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Looking Beyond the Gap -- Diastasis Recti (DRA)


Diastasis Recti is a thinning and widening of the linea alba (connective tissue that runs along the midline of the abdomen), which joins the right and left rectus abdominis muscle bellies. Diastasis Recti is a natural part of pregnancy because the abdominals must lengthen and stretch to create room for your growing baby! Studies have shown that 100% of women had some form of diastasis at 35 weeks pregnant.


In the past, the focus of rehabbing DRA was primarily on reducing the gap and the thought was that if we can reduce the gap, then the function of our core will be improved and the appearance of our abdomen will improve also. However, this is not necessarily the case, which leads us to the need for a change in our framework in how we are rehabbing and rebuilding the postpartum core! DRA is more than the gap, because not just the linea alba was stretched during pregnancy. The entire abdominal wall was stretched, including the fascia/connective tissues of the abdomen.


So, how do we rebuild the postpartum core??

  • Restore strength and function of ALL of the abdominal muscles

  • Improve stiffness/reduce compliance of the abdominal wall (basically, this means if you have a lot of connective tissue laxity/thinness -- that means you have high compliance of your abdomen and we are going to work to improve the stiffness of this tissue)

*Notice, I did not say "Narrow the Gap." Now, the gap will likely narrow to a degree as a result of strengthening all of the abdominal muscles and improving the stiffness of the tissue, however the narrowing of the gap is dependent on other factors as well. *When it comes to appearance, narrowing the gap is not necessarily correlated with improved appearance of the abdomen. Improved appearance is typically associated with posterior translation of the abdomen (i.e. less abdominal distension), which occurs by doing the above things (restoring strength/function of all abdominal muscles & improving stiffness of the abdominal wall).


When working on rebuilding and strengthening your core postpartum, here are some measures that can help you monitor progress:

  • Narrowing of the inter-recti distance (gap/width measured in finger widths)

  • Depth of the linea alba becomes more shallow (how far you are able to sink your fingers in)

  • Quality/thickness of the tissue improves (this may occur with no change in the gap or depth)

  • Improved ability to draw the abdominal wall inwards (lower, middle, and upper) & ability to do so with less mental effort

  • Improved ability to control any doming/bulging in the abdomen

  • Abdominal circumference (this demonstrates progress in the change in the position of the abdomen -- with abdominal distension, we can work on strengthening the entire abdominal wall to help reposition the abdomen more posteriorly)


How long until my DRA is "better"??


I get this question a lot...How long until my diastasis or core is healed?? This is a hard question to answer, because everyone's perception of "better" and "healed" might be different as well as everyone has different goals!


"Better" under the framework I use for treating diastasis recti means a few things. It means improved strength and function of all of the abdominal muscles and improved stiffness of the abdominal wall. These things typically also lead to improved appearance of the abdomen, which is a common concern of many women that come in to see me with diastasis recti. "Better" might include a narrowing of the gap, but this is not always the case as narrowing the gap may not be necessary in order to restore function of the core. "Better" also means you are able to return to any form of exercise that you enjoy or want to do without feeling "weak" in your core or without difficulty! This might include things like yoga, pilates, bootcamp classes, CrossFit, running, Orange Theory Fitness, etc.


In terms of prognosis when rebuilding the postpartum core and rehabbing diastasis, we have to consider a lot of factors when it comes to healing times:

  • You might start feeling stronger before you actually notice a difference in appearance of your abdomen

  • Consider the current strength of the transversus abdominis (deepest abdominal muscle) and the other muscles

  • Consider the amount of distension of the abdomen that you started with & the amount of laxity in the connective tissues of your abdomen

  • Consider the level of mind-muscle connection that you have initially

  • Consider the amount of time spent on exercises

  • Consider any excess baby weight, nutrition, the amount of sleep you are getting, how much stress you are under, etc.

