Back Pain Pregnancy 2: Biomechanics, Diastasis Recti & Pregnancy Yoga.

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Welcome to the Back Pain Solutions Podcast – Back Pain Pregnancy 2: Biomechanics, Diastasis Recti & Pregnancy Yoga.

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Introducing Back Pain Pregnancy 2: Biomechanics, Diastasis Recti & Pregnancy Yoga.

When does back pain start in pregnancy? In our previous episode we discussed how many women experience back pain during the early stages of pregnancy as a result of physiological changes that can impact soft tissues resulting in an increase in the risk of low back pain and low back injury. As pregnancy develops there are physical changes that influence the biomechanics of the lower back, as well as the muscles of the abdominal wall. So how do these changes increase the risk of low back pain and what can be done to manage it?

In this episode we discuss back pain pregnancy during the second and third trimester. We give consideration to the changing biomechanics as a result of weight gain whilst discussing the incidence of diastasis recti during pregnancy. We talk about diastasis recti repair, diastasis recti treatment and diastasis recti exercises. We also discuss pregnancy yoga and give some direction regarding the activities that should be avoided for good back health. Finally, we discuss low back pain risks postpartum and identify some key factors to consider to maintain back health and enhance core strength.

Show Highlights

Focussed weight gain shifts the centre of gravity as pregnancy develops and results in increased activation of the low back extensors, which increases disc compression. However, there are strategies to help reduce extensor activity and relax these muscles to help reduce discomfort. The incidence of diastasis recti is more common than appreciated, and often misunderstood so we provide clarity on the problem and identify diastasis recti exercises to avoid.

Interview Transcription

Unknown Speaker 0:00

When we’re young, we move with freedom and confidence with a great resilience to injury. But somewhere along the line we develop poor habits and become more vulnerable to back pain. Back Pain solutions features evidence based and practical advice to help you take back control of your health and get back to the activities you love. This is your guide to better back health through movement. So join us as we demystify some of the commonly held beliefs about back pain and build your confidence to a stronger back the smart way.

Ben James 0:28

Okay, welcome back to the back pain solutions podcast Everybody with me Ben James, my co host as always, Jacob stain. This is the second episode of our back pain pregnancy podcas miniseries, I guess, where we’re talking today about second third trimester looking at the weight gain those physical changes talking about diastasis recti. Previously we talked about the hormonal changes the impact that has on ligaments with relaxing progesterone, those hormones that impact Impact ligaments and cause the laxity of ligaments, even early on in the pregnancy, and how that can create instability increased risk of injury that leads to more susceptibility of injury. Today, we’re very much focused on the progression of the journey through pregnancy and how weight gain, physical changes can impact muscles, other structures within the spine and can contribute lead to back pain. Now, some of these changes, again, like the hormonal changes are an avoidable, but it’s important to understand how they potentially impact back health and some of the things that you can try to do to limit the risk. So we’re going to focus on weight gain in this physical change. We’re going to focus a little bit around nutrition and we’re also going to talk about diastasis recti. That seems to be a common question among female patients that are pregnant, the concern around diastasis recti. And is it avoidable? And what can you do post pregnancy to try and get those anterior abdominal wall back to normality for want of a better term. We’ll also talk a little bit about some of the things that we need to be focused on post pregnancy given that there’s this potentially your first child maybe and it’s a completely new this additional weight that you’ve got to move around. And some of the things just to consider as part of that process because undoubtedly, as we said in the last episode, had a bit of a increased risk. Before we start just again, reiterating the point from last time that get on over to the www.smartstrong.co.uk website. There’s a free book there. We’ve got a lot of guidance, not just from the point of view of back pain and pregnancy but for anyone suffering from back pain. opportunity to take advantage of a free ebook that’s really going to give you some clear guidance on taking back control of your back pain within the next seven days and powering you to take some ownership with the knowledge you need. For better back health. So Jacob, we talked last time about hormonal changes today, physical changes, weight gain unavoidable and uniquely in this case, weight gain is very much focused anteriorly so if we’re if we’re gaining weight from simply overeating, then often there’s there’s a distribution of weight in other areas of the body and there’s going to be an element of that during pregnancy, but a lot of that weight gain is anterior. So during the second third trimester, one of the things that we see is that that’s pointing to a central point of gravity kind of changes, and that leads to a lot of tension. So the research is evidenced in the extensor muscles of the back and we know the impact they can have on back So, starting off here, increased tension extensors. What does that lead to?

