Building ab strength for every female client

By assessing core control and prescribing exercise accordingly, we can minimise injury and maximise performance for every female client, from postnatal to postmenopausal, says Dianne Edmonds.

Women returning to fitness post-pregnancy and childbirth, whether that be at six weeks, six months or six years, can present to you with physical changes that need specific attention when programming. These can include a lengthened abdominal wall, an excessive abdominal muscle diastasis (gap between the two sides of the rectus abdominis) and/or a potentially compromised pelvic floor.

Personal trainers need to consider these issues when prescribing abdominal exercises for female clients, and to assess the level of core control and match it with appropriate levels of exercise. This will assist in minimising injury and maximising performance for clients who are in the postnatal year, and who have previously had children, as well as those who are postmenopausal.

Planks and mountain climbers are commonly prescribed for core training, but for some clients these are unsuitable due to their lower level of core control, or an underlying area of weakness in their pelvic floor or abdominal wall. Establishing a client’s baseline first will help you to protect their pelvic floor and abdominal wall and retrain their core, rebuilding from the inside out – and setting the foundations for performing a safe and strong plank.

Assessing a client’s core

When assessing a client’s core, you should consider the following changes.

Lengthened abdominal wall

In instances where the abdominal wall is unrehabilitated from previous pregnancies, it may function better when recruitment is started from a lengthened position, such as in 4 point kneeling, rather than in shortened position such as supine. Check and progress each client from the optimal starting positions for them.

Balance between the layers of the abdominal wall muscles

Clients who have done extensive training involving the upper rectus abdominus and external obliques will often have preferential recruitment of these muscles when activating the core. Checking the client’s depth of control of the deeper layer, using the pelvic floor to activate with transversus abdominus and internal oblique activity prior to strong engagement of the outer muscles, can assist in restoring the balance between the layers of the abdominal wall. Look for an ‘in-drawing’ of the lower abdominal region, with relative relaxation of the upper abdominals under the rib cage.

Abdominal muscle separation

While a proportion of abdominal muscle diastasis cases resolve spontaneously, some women will have an unresolved diastasis ‘gap’ of over 2cm and will need specific attention placed on avoiding strain on the linea alba and, ideally, reducing the size of the gap. Start by assessing for a diastasis in supine: if one is present then it is important to check for closure and avoidance of any bulging or widening with exercise.

Pelvic floor

Based on the fact that 1 in 3 women who have ever had a baby will have a problem with urinary incontinence, and 1 in 2 women may have a pelvic organ prolapse, it is likely that some of your female clients will experience these problems. Some women are more at risk, particularly if they have had multiple births, a tear that extends to the back passage, a long pushing stage (over 1 hour), a forceps or vacuum birth, or a large baby (over 4kg).

Determining strength of floor

To provide clients with ways to train the abdominal wall without excessively loading their pelvic floor, we need to teach them to develop an awareness of their current level of pelvic floor fitness, and its response to different loads/exercises.

When a pelvic floor is functioning well, it is:

• responsive to Intraabdominal Pressure (IAP) and postural changes
• fast to recruit with a strong response when required
• able to relax.

A weakened or poorly functioning pelvic floor is unable to counteract the force generated within the abdominal cavity (IAP), and there is a risk of causing damage to the tissues in the pelvic floor, which can contribute to the development or exacerbation of pelvic organ prolapse or stress urinary incontinence.

A number of researchers have found that the pelvic floor muscles contract synergistically with lower transversus abdominis (TA) (Sapsford 2001, Neumann 2002, Urquhart et al 2006).

This pattern can be disrupted and does not always occur automatically if there is pain or dysfunction, enhancing the need for assessment of the level of load applied with core control work for each female client.

Depression instead of elevation of the pelvic floor

Some clients will have an incorrect pattern of recruitment within their core, and despite aiming to activate and lift their pelvic floor, it can descend instead. Using real-time ultrasound, Thompson et al (2003) found that 43% of subjects with incontinence and prolapse depressed their pelvic floor when instructed to lift. They were using a ‘bearing down’ or straining strategy when attempting to lift the pelvic floor muscles, highlighting the fact that we cannot assume that a client is correctly activating their pelvic floor as a part of their core, even when instructed.

A study by Bo and Sherburn (2003) with physiotherapists who had already demonstrated that they had correct pelvic floor technique, found that 30% of subjects depressed their pelvic floor when asked to perform TA contraction alone. This has since changed the focus of instruction to lifting the pelvic floor first in order to assist with initiating activation of the transversus/IO, rather than focusing on abdominal draw in alone.

Pelvic floor fitness and core control

Pelvic floor muscles, when assessed by a pelvic health physio, can be graded for strength, endurance, hold times, reps and coordination. Some women are unable to counteract the forces generated within the abdominal cavity with particular core exercises.

The top graphs represent examples of the strength and endurance capacity in the pelvic floor.

To provide the right level of core training for a female client, we must match their functional level of pelvic floor control with the force generated during the training.

For example, a client with a 3-second pelvic floor hold, with a weak contraction, needs controlled positions for training, as illustrated right:

Before progressing to the next steps in core training, clients need to rebuild their level of core control, including:

• pelvic floor fitness awareness
• breathing and coordination of control during movement
• building endurance hold capacity during training
• matching level of core control with building load and increasing level of resistance.

A client with a 9-second pelvic floor hold, stronger Grade 4 contraction, still slow to recruit fully, can build to more dynamic movement and more challenging positions, as illustrated below (taking care to ensure no issues occur due to fatigue onset):

What compensatory mechanisms do clients use?

