Diastasis Recti: Gap in Abs, Gap in Knowledge (Part 1)

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Pregnancy and postpartum recovery are periods of great transformation in a woman's life (which, if you’re pregnant/recently had a baby, is probably the biggest understatement of the year!). The human body displays its incredible propensity for adaptation, healing, and resilience during those 9+ months of a pregnancy and as it recovers. Although the body has the capability to carry a baby to term and repair itself afterwards, the process doesn't always go as smoothly as we wish it would! Pregnancy and birth are associated with conditions that affect a woman's health, function, and appearance, and diastasis recti abdominis (DRA) is one such condition.

Diastasis Recti?!?! What's that?

Before we clear up the common misconceptions about diastasis recti, and how to ‘treat’ it, here's a brief overview of the condition:

Diastasis Recti Abdominis refers to the widening of the gap between the two portions of the rectus abdominis muscles (your "6-pack" muscles). This "gap" is actually a fibrous band of connective tissue called the linea alba which runs from the xiphoid process (a cartilaginous process with a fun name at the base of the sternum) to the pubic symphysis (the joint in the middle on the front side of the pelvis, where the two pubic bones meet) and functions to unite the muscles of the abdominal wall. During pregnancy, it stretches to accommodate the growing baby (similar to malleable Saran wrap), moving the rectus abdominis muscles farther away from each other (something which some women will notice when they glance down at their bellies). While this may seem disconcerting, know that this ability of our body is a crucial one, as the expansion allows the space for baby to grow without one's abs "ripping" apart (a common misconception is that DRA involves muscles brutally tearing apart. This is not true!).

When the gap broadens beyond 2.5cm (roughly two fingers), it is classified as diastasis recti abdominis (we will discuss below why only evaluating the distance does not give you all the info needed, but for now, know that that is the criteria used to distinguish DRA). The most common symptom is a bulging or doming of the linea alba outward during certain movements (sit ups, for instance), a feeling of not being supported in the abdomen, and the appearance of protruding belly.

Now that we've covered the basics, let's clear up the common misconceptions about DRA:

1.) "Diastasis Recti is primarily a concern of appearance."DRA is a medical/functional concern and while it has an aesthetic component, it isn't just about looks.

We prefer to refer to DRA by its clinical name as opposed to "mummy tummy" or "mom pooch" for this reason, as reducing it to a name (and one that isn't very kind, at that) that focuses on the outward appearance gives the erroneous message that a DRA doesn't affect more than the look of one's belly. In a cultural climate where women often have difficulty having their medical concerns addressed seriously, or financially covered with their insurance, we feel that it's especially important to reinforce the reality that DRA impacts more than just how a woman looks. DRA impacts her total body's function and, as a result, it is important to address.

Additionally, DRA may or may not be why your postpartum midsection is different than it was previously. Meaning, you can have a “pooch” and not have DRA and you can have DRA and not have a “pooch”. Addressing your DRA will likely change the appearance of your abdomen to some extent, but may not give you the flattened stomach you anticipate (which, by the way, is totally ok! Bellies come in all different shapes and sizes). The entire abdominal wall stretches to accommodate a full-term pregnancy and this stretching can lead to a broader or “poochier” belly, even in the absence of DRA. One last note on belly size: we have been led to believe that abs should be taut, bellies flat, and waists narrow in order to be attractive and functional. This is a false and potentially very damaging thing to believe. “Normal” bellies are as diverse as we are and there is simply no right or wrong way for a postpartum belly to look.

2.) "Diastasis Recti is rare." or  "DRA is so common that everyone has it, so who cares?!"

Research (1) found that 100% of women have a DRA by 35 weeks gestation (remember how cool it is that the body can adapt to pregnancy?!) and that 35-39% had a DRA that persisted at 6 months postpartum. Similar research(2) also found 100% of women to have DRA by 30 weeks gestation, while another research study(3) notes 66% of women had DRA by their third trimester (and that 36% continued to have DRA at 7 weeks postpartum). The variance in statistics may reflect a difference in the method of measurement, or the criteria used to "diagnose" DRA, and also speaks to a lack of research on the topic. What is clear, however, is that the vast majority of women have DRA by their third trimester and many will find that their DRA persists postpartum, without intervention.

The greatest time of healing occurs between 1 day postpartum and roughly 8 weeks postpartum. After the 8 week mark (4), progress tends to slow without intervention.

3.) "Diastasis is entirely preventable!" / “There’s nothing you can do to influence it!”