Jacob Steyn 4:08

Well, it leads to more pressure going through the spine. And that’s that’s the whole concern here. Like you say there’s a weight gain and on the anterior aspect of the body so the belly gets bigger. And so the muscles on the back of the spine, at the low back, especially also at the upper back, they have to work harder to carry the weight in the front, a bit like a crane, you know, you need more weight on the back, depending on how much weight you’re going to be lifting at the front of the crane. So the muscle contraction in the back those extensors you just mentioned when they will literally because they’re so close to the spine, cause compression of the spine, it’s almost like you’re pushing the spine. You know you’re you’re pushing two vertebrae towards each other and that’s just compressing the disk.

Ben James 4:59

Yes. We’re kind of squeezing them together because those muscles are compressing it like an accordion, for example, it’s squeezing the spine together but also good example, the tightness in those muscles. Is it in itself a pain source potentially because if you’ve got that continuous contraction of those muscles, particularly when you’re standing then that in itself can lead to discomfort, which is when a lot of people would try and stretch out those muscles and flex through the spine to try and stretch those muscles out which is what we always recommend to avoid more difficult with with in pregnancy anyway because the growing foetus/baby is it prevents a lot of that kind of anterior bending, but it’s often one of those things that people try and stretch through. So something to avoid doing because really, that that movement is then adding compression to the back or to the to the disks and county compact In the problem

Jacob Steyn 6:01

Exactly. And just like you said, I think that it’s all about the, the endurance factor. So, you know, the spiders in during this compression and at a certain point that reaches too much compression for too long and then you start getting pain and symptoms and what we recommend doing is not to hang forward and stretch out the low back muscles, but actually, in the case of, of a pregnancy, you know, try and find a comfortable position on your back or on your side where we decompress. We allow that disk to be freed up because of the muscles now relaxing. And that’ll give you a second breath and enable you to do your thing again when you get up.

Ben James 6:49

Yeah, do you, do you advise patients in terms of a good position of comfort to relax those back muscles because often with with general back pain suffers, we would recommend that the tummy line exercise where you’re you’re lying on your tummy. Allowing that back to relax takes a lot of pressure on the discs allows those extensors to to relax as well. But clearly, depending on the stage of pregnancy lying on the tummy becomes ever, ever more difficult.

Jacob Steyn 7:18

Exactly. So when you reach a point where you can’t line your time anymore, what I recommend to patients pregnant ladies is that they should try to find a comfortable position on their side. Generally pulling the knees up, knees on top of each other, so the the pelvis and you know the hip bones and the shoulders are lined up. So there’s no twist going through the spine. But also, they can alternate that worth or try for this position which is lying on their back and having their legs or put their feet onto something so not maybe as high as a chair, but maybe 10/20 centimeters off the ground right Their feet on there, because that that causes the low back, or at least causes the the pelvis to rock back. And so you get a little bit of length in the low back. because quite often a lot of pregnant women will experience increased lumbar lordosis, which means the low back will, will be arched even more. And that obviously goes together with the muscle contraction and that causes even more compression on the on the spine itself. So when they’re lying, they’re back. And you have the feet on something.

Ben James 8:35

And cushion or pillows.

Jacob Steyn 8:37

That will work. Yeah, exactly. And they do a little bit of belly breathing. Then the extensor muscles, the low back muscles will will gradually relax and they’ll in most cases feel a lot of comfort in that position.

Ben James 8:55

And you mentioned belly breathing. Do you want to just explain that just for the for the listeners, just so that that’s clear.

