A fit pregnancy will help you bounce back after pregnancy.
Lots to unpack here, but let’s keep it simple. Yes, it’s a great idea to stay as active as you can during pregnancy (for you and the baby). Yes, it’s important to have a plan and support team to return to exercise postpartum. But let’s be clear, where are we bouncing back to and why is it so important that we constantly guilt moms throughout this entire experience?
I’m 100% sure I didn’t bounce back after either of my pregnancies. It’s pretty hard to bounce when you’ve unexpectedly been in the hospital nearly a week, did the better part of a vaginal delivery only to end up with a C-section and every appendage is so swollen that you have to send your mother in law to @target to get underwear with leg holes large enough to accommodate your swollen thighs.
Nope. No bouncing back.
Even with the perfect pregnancy/delivery without complications, why are we so anxious to bounce back? I have no desire to bounce back to a time when I wasn’t connected to my body and had a distorted idea of what post-partum looked/felt like (even after working with post-partum moms for nearly 10 years!)
Bouncing implies a rush, a quickness. Post-partum is anything but that. Days are long and nights are longer. You see other moms casually pushing a stroller, clutching their non-fat mocha latte- trust me, there are tired eyes under those sunglasses. The mom that returned to CrossFit before the 6-week postpartum mark, unless she’s seen a pelvic PT (and I have friends who have returned early but they got checked first and were being monitored), she may be ignoring leakage with her doubleunders, afraid that if she stops going to the gym she’ll have no outlet for her stress or connection to who she once was. We can do better to support our moms.
If you’re not bouncing back, then where to? How about reality. Kids are progressive resistance. Just getting them out of the house to go for a walk is an endurance exercise in of itself. Find your deep core while finding your community. One of my very closest family friends is a mom who I met at mommy baby yoga when our boys were 4-5 months old. The family moved a few hours away but we’re still close. Trust me, you’ll need that support. The best part is, when we’re all together now, we move. We ski, we run, we paddleboard and swim.
We only get to do post-partum as often as we have kids. See it for what it is, an opportunity to give yourself grace, and intentionally find the pathway back to wherever you’re going that works for you. Plan for it to NOT go according to plan. The baby weight may stay a little longer than you thought, your abdomen might feel like a hollow cave or your descending organs may be a parting gift that your child decided to take along with them during delivery. Support each other. Get educated. Get help. There is a better way.
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 IRD2,6,11,13,15,16. 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.
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.
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.
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.
Hills NF, Graham RB, McLean L. Comparison of trunk muscle function between women with and without diastasis recti abdominis at 1 year postpartum. Phys Ther. 2018;98:891–901.
Keshwani N, Mathur S, McLean L. Relationship between interrectus distance and symptom severity in women with diastasis recti abdominis in the early postpartum period. Phys Ther. 2018;98:182–190.
Mota P, Pascoal AG, Caritac AI, Bo K. Normal width of the inter-recti distance in pregnant and postpartum primiparous women. Musculoskeletal Sci & Practice. June 2018;35:34-37.
Tuttle L, Fasching J, Keller A et al. Noninvasive Treatment of Postpartum Diastasis Recti Abdominis: A Pilot Study. J Women’s Health Phys Ther. 2018;42(2):65-75.
Blotta RM, Costa SDS, Trindade EN, et al. Collagen I and III in women with diastasis recti. Clinics (Sao Paulo). 2018;Jun 7:73.
Kamel D, Yousif A. Neuromuscular Electrical Stimulation and Strength Recovery of Postnatal Diastasis Recti Abdominis Muscles. Ann Rehabil Med 2017;41(3):465-474.
Chiarello C. Pregnancy-Related Pelvic Girdle Pain and Diastasis Rectus Abdominis. J Women’s Health Phys Ther. 2017; 41(1);3-9.
Mommers EHH, Ponten JEH, Al Omar AK, et al. The general surgeon’s perspective of rectus diastasis. A systematic review of treatment options. Surg Endosc. 2017;31:4934–4949.
Sperstad JB, Tennfjord MK, Hilde G, Ellstrom-Engh M, Bo K. Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. Br J Sports Med 2016;50:1092–1096.
Lee D, Hodges PW. Behavior of the Linea Alba During a Curl-up Task in Diastasis Rectus Abdominis: An Observational Study. J Orthop Sports Phys Ther 2016;46(7):580-589.
Keshwani N, McLean L. Ultrasound Imaging in Postpartum Women With Diastasis Recti: Intrarater Between-Session Reliability. J Orthop Sports Phys Ther 2015;45(9):713-718.
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Pelvic girdle pain (PGP) is pain that you might feel in the back of the pelvis (near the sacroiliac (SI) joints or buttocks) or at the front of the pelvis (symphysis pubis or pubic bone). This pain might shoot down your groin or thigh and is common during pregnancy (definitely not limited to!) Hormone and posture changes during pregnancy can increase the likelihood of PGP during pregnancy and it may worsen with a growing belly! If you’ve had PGP then you’re more likely to have it again during or after pregnancy. The good news is pain and function can be managed well with physical therapy manual techniques, prescriptive exercise and posture management!
Pregnancy can be exciting but challenging to know what your body is supposed to feel like and how it’s supposed to function! It is common to have aches and pains during pregnancy, however being pregnant doesn’t mean you can’t do something about it! We commonly treat patients for pelvic girdle pain (symphysis pubis or Sacroiliac pain), nerve pain that might shoot down your leg or even prevent you from walking or exercising! We work together to help you find comfortable movement, exercise safely and prepare with your medical team (including midwives and doulas!) for your delivery! We also prepare as much as possible to get you ready for the first few weeks of post-partum which may include setting up an initial visit within 3-4 weeks of your due date so you can get a jump start on your recovery!