This coming weekend I will be attending the Bellies Inc Course for Pelvic Floor Physiotherapists in Ontario. Their vision is to help eliminate “Mummy Tummy” – aka Diastasis Rectus Abdominis – by providing education, training and products. DRA It is a common condition that can affect a men and women, and it seems to be getting more “press” these days – which is a great thing! You will not believe the number of post-partum women who have been told something along these lines: “it’s just your new post baby body” or “there’s nothing you can do” or “just work on losing the weight”. But with new research coming out and with increasing awareness that DRA is not normal, more and more mamas are less and less willing to live with Mummy Tummy (ie. the Jelly Belly), which can wreak havoc in so many areas of life.

So what exactly is Diastasis Rectus Abominis?

• It is a separation and thinning of the rectus abdominis muscles (6 pack muscles – the most superficial layer of the abdominal muscles)
• It involves a stretching and thinning of the linea alba. The linea alba is a fusion of connective tissue formed by fascia of the abdominal muscles. It is found in the midline of the abdomen and runs from the xyphoid process to the symphysis pubis. This line is what turns dark during pregnancy…and then it’s called the linea nigra.
• The linea alba transfers force between the left and right sides of the abdominal wall, and it needs to be able to stiffen and generate tension to do its job effectively. (Side note: during a c-section, this important piece of connective tissue is cut and then, after the baby is born, is sutured up. There are 2 locations to suture the linea alba – the front and the back. Sometimes surgeons will suture both locations and other times they will only do one location. This can impact on the ability of the fascia to generate tension.)
• DRA can occur along the entire length of the linea alba, but is most often at the level of the umbilicus (belly button), which is where your belly gets the widest during pregnancy.

What causes Diastasis Recti? Who gets it?

• Pregnancy is the most common cause of DRA. It’s estimated that 90% of women in their 3rd trimester have some separation of the recti muscles. A separation is actually a natural adaptation of the body caused by the growing abdomen and stretching of abdominal muscles, and pressure from the baby.
• Women who have multiples (twins/triples), women who have had more than one pregnancy, women who are over 35, and women who have had abdominal surgery (including a C-sections) are more likely to have this condition post partum.
• Other individuals, including children and men, weightlifters, and other athletes can have DRA. It is usually caused situations that increase intra-abdomial pressure (IAP) such as obesity.

So if it’s considered a normal adaptation, what’s the big deal?

• The problem is when an abnormally wide gap (which is correctly termed the inte-recti distance – IRD) does not return a “normal acceptable” distance by 8 weeks post-partum. I have put quotes around “normal acceptable” because, as it turns out, it’s not really about the size of the gap. Although classic treatment for DRA has focused on closing the gap, clinically, we see women who are able to function just fine even though they still have an increased IRD after therapy. So if it’s not about the gap, then what?

• The main problem occurs when function is impaired through the abdominal canister. By 8 weeks post-partum, you should be able to generate tension along the entire linea alba while doing a correct contraction of the abdominal muscles. This piece of connective tissue and how it’s structured plays a very important role in maintaining the integrity of the abdominal wall. The linea alba, along with the the spine, bony pelvis, pelvic organs, and core muscles (diaphragm, pelvic floor, transversus abdominis, and deep multifidus) all work together to help transfer loads in an optimal way during daily movement tasks.
• If the linea alba and abdominal muscles thin out and stretch, and stay that way, their new state will compromise the overall function of the abdominal canister and core. This can lead to pain, increase risk of umbilical, aortic or inguinal hernias, decreased protection of aortic pulse, decreased strength and stability for daily tasks, risk of pelvic floor support related impairments such as prolapse or incontinence, increased exposure of abdominal organs, and sexual problems.
• Research shows that if a diastasis recti persists after 8 weeks post-partum, active intervention is needed otherwise it will not get better and will likely worsen.
• Much of my approach to treating DRA arises out of Diane Lee’s research and work. She is Canadian physiotherapist who is internationally renowned and written text books, published many articles and frequently gives conference presentations. Diane Lee is a leader in much of this new thinking on DRA and the function of the linea alba. You can check out some of her work here: http://dianelee.ca/article-diastasis-rectus-abdominis.php

What is considered to be a “normal acceptable” IRD?

• There is debate in the research. Typically, a DRA is considered to be a problem if the IRD is over 2.5 cm (about 2 finger-widths, depending on the size of your fingers.) However, various research articles cite various figures.
• Remember though, that the function of the abdomen is more important than the actual IRD. If the abdominal canister can function normally with an increased IRD, then the current thinking is that all is well. The goal of therapy is not just to “close the gap” but to restore normal functioning of the abdominal wall, of the muscles of the core including the pelvic floor, and generate normal degrees of tension through the linea alba so movements and daily activities are performed optimally without pain or dysfunction.
• For many women though, it is not just about function. As a physio, I need to be aware of this. Looks are important for many of my clients, not just function. They want a flatter belly, less flabbiness and better tone. Closing the gap is important for them too! Thankfully, with correct physiotherapy to treat DRA, function will return, and it is most often accompanied by a much nicer looking, firmer mid-section.

How do I self-assess for Diastasis Rectus Abdominis?

