable. Widening of this fascia indicates susceptibility to tearing and evidence of tearing indicates a hernia. In fact, when non-pregnant individuals have this same condition near their umbilicus, it is referred to as an umbilical hernia.
A study by Columbia University in consultation with Julie Tupler, RN, found that exercise dramatically reduces the incidence of diastasis recti abdominis (DRA). In the study of pregnant exercisers and non-exercisers, ninety percent of non‐exercising pregnant women exhibited DRA while only 12.5% of exercising women had the condition (Chiarello, Falzone, McCaslin, Patel & Ulery, 2005). Anyone with a weakened abdominal wall is at greater risk and that risk is increased by outwardly direct abdominal pressure too great for the abdominal wall to bear. Moms with multiple pregnancies and obese individuals are at even greater risk, given the distension of their abdomen (similar the effects of a pregnant belly) (Mayo Clinic Online, n.d.).
Acing the Diastasis Test
Fitness professionals who are trained in prenatal/postpartum protocols know how to conduct a diastasis check. However, most health and fitness professionals do not regularly monitor the width and integrity of their clients’ linea alba and will only know to do this if they pursue the proper training. Professionals trained in the procedure can perform the check for all their clients and gain useful insight into their programming. For those without the training, fitness professionals can actually make the issue worse if they are unaware of a problem their client might have.
Regardless of what can be read in a book or seen in a YouTube video, it is important to take a class or learn the diastasis check protocols for prenatal and postpartum from an experienced fitness educator or healthcare professional. It’s also helpful to recognize the variances in technique. For example, some instructors teach to cue the client to come into a full crunch, whereas other teachers recommend the trunk flexion be done in a partial ROM, flexing only to the moment activation is palpable. These are similar tests but not the same, and the outcome is not at all the same to the practitioner. Additionally, some practitioners learn to palpate using more of an intermittent press-down (similar to a poke) while others remain in contact with the linea alba throughout the palpation.
What to Do When You Find a Loss of Abdominal Fascia Integrity
The most essential ingredient I’ve found in core training for the prenatal and postpartum population is the integration of imagery. That’s probably not the answer most would expect, but I can attest it has been most effective.
I coach mothers to hold the image of bringing the two vertical halves (right and left sides) of the abdominal wall toward each other. One of the most valuable cues I’ve given for this is, “Close your coat.” From a programming perspective, I select exercises that will help mothers make this correlation in their mind, but carefully, so as not to impose forces against the linea alba that the client can’t overcome. These choices are based on each mother’s ability, stage of pregnancy, value and appropriateness of the exercise for her life. The process for choosing and using these exercises and the demand from other practitioners led to my developing Core for the Sport of Motherhood™.
In the case of expectant mothers, who will undoubtedly be facing increased tension on the linea alba, it is important to program with the goal of performing movement and stability functions without increasing torque or outward intra-abdominal pressure directed against the linea alba. (For an example of increasing intra-abdominal pressure, see the photo to the right.)
The risk of injury through excessive intra-abdominal pressure becomes more and more relevant as a woman's pregnancy progresses, as does taking the impending delivery into consideration and maintaining her ability to engage her abdominal wall (Boissonnault & Blaschak, 1987). It is also why full ROM crunches in the advanced stages of pregnancy are likely to do more harm than good. The current research points to the intra-abdominal pressure caused during inhalation to stabilize the spine actually being less beneficial than bracing (Akuthota et al., 2008;Grenier & McGill, 2007; Vera-Garcia et al., 2006). The intra-abdominal pressure caused during bracing can be helpful in control and management of loads or forces acting on the trunk. (This has not shown true for hollowing, which is not effective for creating substantial pressure or managing higher forces in the trunk) (Grenier & McGill, 2007; Vera-Garcia et al., 2006).
The Importance of Pelvic Floor Integrity
All one has to do is take a look at daytime television advertisements to know that incontinence sells. It may not be sexy, but it is prevalent. Incontinence is one manifestation of compromised pelvic floor function. Mothers, both pregnant and postpartum, clearly do not have the monopoly on incontinence.
