Postpartum

I’ve been a women’s health physical therapist treating diastasis recti for nearly 20 years.  Ironically, after 3 pregnancies & 2 C-section deliveries, I diagnosed myself with diastasis recti.  I remember initially addressing it conservatively, not wanting to make things worse, wanting to follow the rules, and accept there may be things I wasn’t going to be able to do the rest of my life including certain types of ab training.  It took another physical therapist and a coach to help me realize I was self-limiting my movement out of fear of DRA.  It took others to help me realize I wasn’t broken but I was weak, and there are endless options for exercise in the context of DRA.

Whenever I work with clients with diastasis recti, my first question is to ask how far down the DRA internet rabbit hole they’ve gone.  If you search online for “diastasis recti,” in a few clicks of the mouse you are either completely confused about planks and sit-ups, have a sudden burning desire to throw down a few bucks for online programs promising a proven way to fix your DRA with one exercise or you’re completely paralyzed with fear that you might do the “wrong exercise.”  It’s challenging to navigate the confusing waters of exercise in the context of a DRA diagnosis.  Consider this your guide.

First, the basics. Diastasis recti (DRA) or abdominal separation, is commonly experienced during and after childbirth.  There are no clear criteria to identify women who are likely to have the abdominal separation that persists months after pregnancy nor do we have a concrete idea of how to prevent DRA.

Many women seek out help with DRA because they feel weak and don’t like how they look.  Women often feel their post-partum body is foreign to them since having children.  In many cases, they are looking for the quickest path back to how they looked and felt before becoming pregnant.  Expectations can range from acceptance of the change to complete rejection of a belly that met the enormous challenge of growing a small human for nine months.  Social media has intensified post-partum messaging, causing many women to feel inadequate or implying they did something wrong if they have a separation in their abs.   More and more voices are providing education, frequently from fitness professionals hoping to teach others from their own experiences.  Take my story for what it’s worth- I was educated, did my due diligence during both pregnancies, and still had issues.  It’s complicated, plain, and simple.

An extremely important part of working with these clients is to dispel post-partum perfection myths, reduce fear, and provide a realistic, progressive exercise program to help them achieve their goals. First and foremost, women with DRA are not broken.  Assuming an umbilical hernia isn’t in the mix, primary abdominal training issues in women with DRA need to focus on addressing inefficient control of intra-abdominal pressure and abdominal weakness, both frequent issues following childbirth.

A rundown on the research:

In order to help, it’s important for women, trainers, coaches, and rehabilitation professionals to understand, there’s a lot we don’t know about DRA.  DRA research is slim compared to other more mainstream issues like low back pain, but the quality and quantity are improving.  We are learning that some factors influencing DRA may or may not be under our control.  One recent study looking at collagen types found that “collagen make-up in the midline of the abdominal wall may play a key role in the development of diastasis recti.”⁷ Translation: blame your parents!  Some collagen types may not be as supportive or elastic, potentially influencing the gap or ability to manage intra-abdominal pressure.  “Gender, concomitant hernias, previous abdominal surgery, number of pregnancies and multiple births, spontaneous birth or caesarian section, skin condition, diagnostic procedures,” all which may potentially influence a patient’s DRA diagnosis.¹  Activity related intra-abdominal pressure control strategies before and during pregnancy including Valsalva maneuver with weight lifting or chronic straining with toileting are the focus of many commercial training programs, however, need further research to show efficacy in prevention of DRA.  Translation:  we know focusing on pressure control helps after DRA but lots of other factors are in play.  We still don’t understand how to best prevent DRA in all women.

Does the gap matter?

The jury is still out on this one and many questions persist.  DRA has been historically defined by “the gap,” or the IRD (inter-rectus distance).  Until recently, the goal of many post-partum exercise programs was to reduce the gap, resulting in a “fix” or recovery from DRA.  We do know there may be a potential correlation between the gap size and poor body image in women within the first few weeks after delivery.⁴ This isn’t surprising (I don’t recall sleepless nights, breastmilk stained clothing and gnawed nipples helping with my body image during that time either).  Past exercises have focused on physically bringing the two sides of the abdominals together with crossed hands or a band to “close the gap”, hypothesizing that training the muscles close to each other would teach them to function that way again.  Fortunately, the evidence has progressed from this limited and incorrect understanding.  Now there are fewer limitations on what women with DRA can do with respect to exercise.