Consider this: research supports the fact that a vast majority (if not all) of women have DRA by the end of their pregnancies, and the stretching of the linea alba is a response that allows the baby room to grow. Is it reasonable to suggest that we can prevent DRA from occurring at all? No! And not only that, but we wouldn't want to prevent the natural expansion of our abdominal walls! What we can do, is choose activities that hopefully do not exacerbate the DRA, ideally managing the severity of the condition postpartum. There is currently no quality research to support the idea that DRA is preventable. The news isn’t all doom and gloom, though! Despite the studies being of poor quality, there is a bright glimmer of evidence-based hope in this systematic review from 2014 (4) which states that,

“The available evidence showed that exercise during the antenatal period reduced the presence of DRAM by 35% (RR 0.65, 95% CI 0.46 to 0.92), and suggested that DRAM width may be reduced by exercising during the ante- and postnatal periods.”

Again, the studies cited were generally poor in quality (due to a variety of factors), but this does support the idea that DRA severity can potentially be mitigated with exercise. What this tells us, more than anything, is to be wary of programs that guarantee results or that promote the idea that their method is supported by scientific evidence of good quality.

The authors of the systematic review state their hypothesis for why there may be a noticeable effect:

A possible explanation for how exercise during the antenatal period may reduce the risk of developing DRAM is that exercise helps to maintain tone, strength and control of the abdominal muscles, consequently reducing stress on the linea alba. Additionally, women who exercise during pregnancy generally also exercise prior to pregnancy and, therefore, may be fitter and have better conditioned abdominal muscles compared with women who do not exercise during pregnancy.”

The studies that looked at postnatal exercise and DRA were of poor quality and the one random controlled study (considered the gold-standard method) looked at the effect of pelvic floor/abdominal exercise merely hours (6, 18)  after birth and the authors concluded that it failed to be clinically relevant. (Duh, right?!)

Although we do not have substantial evidence of what, why, and how exercise impacts DRA, we have observed positive benefits of exercise in women with DRA (and without!).

What we aim to do at The Lotus Method is mitigate the effects of a growing pregnancy on a woman's abdominal wall (and the rest of her body), as much as possible, theoretically lessening the severity of DRA.

4.) "All it Takes to Fix a DRA is One Exercise/10 Minutes a Day!"

As professionals who care deeply about the moms we're working with, and because we understand that the demands of parenthood are extensive, we wish an answer as simple as "do this one thing for 10 minutes a day" would suffice, the reality is that it's more involved than this. First, although the discussion of DRA involves a specific region of the body (the “core”), DRA does not only impact the core. Sure, you may be doing an exercise that is helpful in resolving DRA for a few minutes a day, but what are you doing the other 23+ hours a day? It is important that we move beyond the idea that movement done during "exercise time" is different than movement we do outside the gym. All movement matters and our day includes endless opportunities to establish better function. If we approach healing DRA as something we do for a small amount of time and then go back to our "normal" ways, we will likely not obtain the results we're hoping to achieve.

5.) "You Just Need to Activate the TrA!" or "Pull Your Belly Button to Spine for DRA Resolution!"

The transversus abdominis (TrA) is our deepest abdominal muscle, commonly referred to as our "corset". Common cues have focused on drawing the belly button in towards the spine and holding there for improved core function. While the TrA is instrumental in proper core function, it does not work in isolation. In fact, no muscle works in isolation! As a result, we prefer to approach core function with a "team" approach. Renowned physical therapist, Julie Wiebe, PT,  provides an easy-to-understand description of this when she refers to the muscles of the inner core unit (the diaphragm, the pelvic floor muscles, multifidus, and yes, the transversus abdominis) as gears working together. If one gear isn't working well, the system is likely not either, but no singular muscle is responsible for the performance of the entire team. Some programs aimed at DRA rehab have only focused on the job of the transversus abdominis without viewing the body as a whole. Full function of the core is reliant on more than the TrA. Beyond the innermost core musculature, the more superficial muscles (the rectus abdominis, the external and inter obliques) are also important in fully regaining (or building) abdominal strength and function.

