Dear Diastasis Community….Can We Talk About Planks?

Planks have become a dirty word in diastasis chat rooms, forums and blogs. Blanket edicts of no more planks have emerged. But this has thrown a lot of women into a state of confusion…we can’t do crunches, and can’t do planks…what can we do? This speaks to the no-man’s land that so many women find themselves in between a history of ab-centric fitness adages that leave them feeling betrayed and diastasis community members telling them never to do a plank or traditional ab work again leaving them feeling paralyzed and fearful not knowing how to move or exercise again.

Do we really mean NEVER do a plank again? Or do we mean let’s restore abdominal function and fascial density and find exercises you can do and gradually progress…which absolutely may one day include a plank? Can we communicate balance to the patients and help create better guidelines as to who are the patients that need to follow stricter regimens.

A recent patient, Maria*, is a great example of how this is all falling out on the street and how critical it is for us to help women distinguish between a diastasis that is just a piece of a larger puzzle, vs a diastasis that is truly the primary contributor to the dysfunction that women are experiencing and may require the significant precautions, bracing, etc. Maria self-referred to address her 4 finger-width diastasis, and she also had bilateral hip pain with standing longer than 30 minutes (she was a mom and worked at a standing desk…so lots of standing in her world). She had been initially measured by a ‘diastasis expert’, who showed her how to keep her TA engaged during the day, and gave her a laundry list of exercises to avoid until the diastasis closed, including planks, crunches, frog kicks (breast-stroke), and yoga moves such as twists, bridge, boat pose etc. She was devastated. She felt betrayed because since having her baby she had been attending yoga and other exercise classes to get fit and ward off post-partum depression. This included an intense core-workout class that was marketed towards post-partum moms, all the while thinking that she was getting her body back while in fact she was doing ALL of the ‘bad’ activities on the list. In her own words: “All the things that I’d been doing were supposedly making the diastasis worse and resulting in a bigger mummy tummy! So I stopped. And then I felt taken hostage. I wasn’t exercising and I was scared to move…. It’s hard to know what to do. I was so frustrated.”

Her doctor measured her at 3 fingers width, and suggested physical therapy. My evaluation concurred with her doctors, and I also noted she created minimal fascial tension with exertion (per our new understanding the restoring fascial density is more critical than closing the gap, via Diane Lee). I guided her through a multifactorial program that accessed that deep central stability system (diaphragm, TA, pelvic floor) that re-creates tension over the fascia, regulates abdominal pressure and supports hips from the inside-out. I showed her an alignment that reinforces the system. Critically, she learned to access that system to pre-tense the fascia before each movement and activity via exhalation before exertion (“blow before you go”).

She went home to work on that and returned for follow-up in 2 weeks. When we re-measured the diastasis at 2 weeks, it was resolved, except for a 1 cm gap right at the navel, with improved fascial tension. Was it a miracle?  Does everyone get better that fast? Nope and nope. Or was it the type of diastasis we are concerned about, that requires severe precautions or possibly bracing? Nope. Her hip pain was also improved, she was tolerating 2 hours of standing after a few weeks of practice. I cleared her for exercise, as long as she kept in mind what we had discussed. She was thrilled and hopeful.

While I appreciate the intention of those who say no planks, their reported concern is that the position causes the organs to place excessive pressure on the diastasis creating a larger gap. I have found that for some women the pull of gravity actually helps them reconnect with the abs and make them work. Their form or the level challenge (against a wall or on a countertop) may need to be modified to promote control vs compensation that could aggravate the diastasis. But some women absolutely do have the capacity to create fascial tension, control their central stability system and can tolerate a prone position without any adverse effects.

I could actually make a similar argument against women laying on their backs, particularly in faulty alignments. For example, laying on your back with your ribcage flared and jutting out will pull the edges of the diastasis further apart. Does this mean we shouldn’t allow women to do activities on their backs? Or as suggested with the planks above should we modify the patient’s position or challenge to prevent the increased gapping. Try it! Support the head and shoulders with a pillow to bring the ribcage that flares open into a more closed position, this will approximate the diastasis borders and the abs have more mechanical advantage to meet a challenge.

I think absolutes are tricky, but I agree we need parameters to help women proceed safely back to a restored abdomen that is ready for challenge. However, we need to communicate the purpose behind the parameters and present them in a balanced way vs a blanket edicts. Teaching women how to test and retest the abs and fascial density before and after exercise is a great way to help them determine if they are safely AND effectively participating in an activity. Can we also teach women how to assess fascial tension or capacity not just the width of their gap? For example, when you touch the tissue in the space between the abdominal edges does it feel like your cheek or more like the tip of your nose, we want it to feel more like your nose**? Does it pre-activate before you test with a curl-up (become like the tip of your nose before you challenge the center)?

My goal is always confident independence. The overarching rules I set for my patients are if you lose your breath or your alignment (form) during the activity, it is too challenging. In my opinion, appropriate abdominal function, inside-out muscular recruitment, and connection to your central stability system, go hand and hand with the ability to maintain form while maintaining breath. So plank (or all-4s or whatever) are OK in my book only if you can maintain those rules. This helps to set individualized parameters as patients engage in a gradually progressed program of any exercise, not just planks. ( Just to be clear, I think of a full, parallel to the ground plank as a progression from a strongly restored center vs starting a program with a full plank.)

One final, and very important point to consider. I posted some of these ideas on my Facebook thread and it sparked a great discussion. In response to the idea that prone positioning caused too much organ pressure on the anterior abdominal wall, one of the main arguments against planks, Ramona Horton weighed in. For those of you who don’t know Ramona, she is an internationally respected authority on visceral manipulation, and fascial work (and speaking on the topic at the APTA’s CSM 2015). Here is what she had to say:

“Seriously, where do people come up with this stuff?? Avoiding planks because the viscera would be putting too much pressure on the abdominal wall?? That is pure conjecture and a load of balderdash. The visceral structures are held in place by turgor (think 2 plates of glass with water in between) in a prone position are suspended in the abdominal cavity (a closed system) off of the posterior peritoneal wall the same as any other position. That is like saying avoid a head stand or inversion postures in yoga so your stomach does not herniate through your esophageal hiatus. As long as the patient has good control of TA function and not breath holding/valsalva there is absolutely no reason to avoid planks.”

So I hope this all leads us to some questions we need to ask and discuss as a community: Are planks the big no-no they have been made out to be, particularly for the reasons they have been restricted? How do we define improving abdominal function for the patient so they know if their program (planks or any other exercise) is promoting or hampering it? What are your suggestions for communicating improved abdominal function to patients? (PS-you aren’t allowed to say load transfer, because that means nothing to patients) How do you help your patients self-evaluate if an activity is right for them? Everyone’s abdominal/pelvic/exercise challenge balance is a little different, how do we communicate with patients how to find their balance? Can we develop messaging to help women understand how the parameters for return to exercise applies to them?

Lots to ponder! I would love to hear your thoughts, please join the discussion below! Women in need, don’t be shy, you are the most important part of the community. I would love to hear your thoughts, too!

*Maria is not her real name, but the patient gave permission to use her story for the blog.

**Need to credit my pal Shelley Mannell for his analogy…I think it is awesome!