Jacob Steyn 9:01

Absolutely that’s a good one because I think for a lot of people, especially my patients of all kinds, belly breathing is something that since I get them to, you know, put them on the spot in a second, I wanted to do some really breathing and we use some feedback, putting one hand on the belly one and on the chest, they quite often, they’re not simply not able to even do it. And what we really want to focus on is keeping the chest still. So breathing through the chest, into the belly, you’ll feel the belly when you’re lying in your back, for example, raising, right so there’s as little as possible chest movement, if you really focus on purely belly breathing, but otherwise, you’ll have minimal chest movement, chest expansion, or raising of the chest if you have your hand on your chest, but you have the belly becoming big as you breathe in and that means that you’re using the diaphragm and You know, it’s a muscle, that word contracts, it’s actually pushing the gut and all the organs downwards towards your pelvis. And so the belly gets bigger. And I’ll just explain what that actually does when you either because you know, it’s important, I think for people to know why it has such a big effect. Well, first of all, it moves you towards the parasympathetic nervous state, which means that you’re, you’re going towards relaxation, a bit like when you do meditation or relaxation exercises or going into sleep. And that’s going towards recovery, but also what it does is when you lie in your belly, doing the tummy lying excites me, like we recommend for low back patients, or in this case, maybe in your side on your back. The belly breathing action will cause a sort of movement through the spine. So it’s, it’s in a way, it’s elongating the spine. So it’s, it’s, it’s having this pumping effect of a decompression of the discs. And that allows the discs to, you know, it stimulates the drawing up of water and fluid. And that’s exactly what we want.

Ben James 11:23

Yeah, great. I think that’s important because if, if you’re going to be doing this, this exercises relaxation exercise in your back then certainly it’s a good opportunity to try and employ that breathing strategy, which is far better, again, with regards to stability of the spine than the kind of lazy breathing that we see quite often in it. And it’s one of those things that a lot of people will just not even make consideration for or have an idea that that they’re doing. So I think it’s a really valuable point. Back to your point on Tommy Lyon. You mentioned bringing their The knees up. We’ve talked before about knees to chest stretching. And just to clarify here, we’re not talking about knees to chest stretching, we’re talking about just bringing those knees up a touch, but keeping that that back as always in neutral.

Jacob Steyn 12:18

Exactly. So yeah, we, we don’t want to, like you say, we don’t want to pull the knees up, because that’s, in some cases, if there’s irritation of a disk, that’s gonna cause that pelvic rock to go too far. And then we cause a sort of where we have a flexion movement in the low back. And that’s going to compress that irritated disk and that might feel like you know, sometimes we like that low level. Okay, I’m looking up the pain stimulation, and we wonder, Is it good because I got to get some movement through there. But what we’re actually in most cases, what we’re doing is where we’re just stimulating and causing or going towards that pain, trigger. So we’re, we’re just irritating that injury and that’s exactly what we don’t want to do.

Ben James 13:04

No Absolutely. So, like with in the last episode we talked about hormonal changes, they’re unavoidable, you know, if you’re pregnant then that that’s gonna happen and that’s going to lead to ligament laxity increases risk. Similarly, if, as the journey through pregnancy proceeds, the the weight gain is going to increase and the anterior weight gain is going to increase as baby grows, so you can’t avoid that weight gain clearly, and the center of gravity does move forward into shift, which does put more pressure on those extensor muscles. So as you’re walking, you may notice this difference in the low back. Don’t be tempted to really try and stretch those muscles out focus on trying to relax those muscles with the sideline or line on your back exercises to scribe that’s going to be far more beneficial to those muscles into your your spine health and trying to stretch through the back which is maybe going to give you a short term feeling of relief, but it’s not going to be beneficial. Really, because it’s not not going to be stretching those muscles either gonna do it’s relaxing those muscles. And you mentioned about the lumbar lordosis Jacob we’re not seeing structural changes here guys, the limit or dosis doesn’t really aren’t more and stay in that that way is very much the evidence says around the tension in the extensor muscles. And so that’s why it’s important just to focus in on those and allow those to relax. Good point here Jacob maybe just to talk a little bit about nutrition because the weight gain with with pregnancies, you know goes with the territory, but of often nutritional choices can impact weight gain. So we can limit weight gain, we can we can help manage weight gain as part of this process. Yes, it’s going to happen to some degree which is going to influence spine mechanics and tension on certain muscles, as we said, but nutritional choices will have an impact and an influence on the amount of weight gain, but also the potential for inflammation and other effects. So do you want to talk a little bit about some of the nutritional strategies to consider in terms of meal frequency and those kind of things that could be of benefit at this point?