And if the lure of not leaking urine were not enough, we have many more incentives to condition our pelvic floor. These muscles provide essential support for the many organs of the region. These include the bladder, intestines, and rectum, all of which are not exclusive to females. Organ prolapse can happen to anyone with significant, sustained stress placed upon their pelvic floor, which means it can happen to heavy lifters with poor technique. This is evident, too, in clients struggling with eating disorder behaviors such as forced vomiting (Guerdjikova, O'Melia & McElroy, 2011).
Lastly, but undoubtedly to most not least, the pelvic floor plays a role in sexual function. Conditioning the pelvic floor has been connected with increasing sexual response.
Pelvic floor dysfunction can develop from lack of use or trauma (childbirth is included in this category). One of the best low intensity exercises for the pelvic floor is walking. People who sit all day with little change of pressure for their pelvic floor may find these muscles harder to recruit at first. People with S2-S4 dysfunction may have issues with their pudendal nerve and therefore issues with their pelvic floor (Benevuto & Sipski, 2002).
The Missing Piece is Letting Go
The use of imagery during recovery from pelvic floor exercises – emphasizing the relationship between the pelvic floor and abdominal wall – is essential. Imagery is a critical and often missing aspect in core conditioning. Core programming should reinforce the mother’s ability to relax her pelvic floor. This is NOT the same as bearing down, which is contraindicated. If all the pelvic floor conditioning expectant mothers ever do is perform multiple repetitions of actively contracting her pelvic floor or worse, try to hold it in contraction over long periods of time, they may not have the pliancy they need when it comes to delivery. It would be similar to trying to squeeze toothpaste out of a tube with the cap still on, even loosely.
When delivering a baby, a mother’s ability to allow her pelvic floor to do what it needs to do (rather than consciously performing the clamping together and upward movement of a traditional Kegel) can make delivery less stressful on her pelvic floor and potentially less traumatic to the tissue.
For non-mothers, the importance of conditioning release is the difference between cultivating tight, facilitated pelvic floor musculature or a pelvic floor with purposeful function.
Up in the Air…and How to Gauge
The science is not yet definitive on the big core questions for moms – such as whether intra-abdominal pressure has a threshold where it goes from helpful to harmful, and if the diastasis recti can improve with exercise and, if so, which exercises are best. So when it comes to exercise choice and intensity, we must use our judgment and rely heavily on the mother’s (and all of our clients’) feedback.
What’s Good for Mama Can be Good for Everyone
Everything that’s “pregnancy-proof” is also effective for the general population, as long as it is appropriate to the needs of the person in question. The general population just has other options that would be dangerous for pregnant mothers and postpartum clients who lack abdominal wall integrity. We all need our cores to function well at both low- and high-threshold levels and, while we may not be at the same risk as pregnant clients, we still need to maintain abdominal integrity.
The exercises we use for moms also work well for groups who may be at risk with some traditional core exercises. This includes clients who have difficulty stabilizing sufficiently when they are under load, clients who have had or have post-abdominal surgery, hernias in the abdominal region, narrowing of discs, pelvic girdle pain, as well as obese clients.
Basically, the goal is to condition the low-threshold (slow-twitch/endurance) and high-threshold (stability under greater forces and motion) functions of the core (Comerford & Bergelson, 2010). We have lots of variables to play with, including:
- Body position
- Position relative to gravity
- Action of the body
- Load (intrinsic or extrinsic)
- Movement of load (trajectory, speed, etc.)
- Base of support
- Stability of anchor points and surface
- Perturbation (magnitude, direction, etc.)
- Control (acceleration, deceleration, holds, etc.)
Conscientious trainers use these variables intelligently to program for EVERY client; it’s the client’s condition that makes the core training unique. These are the variables we use to apply for prenatal and postpartum clients, and they have the same value for the rest of our client base.
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