Constantly pulling the belly button to spine, a common cue given by fitness professionals, is unlikely to provide the desired effect of appropriately activating the TrA (which isn't enough to resolve DRA, anyway) in connection to the rest of the inner core unit and may increase pressure on the pelvic floor. To use another example from Julie Wiebe, PT: picture an inflated balloon (your internal abdominal, responsible for managing pressure) and then imagine squeezing the balloon in the center. What happens to the balloon? It bulges down and up, around the brace you've created by squeezing it. That pressure has to go somewhere and in many women who either consciously or subconsciously grip or squeeze their abs in all day, it may end up traveling downward on the pelvic floor. When the pelvic floor is unable to maintain that downward pressure, leaks may happen, prolapse may happen, discomfort and dysfunction may happen. When we only consider one part of a larger system, we run the risk of creating more issues on a path to solving another.

Fitness, pilates, and rehab professionals have long asserted that drawing the umbilicus towards the spine was the way to better abdominal function and support.  They describe the TrA as functioning like a corset and “drawing the abs together”. Recent research(5) found the that the drawing in maneuver actually slightly increased the IRD when compared to the crunch, as exercise that has long been discussed as the worst possible thing one could do for a DRA. Keep in mind that our primary concern is function, not solely the IRD and this is why we pay greater attention to the bigger picture instead of myopically focusing on the gap. TrA activation (as tested by the “drawing in” movement) broadens the IRD, at least in the short-term, and a crunch narrows the gap, at least in the short-term. Some would take this to mean that we should go back to just doing crunches and forget about the TrA entirely. This would be a misguided move, as the study doesn’t discuss the depth of the gap, the function of the rest of the “core”, and what happens in the long-term. Further research on crunches(6) concluded that the IRD is in fact narrowed by the crunch, but that the linea alba is also distorted. When the crunch was preceded by a pre-activation of the TrA, the IRD didn’t narrow as much, but the linea alba distorted less, suggesting that it may have a greater ability to transfer force between the two sides of the abdomen.  This research is included not to confuse you (although it is confusing!) but simply to challenge the notion that the TrA is the hero of “narrowing the gap” and that narrowing the IRD ought to be the sole pursuit of DRA recovery programs.

In “optimal”/”normal” core function, the diaphragm, transversus abdominis, pelvic floor muscles, and multifidus work together to create a reflexive, adaptive, mobile system that manages pressure, and provides mobility and stability. On inhale, the diaphragm and pelvic floor descend, the rib cage and abdomen expand, and on exhale, the opposite occurs. Reestablishing this pattern postpartum will almost certainly be more successful than just drawing in your belly button. Yes, on exhale, the belly button will gently move inward, but just pulling it in is not the path to a strong core.

Many professionals draw conclusions of support to their TrA-isolation programs from studies conducted by Paul Hodges, PhD, a world-renowned researcher. They appear to have simplified his findings, as an article of his from 2008 (7) states that

“While changes in transversus abdominis (and other muscles such as multifidus) can be a useful marker of dysfunction in the system (and recent data show that patients with delayed transversus abdominis do better with a motor control training approach than people without a delay),to limit treatment to this muscle is unlikely to be beneficial. The days of contracting transversus abdominis as the primary exercise and then sending the patient away are over.”

Certainly, the TrA is an important muscle. Is it the most important muscle in healing DRA? Not necessarily.


6.) "The Gap is The Only Thing That Matters." or "Results Can be Assessed by Circumference Measurements."

Recent research supports our broadened understanding that it is not just the distance between the rectus abdominis portions that we need to be concerned about, but the tension of the linea alba. A DRA may not become smaller than 2 fingers in some women, but if their linea alba is able to generate sufficient tension, we would consider their DRA to be "functional", or healed. Many women will mistakenly believe they have DRA when they self-assess because they were not informed of the importance in gauging the tissue quality of the linea alba. Similarly, some women are assessing their DRA by doing circumference measurements. The circumference of one's abdomen will vary depending on hormones, what she ate that day, how relaxed she is, whether her bowels are full etc.

Another thing to consider is that the measurement of DRA in finger-widths is far from scientific. My fingers may be much larger than yours, for instance, making validity difficult. Similarly, some sources consider DRA anything above “1.5 fingers”, some say 2.5. Again, 2.5 large fingers? Tiny fingers? Who knows?! What you need to know is that an inability to generate tension through the linea alba is suggestive of DRA and a large gap is likely problematic. Don’t get hung up on the minor details, though.

7.) "One Exercise/Exercise Modality Will Fix Everyone." / "Everyone Can Heal Their DRA with *THIS* Program!"