Jacob Steyn 15:29

Yeah, sure. First of all, we we have to make a little disclaimer, Ben that we’re men and we were treading on very. So when wasn’t telling anybody what they should do? I mean, we both have little ones. And so we’ve, we’ve been, we’ve gone through it together with our wives. Just for a little bit of clarification, but yeah, sure. So the I think the the The rule is generally that when you’re pregnant, you should not go hungry, you know, as someone who would be dieting or something of that sort, because the idea is that, of course, you need to provide the fetus worth enough nutrients and if you go hungry, then there’s a chance that you’re not doing that. Sure, but, but the thing is that we can, we can, we can go different down different pathways to make sure that we get enough food or we, we feel full after meals and the so the idea is that we want to not, as we would call, eat a lot of empty carbs would we want to go towards nutrient rich and a sort of anti inflammatory diet, which is going to support the growth of the fetus. In other words, we want to make sure that we get a very, very nutrient dense diet. And I especially, I would like to refer to the micronutrients, but also making sure you get enough fat. Because this is very important for the development of the baby and the growth. And, you know, we don’t necessarily need a hell of a lot of carbs in a case. And so the idea is that if we, if we eat a lot of carbs, which generally if you look at a plate of pasta, bread or a lot of rice, then you know, it’s not going to be as nutrient dense as other foods, which means you’ll probably eat a lot more before we reach that satiety level in the brain, which gets signaled by by getting enough micronutrients into your body.

Ben James 17:46

Yeah, great point. And I think like you say, we’re, you know, we’re not here to preach about nutrition. We’ve we’ve both had partners that have gone through this process and there are food cravings, there are certain things that, you know, my wife had, she was particularly expense a lot of morning sickness. And there were certain foods that just really helped with that bread toast in the morning was one of those, you know, so you’ve got to do to a certain degree what you’ve got to do, but it’s certainly some some beneficial insights that could help just in terms of that satiety, adjusting terms of nutrition and just in terms of that contribution to back health in an indirect way, in terms of trying to manage the the levels of weight gain that are experienced. And I think, as that weight gain increases as that that to me expands, this is when we get that risk of diastasis recti. We know about the anterior abdominal wall, we know about the importance of that for contributing to to start spine stability. So they asked us this correctly. A lot of the evidence would say that most women are going to experience it to some degree And how can you not because diastasis recti, which a lot of people think is a separation of muscles, it’s actually a separation of the connective tissue between the two columns of the rectus abdominus, the this kind of six pack muscles, the columns of muscles that are joined by connective tissue, as a baby grows, you have to have expansion of the anterior abdominal wall. Otherwise, there’s no room for that development. So everyone’s going to experience it to some degree that connective tissue is going to separate is going to expand to accommodate the baby. What can we do to limit that? Can we do anything to limit that or is it just a mis-conception about that issue, Jacob?

Jacob Steyn 19:54

Yes, that’s a good question. Well, we spoke a little bit about this And I also looked into some of the research and it was quite easy to be convinced that there’s a lot you can do to well not prevented, but prevented from being a real problem. And making sure that the the recovery afterwards and the returning of the muscles, you know that getting the diastasis recti to, to lessen and get back to a normal state like it was before you got pregnant is actually a big possibility, you know? And so then the question is, how do we do that? And the answer is very simple. It’s doing core exercises. So especially strengthening the abdominal wall. And of course, the timing of doing that is very important. If you have that already strong before the pregnancy that’s gonna be a big advantage, but also doing exercises during the pregnancy especially in the first phases because later it becomes very difficult and then we have to let the body do its thing and the exercises would not be focused on especially in the second offer through the second especially third trimester. The exercises we recommend would be more focused on the past year chain and walking and relaxation exercises but then also after the pregnancy then you know that it’s very good to get to gradually throughout the healing process, increasing the level of core exercises and building the strength again around that protective muscle layer, especially in the front and the sides of your of your abdomen.

