Diastasis Recti : Now What?! (Part 2)

(Pssst....make sure to check out Part 1 first!)  

Now that we've established that many of the popular messages we hear about diastasis recti abdominis aren't entirely accurate, let's come up with a better way to address DRA!

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First, let's make sure you're assessing your DRA correctly.

  • First, lie down on the ground with your knees bent, feet flat on the floor. (Placing your hands directly on your skin (instead of your shirt) give you better feedback as to what your tissue is doing.)

  • Place three fingers horizontally across your belly button (to start) and press firmly as you lift your head off the ground, towards your chest. You're feeling for the ridges of your rectus abdominis ("6-pack" muscles) and the tissue between them. As you press into that space, gauge the distance (in finger-widths) and the tension (does it feel firm, like the tip of your nose? or soft like your cheek?) Write down these findings.

  • Repeat the measurements halfway between the belly button and the sternum and halfway between the belly button and the pubic bone and note your findings there, as well.

  • Now, repeat the test but use your "piston breath" (a la Julie Wiebe, PT). Inhale, and then begin your exhale, gently lifting your pelvic floor muscles (imagine drawing a bean up into your vagina/anus) before and as you lift your head. Do you notice a difference? Repeat these measurements above and bellow the belly button.

Most women will find that their linea alba is able to generate more tension when they exhale and lift versus when they just lift their head. This is great! This gives you an indication of how your inner core system is better able to support you with an intentional exhale (which supports to integrated functioning of the inner core unit) and may lead to what had previously been considered a DRA to be what we refer to as a "functional" DRA. While a gap still exists, the abdominal wall is able to generate enough tension and manage pressure well.

Many women will also note that if they change the position of their pelvis, or bring their head up more, their gap and tension will change. This is a good reminder that the rest of our body impacts our core. This also reminds us that there is no real standardization in measurement and so it’s important not to get hung up on the numbers.

If you've assessed yourself and find your linea alba to be in need of some TLC, consider these strategies to help rebuild your strength and stability:

What to try: Seeing a Pelvic Floor Physical Therapist (PFPT).

How it can help: It would be remiss of us to neglect to mention the value of a trusted PFPT. Our scope as fitness professionals is limited and we encourage everyone we work with to see a PFPT after birth, or whenever indicated. The pelvic floor sets the foundation for the rest of the core's functioning and while we can offer tips on how to get a general idea of how its functioning, the most accurate way is by getting an assessment with a PFPT. They can also better assess how the rest of your core is functioning due to their advanced training and speciality in rehab. We strive to maintain close relationships with PTs practicing in our area so that we can better service our clients. A PFPT also has access to tools that some women may find helpful - SRC recovery shorts (for early postpartum), kinesio tape, etc.

What to try: Pay attention to your daily postural habits. How do you stand/sit all day? Are you thrusting the rib cage? Tucking your pelvis under? Always carrying a child on one hip?

How it can help: There is no such thing as "perfect posture", as our bodies are capable of assuming a variety of positions and should be encouraged to express this variety but often, we will find that we tend to always wind up in the same position over and over again and it's not always one that promotes our muscles being able to work most efficiently or effectively. Particularly during the initial stages of DRA, a ribs-over-hips alignment is preferred, particularly when the body is under load. You won't (and don't need to) maintain this position 24/7, but an awareness of what your body is doing can help!

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What to try: Pay attention to your breathing.

How it can help: Our inner core musculature is deeply (no pun intended ;) ) involved in our breathing. When we inhale, our diaphragm descends to allow for the lungs to fill with air. Our internal organs (and potentially our growing baby) head downward and our pelvic floor musculature descends to receive the change in pressure. Additionally, the ribcage and abdomen expands to make room for the inhaled air. On exhale, the reverse happens: the pelvic floor recoils, the abdomen and ribcage gently "deflate" and the diaphragm ascends. This balance allows for intra-abdominal pressure to be managed, and for our bodies to stabilize from the center: two things that are important for DRA improvement.

Many of us hold our breath to complete low-level tasks (like picking up a piece of mail off the ground, or getting ourselves out of a chair). For most of us, this level of difficulty isn't anywhere close to our maximal lifting capacity (where a breath hold is going to be appropriate and necessary). In life, and in fitness, and especially when managing DRA (a condition of poor pressure management), using our breath is helpful for optimal results.

Julie Wiebe's "Piston" approach is our preferred way to communicate and implement a strategy of breathing that works to retrain automaticity and full function. Before exertion, we use a "blow before you go" (a term coined by Wiebe) cue that triggers the inner core unit to engage when we need the greatest support. The "exertion" is usually described as the "hardest" moment in a movement, for instance, coming up from the bottom of the squat (you would "blow before you go" (BBYG) just before you stood up). You may find, especially in the early stages of DRA healing, that an exhale (and BBYG) throughout the entire range of motion (in the squat: throughout the descent and ascent) feels more supportive. That's a great choice for you, then! You will want to play around with what feels best for your body, during your movement.