1. Lie on your back with knees bent and feet on the floor with hands by your side. Then check the state of the linea alba from top to bottom and the left and right rectus abdominis muscles just to get a baseline idea of what it feels like without any tension.
2. Then place your fingers along the midline (linea alba) and slowly lift your head off the ground keeping chin tucked in. Come up one slowly until you feel a tightening or tensioning under your fingers. Use your fingers to feel along the entire length of the linea alba for tension. It should feel like a hardening or tightening under your fingers. Then lower your head.
3. After, you can check for the IRD (the gap). Starting with your head down, place one finger perpendicular to the linea alba, at the level umbilicus.
4. Lift your head slowly with chin tucked in very slowly. Continue lifting until you feel the borders of the rectus muscles starting to squeeze your finger. Then lower your head. Add another finger beside the first one (running horizontally) and slowly lift your head until you feel a little squeeze or hug on the sides of your fingers. Lower, then repeat until you can’t fit in any more fingers. Do not consciously contract your abs – you are not trying to do a crunch here. If you engage your abs consciously you are likely to get an inaccurate result.
5. What do you observe with your self-assessment?

• Is there bulging or tenting of the abdomen?
• Do you feel a separation or do you feel the muscles “grab” your fingers?
• How far apart are the borders of your rectus abdominis?
• Do you feel tension or not along the length of the LA or is it soft?
• Do you have pain in your back, pelvic girdle, or abdomen?
• Can you feel a pulse?
• Do you fingers keep sinking deep in and you feel no real end?

How does a post-partum mom fix a DRA?

• It basically comes down to two big ideas. 1) Stop doing what will make it worse! 2) Start doing what will help it out! What will help it out? A number of things which a trained physio can tell you all about. But the basic principle is to create loading (ie. tension) through the linea alba. Diastsis recti is not healed by passively bringing the two rectus abdominus muscles together to meet in the middle. Load is needed to heal because this is how connective tissue is repaired. It’s a similar idea to if you have a muscle that is over stretched or torn. You can have to actually load (ie. train and exercise) that muscle gradually and progressively in order to repair it.

So how do I prevent Diastsis Recti from worsening?

• Prevention is the best medicine. While you’re pregnant there are many things you can do to minimize a DRA and promote faster healing. It involves practising in advance the same exercises and concepts you will need to do post-partum.
• After you’ve had your baby, avoid typical abdominal workouts, especially crunches, double leg lifts/lowers, or anything that increases pressure through the abdomen – ESPECIALLY in the first 8 weeks post-partum. It’s important to get checked around 8 weeks to makes sure you’re ready to return to sports or the gym.
• Avoid positions that over stretch the already over-stretched rectus muscles -a trained physio can tell you what some of these positions are.
• Wear a belly wrap during the first 8 weeks post-partum to support the weakened abdomen. This is when you are most vulnerable to worsening a DRA. The wrap is not to “close the gap” but rather to support the abdominal canister while recovery takes place post birth. There are several different types of supports out there. Talk to me to find out which might be best for you.
• Do not jack-knife out of bed or when rising off the floor or from a lying position – instead, log roll to your side and push up with your arms. Same thing applies when getting back into bed. Don’t do a “reverse sit up” to lie back down.
• Avoid postures where your pelvis is thrust in front of your thorax or is behind your thorax – instead, stack your thorax over your pelvis. This is very important – alignment, alignment, alignment – it cannot be overstated. Many postures mamas assume post-partum actually cause problems through the abdomen, pelvic floor and back.
• Avoid exercises, movements or activities which will increase intra-abdominal pressure (IAP). You may need to take a break from high intensity exercises or sports, or modify your work out then gradually build back up as your core capacity for tolerating that sport/exercise routine increases. You will need to take care to protect your core during high IAP generating events – such as sneezing, coughing, and moving your bowels.
• Engage your core correctly when picking up baby or objects. You may need to be taught how to do this the right way.
• Everyone is different – so the best thing is to get assessed and then generate a list of specific things that YOU should avoid or modify or discontinue all together.

What can you, a pelvic-floor physiotherapist do for my Diastasis Recti?

• A lot, actually. =) First of all, I assess. Not just your abdomen but your entire system. This includes your alignment, how you move with specific tasks (bio-mechanics), the status of your pelvic floor, your core recruitment strategies, how your breathe…just to name a few. It’s important to look at a DRA in the wider context of your body and daily function. A thorough assessment will help us determine all the factors which may be causing or contributing to the DRA
• Then we come up with a plan. We look at what areas need to be fixed (is it your alignment? is it how you breathe? your weak and lengthened pelvic floor muscles? etc) and then systematically address each one. I ask the question “what is driving the dysfunction here?” and seek to treat the driver.
• Training the core (pelvic floor, diaphragm, transversus abdominis and deep multifidus) as a coordinated unit so optimal load transfer can take place through the abdominal canister is tres important. We focus first on training the core in unloaded positions (ie. lying down) and then move on to more functional positions – sitting, standing, squat, lift etc – keeping your many daily movement tasks in mind as well.
• And of course, there is a big focus on changing the poor ingrained patterns of movement anddysfunctional strategies which you’ve learned over the post-partum period (or perhaps your whole life!) Remember that it’s just as much about “stopping things that are making the DRA worse” as it is about learning new and more optimal ways of moving. Success with treating a DRA, as with almost anything in rehab, requires a lot of focused awareness and brain retraining until things become automatic.

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Well, I am sure to gain some new insights about diastasis recti after completing the Bellies Inc. course. I will write an updated post to share any new info I learn from the course, so please check back!

If you suspect that you have a DRA, please don’t just accept it as your new normal post-baby body. It will not get better on its own and is very likely to worsen and cause other problems related to a dysfunctional abdominal canister. Contact me for a professional assessment of your pre or post-natal belly and also check out the Mummy Tummy Redefined program – it might just be the thing you’ve been looking for. Also, please share this info with your pregnant or new-mommy friends. And your doc. And your midwife. And anyone else you can think of. Knowledge is power!

I’d like to hear about your experience. Do you have a diastasis recti? Were you told it’s normal and to just accept it? What is your story and how has it impacted your life?