By Heather Jeffcoat, DPT ~
Your body undergoes many changes during pregnancy and the postpartum period. These changes are common, but should not be considered your new normal. The most common outward physical presentation of women I see after childbirth is the presence of a Diastasis Rectus Abdominis (DRA). This is a separation of the rectus abdominis muscle, or the “six pack” muscles. One study reports 100% of women who have gone beyond 35 weeks gestation (Fernandes et al) will develop a DRA (or a “diastasis” as I more frequently see it referred to in on-line mom forums).
A DRA presents typically two ways: A vertical bulge in the midline of the body or as a “valley” or “gap” running down this same line. During pregnancy it typically presents as a bulge, but this can also be seen postpartum.
There is limited research looking at the amount of time it takes to reduce these changes, either with or without intervention. Women may not realize they even have one, but they certainly feel the symptoms of having it postpartum. Common symptoms typically found with a DRA are back pain, urinary incontinence, sexual dysfunction, constipation and prolapse. These are symptoms of a poor functioning core and pelvic floor dysfunction (Delal et al, 2014; Parker et al, 2009; Goudzwaard et al, 2005; Spitznagle et al, 2007; Smith et al 2008). While some women’s bodies naturally recover (without intervention) from a DRA, however this does not occur for all women.
My approach to treating a DRA begins with education. Imagine your core muscles like a canister – you have the four layers of abdominal muscles in front (from the deeper to surface: Transverse Abdominos, Internal and External Obliques and the Rectus Abdominis), the pelvic floor muscles below, deep muscles in the lower back and the diaphragm at the top. The primary functions of these muscles are to provide postural, pelvic, abdominal and breathing support. Specifically, the pelvic floor muscles need to coordinate to open and shut the sphincters at the appropriate times as well as contribute to sexual function.
Some women tend to be more concerned about the physical appearance of this “gap” rather than the functional implications that can lead to back pain or pelvic floor dysfunction. The old school way of treating a DRA was to focus solely on reduction of this space, but newer research indicates that the more important focus should be on creating adequate tension across the midline, to reduce the bulge and properly recruit muscles that will offer support during daily activities. This includes taking care of your child or returning to exercise programs. With the hormonal, postural and activity demands of the postpartum period, women should be cautious in their return to a rigorous exercise program so as not to exacerbate these other concurrent conditions.
Here are some of my favorite early postpartum exercises, from an article I published in the International Childbirth Education Association’s journal. These are great starting points for most women, and should be mastered before venturing towards more rigorous exercises. It is important that the form and proper muscle recruitment patterns are adhered to in order to fully support the other structures in the “canister” without loading too much on your DRA or pelvic floor. In some ways it appears as if one is just going through the motions of the exercise, but it is more about the way you do the exercise that will get you to reach your goals with less long-term negative effects.
Lastly, I understand the cosmetic aspect as well. Our program at Femina Physical Therapy works to not only reduce this gap, but also restore the proper function of your core muscles. We utilize a combination of manual techniques, exercise, coordination training and, if applicable, muscle biofeedback training for the pelvic floor in order to optimize our patients results. Our practitioners believe that restoring core function is an essential component to ensuring new moms can physically care for their babies and return to exercise without pain or dysfunction.
Heather Jeffcoat specializes in treating Orthopaedic and Women’s Health physical therapy diagnoses through the lifespan, as well as developing personalized Perinatal Fitness programs. Her special interests are treating pelvic pain (vaginismus, vulvar vestibulitis, levator ani syndrome, pudendal neuralgia, interstitial cystitis (IC)/ painful bladder syndrome (PBS)), voiding dysfunction, sacroiliac joint (SIJ) dysfunctions, pregnancy and post-partum related disorders (sexual pain, incontinence, back/hip pain, diastasis recti, among many others. She is the author of Sex Without Pain: A Self-Treatment Guide To The Sex Life You Deserve. She opened Femina Physical Therapy in 2009. With 60-120 minute sessions, her office is able to provide the hands-on treatment, skilled corrective exercises and other interventions by specialized and licensed physical and occupational therapists so they can get on the path to putting their pain or weakness behind them.
*Fernandes da Mota PG, Pascoal AG, Carita AI, Bø K. Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Man Ther. 2015 Feb;20(1):200-5. doi: 10.1016/j.math.2014.09.002. Epub 2014 Sep 19.
Of note, this study reports a DRA as 16mm, which is narrower than what other researchers have defined it as (20 mm).
Effect of Antenatal Exercise Program with and without Abdominal Strengthening Exercises on Diastasis Rectus Abdominis – A Post Partum Follow Up. Banerjee, Avaya; Mahalakshmi, V.; Baranitharan, R.; Indian Journal of Physiotherapy & Occupational Therapy, Oct-Dec2013; 7(4): 123-126. 4p. (Journal Article – research, tables/charts) ISSN: 0973-5674, Database: CINAHL Plus
Correlation between Diastasis Rectus Abdominis and Lumbopelvic Pain and Dysfunction. Dalal, Khushboo; Kaur, Amrit; Mitra, Mahesh; Indian Journal of Physiotherapy & Occupational Therapy, Jan-Mar2014; 8(1): 210-214. 5p.
Diastasis rectus abdominis and lumbo-pelvic pain and dysfunction — are they related? Parker MA; Millar AL; Dugan SA; Journal of Women’s Health Physical Therapy, 2009 Summer; 33(2): 15-22. 8p.
Stability, continence and breathing: the role of fascia following pregnancy and delivery. By: Lee DG; Lee LJ; McLaughlin L, Journal Of Bodywork And Movement Therapies [J Bodyw Mov Ther], ISSN: 1532-9283, 2008 Oct; Vol. 12 (4), pp. 333-48; Publisher: Churchill Livingstone; PMID: 19083692, Database: MEDLINE
Relations between pregnancy-related low back pain, pelvic floor activity and pelvic floor dysfunction. Pool-Goudzwaard AL1, Slieker ten Hove MC, Vierhout ME, Mulder PH, Pool JJ, Snijders CJ, Stoeckart R. Int Urogynecol J Pelvic Floor Dysfunction. 2005 Nov-Dec;16(6):468-74. Epub 2005 Apr 1.
Int Urogynecol J Pelvic Floor Dysfunct. 2007 Mar;18(3):321-8. Epub 2006 Jul 26.
Prevalence of diastasis recti abdominis in a urogynecological patient population. Spitznagle TM1, Leong FC, Van Dillen LR.
Is there a relationship between parity, pregnancy, back pain and incontinence? International Urogyn J and Pelvic Floor Dysfunction 19(2): 205-211. Smith MD, Russell A, Hodges P.