As we are "blowing before we go", we're also giving intention to what's happening in our deep core musculature. Another cue coined by Wiebe, "pick up (your) bean" refers to the action of the pelvic floor as it recoils on exhale. We give awareness to "picking up the bean" and "gently zipping up a pair of pants" as cues to bring awareness to the action of the pelvic floor musculature and the transversus abdominis. The eventual goal is a functional return to automaticity, but many women with DRA will initially have to give more intention to their breathing and what their inner core unit is doing during movement (in- and outside the gym).

Here it is, broken down simply. We'll use the example of getting out a chair:

Sitting in the chair (and checking in to align yourself with your ribs over hips), you'll inhale before anything happens, imagining an umbrella opening in your ribcage, allowing for 360 degrees of expansion.

You'll then begin your exhale, gently lifting your bean, and then start your ascent.

Continue your exhale to carry you to the top and inhale as you descend to start the process over again.

Initially, you may find that an exhale throughout the entire range of motion feels more supportive (meaning, you would also exhale as you descend). You can pause in between each movement to inhale and then have your exhale support you as you're moving through the position that feels unstable to you.

You can use this strategy for strength training, picking up your kids, shutting sticky windows, etc.

What to try: Modifying your movements outside of "exercise"

How it can help: Our body works as a system, not in isolation. Even our movements that may not immediately seem to be related to DRA (getting up from a chair, driving to work, etc.) can have an impact on our healing. We're not going for perfect here - we're going for awareness and progress. Many of us wear our babies for hours while thrusting the hips forward and ribs back, potentially creating a situation that may prevent a DRA from healing as efficiently as possible, for instance. We also might be forcefully bearing down (on our pelvic floors) and out on our abdomens when we aggressively sit up each time from the floor, or while getting off the couch. Again, it is not necessary to obsess about every little movement you're doing, but some intention, especially in the early postpartum period, will allow your body to rebuild its strength more successfully. It is also important to assess whether you're gripping your abdomen/glutes/back all day. Many of us hold excessive tension throughout our bodies, instead of allowing for a dynamic state of tension and relaxation throughout the day. We recommend setting an alarm for every hour (or 2) and using that as a designated time to check in with your body: are you holding tension in places where you don't need it? Strive to build awareness on releasing the excessive tension in your body.

What to try: Modifying your "core" movements during exercise.

How it can help: Structured movement that meets you at your current ability level and progressively becomes more challenging provides the stimulus necessary to promote change. Initially, we'll spend some time focusing on building a connection with the deeper core musculature. We recommend doing this in a variety of position, as life occurs in a variety of positions. Many DRA programs have only featured "core" exercise in a supine (lying down, face up) position but we don't live the entirety of our lives on the ground. Here are some exercises that we're fond of that replace typical "core" exercises(not all of these will be appropriate for every person. You can monitor your core's performance by feeling what is happening, as best you can, or by taking a video to watch yourself. You are making sure to not "dome" or "bulge" at the linea alba, you're not holding your breath, and you're feeling gentle activation from the pelvic floor and TrA.) This is by no means an exhaustive list, but these are exercises we felt comfortable suggesting, knowing that some women reading this may not have access to in-person help. (Please, of course, seek assessment from a Dr./PT before beginning any exercise program.)

Lying down:

(P.s. don’t press your low back into the floor, as is often suggested. Allow for a neutral curve in the lower back.)

Supine Marching

Heel Slides

Dead Bug Variations

Supine Cable Pulls

Supine Dumbbell Resists

Pallof Press

 

Quadruped:

(Watching out to make sure your abdomen isn't merely hanging down here)

Quadruped rocking

Bird Dog Variations

 

1/2 Kneeling:

Chops

1-Arm Fly

Pallof Press

 

Kneeling:

Weight Raise

Pallof Press

1-Arm Fly

Cable Press Down

 

Seated:

Marching

(+any of the above kneeling exercises)

 

Standing:

Chops

Cable Press Down

1-Arm Fly

Pallof Press

Weight Raise

Weighted Carry

Unilateral Weighted Carry

Check out this video for an overview of the above:

 

What we’d also like to mention is that, during a training program, we’re implementing exercises that first encourage the retraining of the core system before we’re concerned about intensity or “fitness” in a conventional sense. It is important to address your core’s function in various positions, not just lying down, or seated. We continue to assess and reassess as we progress. There is no list of magic exercises, unfortunately (trust us, we wish that list existed!)