Everyone is different! Everyone's pregnancy is different, everyone's body is different, everyone's preferred method of exercise is different! While the end goal is the same (restore tension/function to the linea alba and promote an optimally functioning core), there are many ways to get there. While the initial stages of healing may look very similar for people, different exercises done in different positions may prove to be more successful for some. The important thing is finding what works for you. This is one of the biggest reasons we, at The Lotus Method, focus on individual training. We use every movement as an assessment and don't believe that cookie-cutter programs are the best route to success. An exercise program is only successful if the person performing it sticks to it, and we're unlikely to stick to things that don't resonate with us. We strive to integrate movements that you like, and movements that will prepare you for the type of exercise you personally enjoy. We can adapt most movements to work with you by changing the strategy you use to perform it.

Remember also that the conclusive evidence on how and what exactly can heal a DRA ,in terms of exercise, is non-existent. The foolproof way to treat DRA has yet to be discovered (or at least validated). We all have plenty of anecdotal evidence: all of the trainers at The Lotus Method have worked with women who have significantly improved their DRA. Unfortunately, this evidence doesn’t yet have good quality studies to support it. Similarly, we all have friends (or perhaps ourselves) who have had “good results” with various programs. This is still not enough to support a method or modality over another for a larger sampling of people. Additionally, correlation does not equal causation.

We wish it were so, but not every DRA can be managed with conservative measures. Some DRAs will require surgical intervention for full function and anyone who tells you that they guarantee that they can solve your DRA should be approached with caution. The reality is, we don't always know how a person's connective tissue will respond to exercise or lifestyle changes and we can't give anyone a 100% guarantee that what we do will work. We do our absolute best, within our scope, to help every woman we meet. That may mean referring to physical therapists or other practitioners who are qualified to help. Even in the event that surgery is indicated, a smart strength training program will still provide several benefits. Surgery won't solve the strategy and won't rebuild total body strength, but exercise can and so it's crucial to continue utilizing movement, even if it ends up that your DRA is in need of surgical intervention for full resolution.

DRA healing is an evidence-guided trial and error process. There is no surefire solution that works 100% of the time. Anyone who says otherwise is selling you something...and something that isn’t necessarily going to work. ;)

8.) "It's Impossible to Tell if an Exercise is/isn't Working for Me."

It may be challenging to know with absolute certainty if you're on your own, but there are a few simple clues to look for: first, what does your abdomen look like when you perform the movement? Is there a ridge protruding from the middle when you do a certain thing? That's a good sign that you aren't able to manage that exercise - yet! Second, what does it feel like? Do you feel like you need to hold your breath in order to complete the movement? Do you feel like your guts are spilling out? Those are good signs that your core system is not managing to meet the demands of the exercise you're performing. Best to scale back, or modify the way you're performing the movement. Although it may be different than the workouts you used to do where you were jamming to music and not tuning in to your body, it's best to spend some time really listening and looking for the clues your body is giving you, especially when rehabbing DRA.

9.) "Only Core Exercise Selection Matters."

For optimal functioning of your core, we need to really think big picture when it comes to movement. How your upper and lower body moves will impact how your core works and vice versa. For instance, if you lack mobility in your shoulders, you will likely need to thrust your ribs each time you reach for something overhead, leading to an extended abdominal wall that may lose its capacity to fire as automatically as required. When this becomes our dominant pattern, we're introducing possibly hundreds of times a day when the abdominal wall remains in a lengthened state and doesn't have the opportunity to work to its full capacity. That childhood song about the "knee bone's connected to the thigh bone...the thigh bone's connected to the -" may not have been anatomically accurate in terms of the technical terms, but it wasn't so far off! We're all connected. What one structure does will impact what a neighboring structure does. This is why DRA is a whole-body issue, not just a core issue. We will certainly include exercises that engage a greater percentage of core musculature (just as we will with every muscle/movement as this is part of how we achieve the progressive overload needed to cause a response from the body), but we don't only focus on "core" exercise when working with a woman with DRA. Muscles of the deep core are always working, whether we're aware of them or not. Because our bodies work as a system, simply doing "ab"/"core-specific" exercises aren't enough for a fully functioning middle.

10.) "NEVER DO CRUNCHES OR AB EXERCISES AGAIN."

