diastasis-recti - Pilates Essentials PlusDiastasis has become a real buzzword and HOT Topic! Anything to do with the belly is always a hot topic! Diastasis Recti Abdominus (DRA) is so far, poorly researched but thankfully the research world is realizing the impact and increased occurrence of this condition so more studies are in the works. Here is what we know from a few of the studies;

Diastasis recti is the separation of the outermost abdominals from the midline where they are connected via the linea alba. The linea alba is a complex, 3 dimensional, highly structured meshwork of collagen fibers (Axer et al 2001) but I will just refer to it as connective tissue. The linea alba is the central insertion point (Boissonnault & Kotarinos 1988; Noble 1995) and the fusion of the aponeuroses of the external abdominal oblique (EO), internal abdominal oblique (IO) and transversus abdominis (TvA) (Axer et al 2001). The linea alba softens during pregnancy to allow the two rectus abdominus bellies to curve round the abdominal wall (Coldron et al 2008)

Some of the consequences or complaints that are associated with diastasis are Back pain (Boxer et al 1997; Boissonault & Blaschak 1988; Toranto 1990, Oneal et al 2011), Pelvic pain (Lo et al 1999, Whittaker, 2013), Incontinence (Spitznagle 2007), Prolapse (Spitznagle 2007), Increased risk of abdominal injury (D. Lee course notes 2011) and Bulging abdominal wall

[a.k.a.Mummy Tummy] (Braumann, 2008). In fact in 2007 Spitznagle found that 52% of women with pelvic floor dysfunction (stress urinary incontinence or pelvic organ prolapse) have a DRA and for primiparous women seeking care for lumbar or pelvic area complaints, DRA was found in 74.4% of them.

DRA is very common in pregnancy and in 1988 Boissonnault & Bleschak 1988 found that:

  • 27% of women in 2nd trimester have DRA
  • 66% of women in 3rd trimester have a DRA
  • 53% persist immediately post partum
  • 36% the DRA remains at 7 weeks post partum

Another study by Coldron Y et al 2008 found that:

  • Spontaneous healing of inter-recti distance at the linea alba only occurs in first 8 weeks
  • No further improvements were noted without intervention
  • Inter-recti distance remains unchanged at 1 year

Some other interesting information:

Other influences that can contribute to diastasis are changes in intra abdominal pressure, posture, the growing uterus, forward flexion movements and pushing but this is by no means an exhaustive list. It is most likely never just one thing but rather a combination of influences.

The 2 recti muscles are never joined or fused together but rather kept in alignment at a certain proximity to each other. The distance between the 2 recti muscles is called the inter-recti distance. What is considered ‘normal’ inter-recti distance has never been determined or agreed upon.

When the linea alba softens and the connective tissue and muscles stretch, it impairs the function of the deep core stabilizing system which results in the development of non-optimal strategies for core stabilization.

The more common compensatory strategies are overusing the obliques (internal or external), reverse breathing or chest breathing, overusing the posterior pelvic floor muscles and tucking the tailbone.

Here is what I know from my own experience:

In my professional experience DRA affects about 80-90% of the women I see and they have a separation of about 3 finger widths or more but it is not necessarily the size of the separation that is the problem. It is the integrity of the linea alba that we need to be concerned with. Part of the function of the linea alba is to tension in order to provide stability. Of those that have a diastasis, about 40% of them are not able to generate tension in the linea alba.

About 60-70% of the women I see have stress urinary incontinence.

Not everyone with a diastasis has a poochy tummy.

The poochy tummy is more a result of poor alignment and posture as well as overuse of the oblique muscles and a tight psoas. To identify if it is internal or external obliques that are overused I watch the rib cage when I am checking the diastasis with the head lift test. If they are overusing the external obliques, their rib cage will narrow as they lift their head and if they are overusing their internal obliques their rib cage will flare as they lift their head. Those with a tight psoas typically have a rib cage that is thrust forward when lying on the floor.

In some people the separation never returns to ‘normal’ – that would be me. I remain 3 fingers at my belly button. I typically consider ‘normal’ to be about 1 finger width.

If the separation never ‘closes’ but the person is able to generate tension in the linea alba and their internal core is synergized, meaning the timing of the pelvic floor, deep abdominals, breathing and multifidus are all as they need to be then there is no problem.

What is the solution?

Everyone is concerned with closing the gap but it is more important to get the linea alba tensioning properly and how you do that is through the pelvic floor. When I test for diastasis I have my client do a head lift (also called the curl up task) so I can get a sense of how far apart the rectus muscles are and if they are even able to approximate (move closer to the midline). I also feel for the integrity of the connective tissue. The next step is to ask my client to do a pelvic floor contraction or a kegel and then do the head lift again. I am checking to see if tension develops in the connective tissue when they contract their pelvic floor and then do a head lift. If it does then there is not a real cause for concern. If it doesn’t then I need to help determine what in their core is over working or under working and get them set up so the over workers can ease up and the under workers can get back to work! Here are some other helpful tips;

Alignment is key as well as the posture you choose through the day. Keeping your rib cage over your pelvis is one of the biggies, along with straight feet and a tailbone that is un-tucked. Being properly aligned and choosing optimal posture will help your core function normally and limit the likelihood of developing compensatory strategies.

Core Breathe daily for 30 seconds to a minute especially if you are pregnant.

After your baby is born take advantage of the first 8 weeks by wearing an AB Tank and doing the Bellies Inc Core Confidence program.

See a pelvic floor physiotherapist who can help you connect with your pelvic floor – the pelvic floor is key in your inner core function and in healing a diastasis.

Stop doing crunches as they will not flatten your tummy and will only put more strain on the connective tissue. Crunches do cause the recti muscles to approximate (come closer together) which sounds like what you should do to ‘close the gap’ but they do not address the connective tissue and again, that is the biggest piece of the puzzle. The connective tissue needs to regain its integrity and that happens with proper alignment and the ability to engage you pelvic floor.

Many pilates movements are similar to crunches in that they are forward flexion movements with the head off the floor. If dealing with a diastasis and an inability to develop tension in the linea alba during the curl up task then you will need to test this with all of the other forward flexion activities you do as well – the hundred’s, the roll up, the roll over, leg stretches, open leg rocker, criss cross…actually it is most of the mat based movements! Also be careful with the twisting movements as they can shear the connective tissue and interfere with healing.

‘Fixing’ a diastasis is about retraining your inner core so it functions as it should.

Diastasis is a tricky one and we don’t have a lot to go on because of the lack of studies but if we sit and wait for more research to come then we will be missing out on opportunities to heal. What we know is that awareness is key and can help prevent or minimize DRA. We also know that the first 8 weeks are critical for healing so take advantage of that. We also know that the common ‘core’ exercises can sometimes do more harm than good so find pelvic floor physiotherapy and fitness and pilates professionals who can help assess and progress you!