What to try: Prioritize whole-body strength

How it can help: Our entire body is at least somewhat affected by a DRA and so we address not only the core, but the body as a whole. Our preferred method for addressing whole-body fitness with mamas is to incorporate movements that prepare them for both daily life, and higher-level fitness pursuits.

Remember, it's not just *what* you do, it's *how* you do it. We recommend implementing Julie Wiebe, PT's Piston approach here. Ribs over hips, hips untucked, blow before you go.  

Here are some (likely) familiar movements/exercises. Each movement has a version that is likely more supportive to the core and one that isn’t. Prioritize rib over hip alignment, that “blow before you go” exhale, and being aware of your core’s function in not only your daily life, or “core” exercises, but in the resistance training you’re doing for your entire body.

 

You don’t need to get too creative here. Focus on first being able to manage your own body weight, then begin to add load. Stick to basic movements and focus on progressively making them more challenging. It is important to continue assessing your DRA and symptoms as you perform exercise. Movements/exercises will vary in their appropriateness for each person and the only way you will definitely know is by trying them and assessing for function/pain/undesirable symptoms (doming, bulging, discomfort, feelings of being unsupported). We make no claims that any of these exercises are appropriate for someone with DRA; instead, we remind you to monitor closely and evaluate your personal needs.

What to try: Consider the programming of various movements

How it can help: In the early stages of DRA healing, we often prioritize upper body horizontal pushing to upper body horizontal/vertical pulling in part because some women will lack the mobility to perform overhead pressing/rows/pull-up type movements without flaring the ribcage. This doesn't mean that there isn't a place for those movements; it just may mean that we are more critical, especially early on, with the distribution of movements in your program. We are also particularly interested in rotational movements and assessing whether the person performing them is able to do so without flaring the ribs or losing power from the hips/trunk. Sometimes, we find that rotating towards (instead of away from) the midline yields a greater ability for the client to feel what’s happening, but this is not a rule.

What to try: Address habits outside of the gym/movement.

How it can help: Your body's first priority, when you're not sleeping, not eating well for nourishment, and chronically stressed, is not going to be to devote energy to healing DRA as well as it possibly could be, if it were better supported. This can be really difficult postpartum; we definitely get it! The reality is, this time period is often so chaotic that taking care of yourself may have obstacles that are too difficult to fully overcome. Instead of hoping for perfect sleep, and the most healing nutrition, focus on what you can realistically do. Can you have your partner take care of baby while you catch up on sleep? Can you outsource meals so that you always have something that nourishes you? Can you enlist in the help of a mental health professional (many work online now!), if you're feeling overwhelmed? Self-care is not selfish and the healing of your DRA can be assisted when more of your wellness needs are being met.

What to try: Getting help from an exercise professional.

How it can help: Having another set of eyes can better help you navigate what may be keeping your DRA from achieving resolution. We're happy to help, of course! If you're not local, please feel free to reach out and we can try to connect you with an exercise/rehab professional in your area.

What to try: Give yourself grace, patience, and support.

How it can help: We know that it can feel frustrating when it feels like your body is not recovering from pregnancy and birth. We also want to gently remind you that recovery from any exhausting event is taxing on the body and takes time. Having emotional support while managing DRA can be crucial. Working on body image, letting go of preconceived beliefs about how your body “should” be functioning, and giving yourself the permission to accept where you are is helpful. Obsessing about DRA measurements and spending every moment thinking about your DRA is neither healthy nor helpful. We support you and want to support you supporting yourself; please reach out to us, if you’re feeling particularly down about your DRA. We will help you get the resources you need.

What to try: Surgical intervention.

How it can help: Not everyone can resolve their DRA with conservative measurements. This doesn’t mean that you failed, or that exercise doesn’t “work”, it just means that surgical intervention is the most applicable tool for your unique situation. The recommended criteria that, when met, suggests surgical intervention is warranted is: a woman is at least a year postpartum, and a proper program geared at restoring function has not led to the desired results, the abdominal contents are easily felt, the woman is unable to control pelvic motion during uni- or bilateral squatting, the ability to stabilize increases when the abs are approximated, in addition to a few other physical and neurological assessment findings. Simply put: if it’s been over a year and you haven’t seen resolution and your function is suffering, surgery may be a good choice.


We hope you've found this two-part series to be helpful. Many new mothers feel overwhelmed with the wealth of information out there for diastasis recti abdominis. We know this was a long read, but we believe that the greatest gift we can give to new moms is the sharing of knowledge. Our knowledge is always expanding. We are constantly evolving our skillset in an effort to greater serve our clients, and as new information arises, we’ll be sure to keep you posted on updates to our approach! If you have any questions, need clarification on anything discussed, or would like to set up an assessment session at any of our 4 Bay Area locations, please let us know! We would be happy to help you as best we can.