Ben James 21:45

Yeah, and I think the the actual muscle the actual exercises that would be would be advised are like with any other back rehabilitation program, they are very much neutral, spine based exercises spine, sparing exercises focused on insurance of those muscles, keeping that spine in neutral to develop the insurance that will ultimately support the spine stability. And there are exercises that you can do throughout the pregnancy, certainly during the initial stages and into the second trimester that that will help you to build that endurance and support, you know, postpartum back health and abdominal endurance and spine stability, which, as always, are in an E book on the on the website, head over to there for some of those resources. I think, for me, one of the big risk factors is is kind of immediately post partum. Because as you’re, as the baby’s growing, the the tension remains on the anterior abdominal wall, to some degree. Yes, you’re going to get that separation of connective tissue, you’re going to get some blastocyst recti, you’re going to experience that too. So degree everyone is what I say everyone is, all women that go through pregnancy are because that connective tissue has to spread to accommodate the baby, immediately postpartum, those muscles aren’t going to just return to the tension they were at before, and you’ve now not no longer got the baby applying that tension internally. And so a bigger risk postpartum, because you’ve not got the country contribution of the anti terror abdominal wall as much to spine stability. So when we suddenly start to lift a baby out of a car, and move that weight around, having a real focus on neutral spine is is fundamentally important because it is much greater risk at that point.

Jacob Steyn 23:46

Yes, I totally agree there. That’s the spinal hygiene that we talked about. The awareness of moving through the big leavers, you know, moving through the knees and through the hips, and understanding what a neutral spine is for you as an individual.

Ben James 24:01

Yeah and I think that it looks like we say with regards to diastasis recti. The focus very much on that that separation of the connective tissue between rectus abdominus there are other muscles that contribute to the anterior abdominal wall the, the internal obliques, the external obliques as example. So, there are a lot of exercises that can contribute and help contribute to anterior abdominal wall strength stability insurance, pre pregnancy, during pregnancy, and certainly post pregnancy that should be recommended at the right time to start to get that abdominal wall strong again, start to help return those muscles to to pre kind of pregnant state as much as possible, because they are fundamentally important to spine health. So once you’ve gone through that process, if you’re focusing on those abdominal wall muscles and exercises then to a large extent tests recti will Return to normality.

Jacob Steyn 25:01

And I just want to get back, Ben to what you said earlier, about, you know, when you do those exercises, you know, do them in a neutral spine and be aware of not, you know, just not doing any sort of flexion based exercises doing doing the exercises properly, that’s not going to cause any problems elsewhere. And I want to emphasize that because what I see a lot of women are doing especially when they get back to full training, and they’ve recovered after they’re after the delivery, is they they think well, all of a sudden, and I’ve never done this before quite often. Now I’ve got to start doing sit ups and I got to start doing sort of Russian tourist variations because you have a lot of yoga exercises where you would be allowed this exercise as well some yoga exercise as well, which is similar. We sit on your bum and you have your knees pulled up feet. off the floor, and your your upper body is also in a 45 degrees off the floor. So you could do like a kind of a V set with your knees bent. And these are all you can almost say extreme forms of flexion based exercises because when you’re sitting like that or making a setup, there’s there’s almost no possible way that you’re going to maintain a neutral spine. In other words, you’re going to put a lot of pressure through the discs, and there’s a good chance that you will get injured, you know, either to the point where you become aware of your injury, but a lot of the injury already happens before you become aware of it. Of course, we have to keep that in mind. But yeah, my suggestion is, you know, if you’re wondering, what should I do for exercises, after of the having given birth, and you’re about four or five, six months and now gradually building up to doing full on hard core exercises. My suggestion is be very careful with flexion based exercises first work on getting strong, your neutral spine. And I will be honest, I would even recommend not going anywhere near flexion based exercises, because they’re not going to provide you with real stability throughout the spine. And the benefits of doing them in terms of working on a diocese’s reg tie. You know, it’s not going to give you any more benefit than the other exercises really, which incorporates all the muscles of the anterior abdominal wall and on the sides. So it’s really not worth the risk, to be honest.