Recent research has looked at gap “closure” by comparing the “curl-up” v. “drawing-in” maneuvers.   (The “drawing-in” maneuver is typically considered a contraction of the transverse abdominals, the deepest of the abdominal muscles.)  Ultrasound imaging has become the gold standard for accurate measurement of the IRD, however, finger width remains the most common measurement utilized in a clinical or training environment. Several studies have noted that the “curl-up” maneuver reduces IRD and the “drawing-in” maneuver increases the IRD^{2,6,11,13,15,16}.  This is where it can be confusing.  If increasing the gap is the root of all evil in DRA exercise, what do you do with all your deep abdominal training?  Are crunches good again?

How about obliques and rotation exercises?  One study identified that “women with DRA demonstrated significantly lower trunk muscle rotation torque and scored lower on the sit-up test than those without DRA³.”  In the context of the idea that there’s less ability to translate forces across a larger gap or un-tensioned linea alba¹³, it makes sense that trunk muscle rotation torque would be less. Is rotation exercises good again, too?

The short answer is that there’s no exercise “off the table” when it comes to DRA.  The more we learn about DRA, the factors involved, and how many women continue to do challenging sports and activities without worsening symptoms, we have permission to keep looking for new answers.  No research specifically states that crossover crunches, bicycle crunches, planks, or sit-ups are bad and are to be avoided at all costs.  We know that unexercised muscles are weaker than exercised muscles.  Fact:  Women who are scared and don’t exercise will become weak.  We need to help find the path back to strength and confidence in their own bodies again.

Play. Monitor. Scale.  Use breath strategies including focused exhalation before and during exertion to use the transverse abdominals to assist in the control of IAP.  If you’re not sure what strategies you or your client is using, collaborate with a physical therapist or rehabilitation professional skilled in rehabilitative ultrasound imaging.  Find practitioners that use imaging to improve muscle activation strategies and learn how breath can assist in abdominal activation under different contexts.

Know the orange flags.

DRA is not directly correlated with low back pain, pelvic organ prolapse, or incontinence.  However, these diagnoses are commonly seen in post-partum women.  Organs, urine, feces, and uncontrolled gas should never have an unplanned exit from the body during exercise.  These symptoms should always be checked out.  Pressure or a feeling of heaviness at the perineum may also indicate pelvic organ prolapse, requiring an assessment from OBGYN or physical therapist.  Pain in the abdomen, pelvis, or perineum is not common with DRA and requires a medical assessment as well.

Know the yellow flags.

Abdominal doming or coning has been in the media more recently, cited as an indicator that an exercise is too challenging (the literature hasn’t taken a position on whether this is good or bad yet…most media says bad though!).  Uncontrolled outward pressure forming a central dome or cone can be used as a potential indicator of inefficient pressure control strategies or of an exercise that may need to be scaled.  It’s not bad.  It’s just something that gives us information about pressure control strategies.  Breath strategies using focused exhalation used in different contexts and scaling movements can address challenges in both concentric and eccentric (shortening and lengthening) muscle activation.

Teamwork

It’s important to notice when what we see correlates with what we feel as practitioners and patients.  It’s important to collaborate with a physical therapist trained in working with athletes with DRA to find pressure control and movement strategies that help your client.  Make sure you are all on the same page with the message that DRA does not equate to stopping movement altogether.  DRA equates to understanding pressure, smart scaling, and progressions as well as dispelling the myth that you or your client is broken.

I’m lucky enough that my work interests kept me from diving down the rabbit hole of DRA, but even the most educated of us need reminders.  I run, CrossFit, do pilates and yoga with the ability to self scale, monitor pressures and know when I can push myself further, not worrying about my gap.  I challenge you to re-examine your beliefs about DRA in the context of the literature.  I challenge you to partner with a physical therapist educated in the context of athletes when working with women with DRA.  I challenge you to work collaboratively to understand fears regarding exercise and help break barriers with educated movement instead of imposing unwarranted limits.  Keep learning.  Keep thinking.  Keep moving.

1. Reinpold W, Köckerling F, Bittner R, Conze J, et al.   Classification of Rectus Diastasis—A Proposal by the German Hernia Society (DHG) and the International Endohernia Society (IEHS). Front. Surg. Published online 2019;Jan 28.6:1.
2. Sandra L. Gluppe, Gunvor Hilde, Merete K. Tennfjord, Marie E. Engh, Kari Bø. Effect of a Postpartum Training Program on the Prevalence of Diastasis Recti Abdominis in Postpartum Primiparous Women:  A Randomized Controlled Trial Phys Ther. 2018;98:260–268.
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