Did you know that MEN, WOMEN, and CHILDREN can have DRA? Let's talk about what is common for women first.
During pregnancy, women experience what we typically consider "normal" abdominal separation to make room for baby. If baby happens to be bigger or your belly experiences excessive stretch (especially with twins or multiples!) abnormal separation can occur, and this is what we consider Diastasis Rectus Abdominis (DRA), diastasis meaning separation and rectus abdominis (RA) meaning of what we think of as the "6-pack" abs. It is hard to determine what the severity of this might be until after baby is born.
Once baby is born, we have to remember a couple of things. It is STILL normal to have a little separation during postpartum or "4th trimester". Remember: Your body just adapted and changed for 40 weeks! That is a long time! So give yourself grace. Remember it is okay that your body will not look the same for a little while.
For 9 months, your body experienced stretch to your abdomen and pelvic floor, along with added pressure to important functioning organs like the diaphragm, bladder, and digestive system. Most doctors tell women to wait 6 weeks to get back to exercise, however, 6 weeks is not a one size fits all number. Each woman is different. 6 weeks is just a guideline! For many that did not know how to activate pelvic floor + core 4 prior to pregnancy, it could take a bit longer to get back to "normal" and that is ok!
The good news! Although you may not be running 3 miles at just 6 weeks postpartum, you CAN start gently strengthening the diaphragm, pelvic floor, and TA at any point postpartum! The second piece of good news is that DRA is OFTEN able to heal with proper training. Please see @getmomstrong on instagram for encouragement. I just LOVE her story of healing from DRA after twins! And she is a FANTASTIC resource of encouragement and how-to exercise for pelvic floor.
Pregnancy isn't the only reason that someone would have DRA! Why else might you see it?
Weakening of the abdominal wall due to pressure over time
Obesity
Injury (less common)
Surgery
Chronic constipation
Chronic coughing
Signs & Symptoms
Doming of the abs with pressure changes (coughing, abdominal exercise, lifting)
Low back pain
Constipation
Bloating
Feeling like you cannot improve core strength with crunches
In extreme cases herniation can occur
Picture via BabyCenter
PROPER TRAINING
So how do we properly train the TA? When most people think about core, they think about the rectus abdominis or "6 pack abs". The rectus abdominus contains individual muscle bellies (most people think of the abdomen as "one muscle") and has a line of connective tissue down the midline called the linea alba (latin root= white line). What separates and stretches during DRA is actually not the muscle itself, but the linea alba. It is what we call a "global muscle" which means it assists us in big body movements, like flexing or bending forward. Because it is a "global muscle", we do not want it to be turned on all of the time! We expend too much energy by activating our big muscles too frequently.
To improve this, we need to teach our body to isolate and utilize "local muscles" or our deep stabilizers. Those deep stabilizers include our "Core 4", being your diaphragm, transversus abdominus, pelvic floor, and multifidi of the spine.
TRANSVERSUS ABDOMINUS (TA)
What is the TA? We hear so much about the rectus abdominis, but not as much about the TA. The TA is a muscle deep to RA and the oblique muscles. It attaches to the ribs down to the pubic bone, and then wraps around to our thoracolumbar fascia (connective tissue of the back) and acts as a "corset" for our body. The TA is great, because it is one of those local muscles I explained about, meaning that its job is to stabilize for longer duration without zapping the energy from our muscles. See my blog post on TA for more info on how to activate this muscle!
TWO SCHOOLS OF THOUGHT
In pelvic floor PT, we use testing to determine severity and improvement. So, although upon someones initial test I may see significant doming, upon retest or after instruction of exercise I will train my patient to perform the same test with tension to reduce doming.
In the past, practitioners focused on the degree of severity being how far the muscle bellies of the RA are separated. There is not significant research on this subject, but based on the principles of muscle training, many pelvic floor practitioners are now looking at the tension as a determining factor to strength and improvement. While "closing the gap" can be an important piece, I am most concerned that with activities I teach my patient to reduce the excessive PRESSURE to the system, and learn how to effectively activate TA in order to improve the TENSION to the muscles.
What does this look like?