Ben James 27:48

No, and I think certainly, you mentioned there about trying to suddenly start exercises in and trying to get the body back to where it was. Before and there’s a lot of pressure for a lot of women that they feel like they need to I think the point is, your body’s gone through a lot of changes Be patient. And yes, from a health point of view, it is beneficial for certainly from a spine hygiene point of view is, which is our focus, but it’s picking the right exercises, and progressing slowly to support that spine and to start to rebuild those muscles and choosing the right exercise frequency. Because otherwise, like you say, Jacob, you’re just increasing your risk. And that risk is compounded if we’re not really focused on movement patterns, because suddenly, you’re trying to lift a baby out of a car or you’re trying to get a car seat with a baby in into the car and suddenly these movements to keep your spine in neutral, become far, far more challenging. You’ve really got to focus on things like the the golfers lift so you can keep your back straight. over your hip, to try and get baby out of the car. Certainly as they grow bigger, these things are so so fundamentally important because if you’re not doing any of that you’re not focusing on that spine hygiene and then you’re going to do inflection basic sizes. Suddenly you find yourself in a vicious cycle of which can really lead to some significant back injuries and back pain. So not only is it choosing the right exercises, it’s choosing the right movements and becoming very, very confident and knowledgeable about those movements, squatting patterns, lunging patterns, all these things that help us to do daily activities whilst keeping the spine neutral and in a healthy position. Because, as you’ll know, Jacob and as I’ve experienced, it doesn’t take long for that baby to put on more and more weight and suddenly, you’ve got to be more and more conscious of that back health.

Jacob Steyn 29:56

Absolutely. And sort of add to that that you know, If you’re finding yourself in a situation where you’ve got to look after a baby now and you know, you’re still recovering, think about the strategy that you use if you just stand still for a second before you pick up your baby or before you do something heavy with your body. Just think of the strategy that you’re using. Where Where do I have to exert power? Where do I have to stabilize? What’s my back position? Like? What do I feel? What do I feel afterwards? You know, and if you start analyzing that then you know really doesn’t have to take a lot of time. You’ll do it a few times and you’re aware of it and you understand it and you don’t have to spend so much time on it anymore.

Ben James 30:41

Yeah, becomes subconscious. It becomes you know, trained kind of Neurology but certainly be more intentional and more conscious with those movements. Exactly. And it is, it is definitely going to be very beneficial for you in terms of laying that foundation and then that platform for this kind of new new world as it were with it with a baby in life. I’m sure you all have experienced Jacob, just how difficult sometimes it is getting that added weight into certain positions in the car and you’re suddenly lifting, heavy pram or you’re lifting more equipment, you’re taking more things with you wherever you go. Really, it is important to consider those movements early on, because, like we say, Prevention is always better than cure and a problem if you’re suffering from back pain at the moment, post pregnancy, then absolutely like with a lot of other patients that we see the neutral spine learning to brace learning key movement patterns, removing those pain triggers, such as bending through the spine are all going to help with that journey to recovery. But if you can be conscious of them before the problem occurs, then clearly you’re going to be in a far far better position. So, Jacob, anything else you want to add? I think the fun for me here that. Again, there are changes that are going to occur which you can’t avoid. But as always, there are things and strategies you can employ to help reduce your risk to, to limit impact during pregnancy to help resolve back pain during pregnancy and post pregnancy. A lot of things to consider when when pregnant and welcoming this new arrival back pain isn’t necessarily high on the agenda, but it soon becomes high on the agenda when it’s causing pain and significant pain which sadly, we’ve experienced with a lot of patients. So anything else you want to advise other than what has been discussed so far?

Jacob Steyn 32:44

No, not really. I just want to say that what you said about prevention, you know, if you are thinking of starting a family or having another kid and you have the opportunity to start working with some of the aspects we discussed here In terms of building capacity building tolerance and have a strategy to prevent your back injury or your body from not being able to enjoy the process that you’re about to start, then I would suggest work on a prevention strategy that would be the best.

Ben James 33:21

Yeah, absolutely. I think that’s a great point. And and as always, we’ve mentioned it once already. We’ve got a great ebook that we’ve created over at www.smartstrong.co.uk. And a lot of the strategies there are very much focused on movement patterns, key pain triggers, things to avoid strategies to help you avoid back pain and start to build endurance safely around those muscles that are so important for spine health. So really get on over to the website and take a look at that download that just so you can really start to feel empowered and take back some control if you’re suffering from back pain because We know it’s not a nice experience, Jacobs had a significant back pain ish problem. I myself have experienced back pain. And these movement strategies undoubtedly help. As always, head on over to iTunes give us a rating on there any feedback is really helpful helps to share the show with other people spread the word helps us develop our content and make improvements through this journey of building this podcast building this website to help support people with low back pain. So we always appreciate the ratings and the reviews that we’re getting. And we’re seeing a number of those come through which is fantastic. So thank you for that. As always, thank you for listening, Jacob. Thank you and we’ll catch you again soon guys with another episode.

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