Why the Abdominal Wall Assessment Matters

Discussed in this Podcast

• Learn more about Pelvic Health Trauma Health Certification
• Gertie Ball
• Breathe by James Nestor
• Get certified in pelvic health from the OT lens here

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Transcript

Hey there, and welcome back! Today, we’re diving into a topic I find absolutely fascinating: the abdominal wall assessment and how it plays into pelvic floor health. This is such an important conversation for practitioners and anyone supporting clients with pelvic health needs.

Now, what initially inspired me to talk about this was research I came across from 2006, 2011, 2014 and 2022. These studies highlighted that without intervention, spontaneous abdominal wall recovery happens very slowly. That means that our clients need us, and our work can make a profound difference. What we’re aiming for is optimal synergy—where the pelvic floor muscles and abdominal wall activate together. And here’s the kicker: the same coactivation loss in the abdominals often correlates with urinary incontinence. So, focusing on abdominal assessment? Absolutely necessary.

Today, I want to walk you through some strategies I use with my clients.

The Abdominal Wall's Impact

The abdominal wall does so much more than people realize—it supports the pelvic and abdominal organs, impacts breathing, and even affects our ability to laugh, cough, sneeze, and void. It also plays a key role in core stability, supporting the trunk, head, and limbs. That’s why I always include abdominal assessments in my pelvic health work.

One thing I’ve learned is that rigidity—in the torso or abdominal walls—can really affect pelvic floor function. In my own practice, I’ve been heavily influenced by Diane Lee’s ISM series and my mentorships with Lauren O’Hagan of Restore Your Core. These incredible teachers have shaped how I approach abdominal wall assessments. If you’ve trained with them or others, I’d love to hear your thoughts.

Where I Begin: Postural Screening

I always start my abdominal wall assessment with postural screening in standing. Specifically, I observe how the pelvis aligns with the trunk, feet, and thorax, and I also assess how the head aligns with the thorax.

Beyond posture, I look at the belly itself—is there a "pressure belly" appearance? This occurs when the external obliques overactivate, and you might see divots where the belly draws in sharply. If you’ve ever Googled “pressure belly,” you’ll know exactly what I mean.

Next, I’ll ask the client to engage their pelvic floor. I observe what happens in the belly during that contraction—not just standing, but also in positions where they experience discomfort, like bending over to pick up a child. This helps us get a real-world view of how their abdominal wall behaves under stress.

Five Parts of the Abdominal Wall Assessment

To make things simple, I break the abdominal wall assessment into five parts:

1. Breathing patterns
2. Scar mobility and visceral mobility
3. Muscle activation patterns
4. Diastasis Recti assessment (or DR)
5. Thorax-to-pelvis relationship (postural assessment)

Since we already touched on posture, let’s circle back to breathing patterns because, honestly, it always comes back to the breath.

The Power of Breath

I recently picked up James Nestor’s book, Breath, and wow—every page makes me think about pelvic health! He talks about how the inhalation must be full to extend downward and become calmly settled, which brings strength and balance. I read that, and all I could think was: pelvic health, pelvic health, pelvic health!

When the respiratory and pelvic diaphragms work together, they act like partners—two parentheses framing the body. The diaphragm, to me, is the conductor of the core. It’s the key to getting the pelvic floor muscles to coordinate properly. And we know that proper breathing is essential for nervous system regulation, which can profoundly impact pelvic health.

Ideally, we’re aiming for 360-degree breath expansion—not just in the belly or chest, but in all directions: north, south, east, and west. I’ll often have my clients place their hands around their lower ribcage to feel this multidimensional movement. I tell them: This is optimal breathing.

Avoiding the Belly-Breathing Trap

One thing I like to caution clients about is belly breathing. While well-intentioned, many people hear this term and force their belly outward, creating tension where we want relaxation. I prefer using the term “tension-free breathing”, coined by Sinead Dufour, who does amazing work with diastasis recti.

Instead of forcing a belly breath, I encourage clients to experience seesaw breathing, which I learned from Lauren Ohayon. This technique helps them notice whether their natural breath patterns favor the belly or chest, and from there, we build awareness and improve balance.

Using a Gertie Ball for Breath Awareness

One of my favorite tools for helping clients feel their breath is the Gertie ball. If a client is a habitual belly breather, I have them place the deflated ball under their belly and roll onto it in a kneeling posture. When they inhale, the pressure of the ball gives them immediate feedback. It helps them notice whether the breath is defaulting to the belly or if they can engage their chest too.

Now, if the client has diastasis or is healing from a C-section, I proceed with caution—always adjusting the pressure so it feels helpful rather than overwhelming. The goal is awareness, not discomfo

Breath as a Dynamic Process

One thing I want to emphasize is that breathing is not static. It’s dynamic and should shift based on the situation. We don’t breathe the same way when we’re sprinting as when we’re lying in bed. That’s why I always tell clients: There isn’t one perfect way to breathe. The goal is variability—the ability to adapt our breathing to match the demands of the moment. 

So, to sum things up, abdominal wall assessments are a vital part of pelvic health. By evaluating breath patterns, posture, and abdominal engagement, we get a clearer picture of how to support our clients. And let’s remember: The magic lies in awareness—helping clients notice their patterns, explore new options, and embrace the dynamic nature of breath.

Scar Adhesions and C-Section Recovery

• 41% of C-sections result in adhesions, highlighting the importance of scar massage.

Recommendation:
Lindsey suggests clients perform curl-up tasks to identify oblique dominance (external vs. internal). Client engagement and feedback using their own hands on the ribcage, abdomen, or perineum are essential for biofeedback.

Reverse Breathing and Dys-synergic Patterns

• Reverse breathing is common, and Lindsey prioritizes client awareness to correct the pattern.
• Tools like tying a TheraBand around the ribcage during daily tasks can guide breath practice.
• She recommends monitoring for nervous system or trauma influences and checking postural tension patterns, like butt-gripping or abdomen-sucking habits.

Diastasis Recti (DR) Assessments

• Lindsey focuses on both distance and depth of the linea alba, favoring a functional approach that assesses springiness rather than strict measurement.
• She performs DR checks with clients lying on their backs, using three fingers to feel for tension.
• Lindsey suggests retesting with pelvic floor activation on exhale to evaluate abdominal engagement.

Client-Centered Approach

• She stresses the importance of assessing abdominal and pelvic function in positions where symptoms arise, such as standing or while carrying heavy objects.
• Lindsey emphasizes functional testing, using daily life tasks to provoke key information and uncover hidden patterns.
• She encourages peers to discuss strategies and learn from each other’s experience.

A Holistic OT Perspective

• Lindsey aligns her approach with the latest research, incorporating variety, posture assessment, and lifestyle goals into treatment plans.
• For clients struggling with pelvic floor contraction or reverse breathing, she recommends shifting focus to building strength in adductors, abductors, or even chest muscles.
• ADLs (Activities of Daily Living) are highlighted as a meaningful way to strengthen and engage clients in functional recovery.