With the onset of fatigue, or the attempt to perform an exercise that is too high a load, some clients will switch to a bearing down pattern in their abdominal wall, including breath holding, switching to the use of excessive amounts of upper rectus and external oblique activity. This, in turn, can result in downward pressure on the pelvic floor, despite an initial correct pattern of recruitment. These changes in recruitment patterns can also occur towards the end of training if fatigue onset occurs and the client compensates with incorrect patterns.

If a client is unable to sustain a plank position without any of the above, consider modifying the exercise to include:

• shorter hold time
• positioning knee closer to hands and then moving further away
• use of a ball under trunk to assist building scapular stability
• moving back to other core control steps until they are ready to retest the plank position.

When to refer

The Continence Foundation of Australia’s 1-page Pelvic Floor Screening Tool can be used to help determine the need to refer clients to a doctor or continence professional, with anyone who answers ‘yes’ to any question in the second section requiring referral.

At the 4th International Consultation on Incontinence, Abrams et al (2009) recommended ‘If an existing pelvic floor condition is revealed by your client, then referring for appropriate treatment is the best practice’; and ‘Pelvic floor muscle training should be offered as first line therapy to all women with stress, urge or mixed urinary incontinence.’

Pelvic floor muscle training has been shown to be effective in the treatment of stages 1 and 2 of pelvic organ prolapse (Braekken 2010, Hagen 2009), in that it can reduce the stage and bothersome nature of prolapse.

To help your client find a women’s, men’s or pelvic health physiotherapist near to them, go to Find a Physio

REFERENCES

Abrams 2009, Incontinence, 4th International Consultation on Incontinence, 4th Edition 2009. Editors P. Abrams, L. Cardozo, S. Khoury and A. Wein. p 1043
Bø, K., Sherburn, M., & Allen, T. (2003). Transabdominal ultrasound measurement of pelvic floor muscle activity when activated directly or via transversus abdominis muscle contraction. Neurourol Urodyn, (22)6, 582–588.
Boissonnault, J. S. & Blaschak, M. J. (1988).  Incidence of diastasis recti abdominus during  the childbearing year.  Physical Therapy.  68 (7), 1082-86.
Braekken (2010). Evidence for PFMT in the prevention and treatment of POP. In K. Bo, B. Berghmans, S. Morkved, and M. Van Kampen. Evidence-Based Physical Therapy for the Pelvic Floor – E-Book: Bridging science and clinical practice (pp 226 – 239), Churchill Livingstone 2nd Edition 2015.
Bump, R C; Hurt, G; Famtl, A and Wyman, J. (1991). Assessment of kegel pelvic floor muscle exercise performance after brief verbal instruction. American Journal of Obstetrics and Gynaecology, pp 322 – 329.
Gill, V., & Neumann, T. (1997). Making the Connections – The Role of Technology in Research and Clinic. (Simultaneous EMG evaluation of abdominal and pelvic floor muscles – a practical demonstration of new technology). Proceedings of Making the Connections. Australian Physiotherapy Association. (p59-69). Continence and Women’s Health Group (SA Chapter).
Hagen. (2009). Evidence for PFMT in the prevention and treatment of POP. In K. Bo, B. Berghmans, S. Morkved, and M. Van Kampen. Evidence-Based Physical Therapy for the Pelvic Floor – E-Book: Bridging science and clinical practice (pp 226 – 239), Churchill Livingstone 2nd Edition 2015.

Neumann, P., & Gill V.  (2002). Pelvic floor and abdominal muscle interaction: EMG activity and intra-abdominal pressure. International Urogynaecology Journal, 13, 125 – 132.
Sapsford, R., Hodges, P., Richardson, C., Cooper, C., & Markwell, S. (2001). Co-activation of the abdominal and pelvic floor muscles during voluntary exercises. Neurology and Urodynamics. (20), 31 – 42.
Sapsford, R., Hodges, P., & Richardson, D.  (1997). Activation of pubococcygeus during a variety of isometric abdominal exercises. Conference Abstract, International Continence Society. Yokohama, p 115.
Sapsford, R., Richardson, C., & Stanton, W. (2006). Sitting posture affects pelvic floor muscle activity in parous women: an observational study. Australian Journal of Physiotherapy, (52)3, 219-222.
Thompson, J. A. & O’Sullivan, P.B. (2003). “Levator Plate Movement during Voluntary Pelvic Floor Muscle Contraction in Subjects with Incontinence and Prolapse: A Cross-Sectional Study and Review.” International Urogynecology Journal and Pelvic Floor Dysfunction 14(2), 84-88.
Thompson, J., O’Sullivan, P., Briffa, K. & Court, S. (2005). Assessment of pelvic floor movement using transabdominal and transperineal ultrasound. International Urogynaecology Journal, 16, 285 – 292.
Thompson, J., O’Sullivan, P., Briffa, N., & Neumann, P.  (2006). Differences in Muscle Activation Patterns during Pelvic Floor Muscle Contraction and Valsalva Manoeuvre. Neurourology and Urodynamics, 25, (2), 148-155. 
Urquhart, D.M., Hodges, P.W., Allen, T.J., & Story, I.H. (2005). Abdominal muscle recruitment during a range of voluntary exercises. Manual Therapy, 10(2), 144-153.
Urquhart, D.M. and Hodges, P.W. (2005). Differential activity of regions of transversus abdominis during trunk rotation. Eur Spine J. 14 (4):393 – 400.

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Dianne Edmonds

Dianne is a physiotherapist working in an Obstetric GP clinic, course creator and Women’s Health Ambassador at Australian Fitness Network and the Director of The Pregnancy Centre. She has worked in women’s health and fitness for 25 years and was integral in the development of the Pelvic Floor First resources.

Acknowledgements
Acknowledgement is made to the Continence Foundation of Australia for the permitted use of their diagrams developed through the Pelvic Floor First campaign, and to Simone Kay from Train for Life, Cairns, and Stuart Frost, photographer for the other images used.