Reduced doming with activities
Activation of TA prior to lifting, coughing, sneezing
Avoiding some movements with exercise and activity until able to do so without doming
Recently I participated in listening to educational podcasts about this topic during 2020's Birth Healing Summit. This is where there is discrepancy in how DRA is treated. One school of thought, is that we must load the tissue in order for there to be strength and fiber changes. This (from my understanding) meaning doming to some extent is okay. A large factor in this thought is that we cannot avoid activities that we HAVE to do, which is absolutely where I am also in agreement. The second school of thought is that we want to avoid doming altogether, as doming increases pressure to the system, which furthers the stretch, strain, and damage to the tissue.
I tend to think in the middle, leaning a little more towards avoiding the doming, but teaching to modify (as much as possible) activities that we cannot avoid (leaning over a crib to pick up your child; taking a baby carrier out 2 days postpartum). While we do need load to the tissues, proper training can assist in avoiding the activities that initially caused the separation. Obviously, low load-long duration pressure would take time to damage tissue, but my thought is that we definitely want to protect underlying structures from herniation or damage over time as soon as possible.
HOW TO TEST FOR DRA
Disclaimer: This is only meant for educational self-testing purposes. I am in no way diagnosing your DRA. Always refer to your physician or midwife with questions or concerns, or get a referral to pelvic floor physical therapy. Secondly, this testing is not meant to be repeated on a daily, consistent basis as the goal is to AVOID movements to reproduce symptoms. This may be an exercise considered after lots of training to DRA but is best done with a physical therapist's guidance.
Figure 1
Figure 2
Lay flat on your back with knees bent (hooklying), preferably on hard surface
Place two fingers at the belly button and put gentle pressure on the belly button (Figure 1)
Gently lift head and shoulders off of the table or surface (like a crunch vs full sit up)
Determine tension (how far your fingers press in to belly) and distance of separation (each finger= roughly 1 cm) (Figure 2)
Repeat about 2 inches above and below belly button
If you have concerns or feel you have DRA, consult with a healthcare professional for the next steps
Normative values= >2.5 cm for finger width
If you have good tension, you will not feel the muscle bellies around your finger. It will
feel flat and firm.
If you have been working on reducing pressure (no straining, activation of TA with coughing, sneezing, lifting) and activating TA, you can retest by first activating TA and the diaphragm and performing steps above. If you do not have doming and improved tension, this is a sign that your efforts are working! Again this is best done under the guidance and instruction of a pelvic health professional.
WHAT SHOULD I AVOID WHILE I AM HEALING?
Constipation (see post on gut health and toileting)
Excessive pressure with lifting and activities
Breath holding (see diaphragmatic breathing)
Improper bending/lifting techniques (squat vs bend at the waist when able)
Exercises that cause symptoms
Again, there are obviously activities you cannot avoid, so the important thing to remember is to attempt to reduce pressure (via breathing) and gently activate TA when you are doing something you can't avoid.
HOW CAN I SUPPORT MY CORE DURING HEALING?
Belly bands and supportive leggings can be a great way to protect the core during pregnancy and postpartum during healing. Some bands that I like to recommend can be found below:
I typically don't suggest binders long term as we do not want to rely on them, rather build up muscle strength, but they can be great for initial support in healing!
As you can see, there is a lot that can go into the cause of and retraining of DRA. I hope this information can help get you started towards healing, but ultimately I recommend visiting with a pelvic floor professional- see my resources page here. While it can be frustrating and daunting to get started, by educating yourself on this topic, you are already on your way to healing!
RESOURCES
DISCLAIMER
Some of the product links on this blog contain affiliate links to products. If you click on the link or purchase an item, I may receive compensation, however there is no additional cost to you to purchase. I only promote items that I firmly believe in. I am also under no obligation to write product reviews on my blog, however I do so because I would like to share products that I enjoy!
This content is created in order for individuals to learn more about the pelvic floor. I am in no way giving medical advice or medically assessing the pelvic floor through this blog. If you ever have any health questions or concerns, please consult with your physician or midwife. If you are ever unsure if you are performing exercises correctly, it may be beneficial for you to get a referral from your physician to a pelvic floor therapist for further evaluation. My blog posts are for educational purposes only! I am not liable or responsible for any damages resulting from or related to your use of this information.
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