The goal with DRA rehab is, if possible, to return to full function. Full function is defined by you (what do you want to be able to do?) but it generally means that you can do a variety of movements without symptoms. Spinal flexion (the action of a crunch/sit up) is a basic human movement and shouldn't be seen as the sole "bad guy". The movement is neither good nor bad; it's the application that matters. Do you bulge when you sit up or crunch? Yes? Then that's probably a good indication that you're not quite there yet. If you're able to manage your intra-abdominal pressure (no bulging, no pain, heaviness, etc) and your core works well in that movement, crunches may not be the villain they're been made out to be and, according to more recent research could potentially be useful! (6) Having said that, does that mean 100 crunches will work wonders for you? No, of course not. We still think there are likely better exercises for you to perform, but in some people, that movement pattern is going to be fine and could possibly be beneficial. We evaluate on a case-by-base basis, just like everything else!

11.) "There are DRA-safe exercises and exercises that no one with DRA should ever do!"

The internet is full of exercises that are considered "DRA-safe" and while the intention is generally good, it's not always the case that these black and white lists include accurate information for the individual performing the exercises listed. We have clients who will experience symptoms when they first do "safe" exercises like heel slides or supine marching and won't experience issues when they do more "challenging" movements. This is why it's crucial to not only look at what exercise you're doing, but how you're doing it, as well. Also, some "DRA-safe" exercises (like supine marching, for instance) will not provide some people with a great enough stimulus to challenge the core to improve and some of these exercises may be too challenging for others. Research also supports this(8) approach: testing of intra-abdominal pressure (IAP) in different women performing the same movements found a wide range, suggesting that some of the subjects were able to complete an exercise (a sit-up, for example) with a very small increase in IAP, while others showed a large increase. The way we do things matters and needs to be part of the equation when deciding what movements to focus on in an exercise program.

It's just not possible, without evaluating someone, to say for sure what movements they should do. (But don't worry, we'll provide some guidelines in Part 2!)

12.) "Just Wear an Abdominal Binder!"

Some gentle compression may be helpful in the early postpartum period. Additionally, some women find taping to be helpful. These tools are useful when the encourage the function of the abdominal wall and when additional loading (movement) is incorporated. They are definitely not a substitute for functional movement and without loading, the abdomen is not given the stimulus it needs to become stronger. Some binders function more as a corset, aggressively cinching the waist. This does not encourage the expansion of the ribcage/abdomen on inhale and can possibly increase downward pressure on the pelvic floor.

13.) "Diastasis Recti Rehabilitation is Too Complicated!"

Yes, the has been a long blog (Whew! Almost to the end!) but the concepts of DRA recovery are actually pretty simple. We've alluded to several of the strategies we use to address DRA, but for a fuller picture, you'll want to check out Part 2 of this blog where we discuss this more in depth! We first wanted to establish the what and why behind dispelling some of the common DRA myths.

References

1. Mota, P., Pascoal, A., Carita, A., Bo, K. (2015). Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with limbo-pelvic pain. Musculoskeletal Science & Practice, 20(1), 200-205. DOI: http://dx.doi.org/10.1016/j.math.2014.09.002

2. Gilleard, W. & Brown, J. (1996). Structure and function of the abdominal muscles in primigravid subjects during pregnancy and the immediate postbirth period. Physical Therapy, 76(7), 750-762.

3. Boissonnault, J., Blaschak, M. (1988). Incidence of diastasis recti abdominis during the childbearing year. Physical Therapy, 68(7), 1082-1086.

4. Benjamin, D., van de Water, A., Peiris, C. (2014). Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review.Phsyiotherapy, 100(1), 1-8. doi: 10.1016/j.physio.2013.08.005

5. Mota, P., Pascoal, A., Carita, A., Bo, K. (2015). The immediate effects on inter-rectus distance of abdominal crunch and drawing-in exercises during pregnancy and the postpartum period. Journal of Orthopaedic & Sports Physical Therapy, 45(10), 781-788. DOI:10.2519/jospt.2015.5459

6. Lee, D., Hodges, P. (2016). Behavior of the linea alba during a curl-up task in diastasis recti abdominis: An observational study. Journal of Orthopaedic & Sports Physical Therapy, 46(7), 580-589. DOI:10.2519/jospt.2016.6536


7. Hodges P. (2008). Transversus abdominis: a different view of the elephant. British Journal of Sports Medicine 42:941-944.

8. Shaw, J., Hamad, N., Coleman, T.,  Egger, M.,  Hsu Y, Hitchcock, R., Nygaard, I. (2014). Intra-abdominal pressures during activity in women using an intra-vaginal pressure transducer. J Sports Science, 32(12), 1176-1185. doi: 10.1080/02640414.2014.889845