  • Genetics


These are all things we must consider when looking at healing times for rehabbing our core! Everyone's timeline is going to look slightly different based on these factors. It's also important that we consider both recovery of the muscles and the fascia/connective tissues. It can take anywhere from 6 months to 2 years for fascia to remodel and strengthen. So, in someone that has quite a bit of laxity in the tissues of the abdomen from being stretched during pregnancy, it may take longer to improve the strength and function of the core postpartum!


Where do I start when strengthening my core postpartum??


A great place to start is learning to connect to and coordinate your deep core system or core canister. The three main inner core muscles that play a role in pressure management of the core canister include the diaphragm, pelvic floor, and transversus abdominis (TA).


Practicing 360 breathing or Core breathing is a great way to work on the coordination of the deep core. Read the information below & check out this video to learn more.





Inhalation:

  • Diaphragm descends

  • Increase in core pressure

  • Abdominal wall eccentrically expands

  • Pelvic floor eccentrically lengthens


*Cues: Visualize you are holding a blueberry in the vaginal opening. Inhale into your rib cage 360 degrees and drop your blueberry (let it go) and relax your abdomen.


Exhalation:

  • Diaphragm ascends

  • Decrease in core pressure

  • Abdominal wall pulls in

  • Pelvic floor recoils up

*Cues: Exhale and lift your blueberry up and in and draw in your lower abs (area below belly button).


I recommend practicing this DAILY until it feels easy to coordinate the diaphragm, TA, and pelvic floor. You should be able to feel the pelvic floor relax/lengthen on the inhale and squeeze and lift up and in on the exhale.


Once you have this coordination piece down, we can use this and progress to more challenging strengthening exercises.


It's important to strengthen the inner and outer ranges of the TA muscle. Find the position where you feel you can coordinate the deep core best (side lying, sitting, or standing). Inhale and allow your rib cage and abdomen to expand, pelvic floor relaxes. Exhale and lift your blueberry and draw in your lower abs. Once you've drawn in your lower abs, extend that up to your middle and upper abs. Once you feel you've drawn in as far as you can go, try to draw in a little bit further. Inhale and release. *This is the full range of the TA muscle and it's important we train the full range in order to improve strength!


Lastly, I wanted to share with you just a few exercises that I love to take this coordination piece one step further and are a great next step for strengthening the core!


*Quick reminder -- There are SO many core exercises out there/that you could be doing. It's not always about WHAT exercises to do or not to do, but really what matters is HOW you are doing the exercise. The goal is to be able to coordinate your breath with your pelvic floor and TA during the exercise. You should be able to do the exercise feeling like you have control over your core, with proper form, without pain, leaking, pressure or heaviness in the vagina, or other symptoms. If you experience uncontrollable doming/bulging of the abdomen, then it might be helpful to modify the exercise. However, if you see doming/bulging and you are able to decrease it by changing your breath or core strategy, then the doming/bulging is just feedback for you as you progress to more challenging exercises!


Side lying 360 Breathing with Ball





In this exercise, we are working on full range excursion of the TA muscle. By pressing into the ball, it helps to create a little bit more tension in our core. Side lying is the easiest position to start in. You can also do this same technique by squeezing a ball between both hands in sitting or standing to challenge the TA a bit more. Find the position where you FEEL your abs working the most. Inhale -- release and expand. Exhale -- lift your blueberry and draw in your lower abdomen, then middle, then upper abdomen as you press into the ball. Once you've drawn in as far as you can go, try to draw in one step further. You can progress this to holding for 10 seconds at a time. Try 6 reps for 2-3 sets.


Standing Endurance Holds





Inhale -- rib cage expands 360 degrees, abdomen releases, pelvic floor lengthens.

Exhale -- lift your blueberry up and in, lower abdomen draws inwards, then middle, then upper. Once you've drawn in fully, try to draw in one step further to tap into that inner range of the muscle. Hold for 10 seconds while breathing in and out. Work up to being able to hold 60 seconds for 2-3 sets.



These are two great exercises to help you move from coordination --> strengthening the TA.


Where do you go from here?!

The next step is really starting to challenge ALL of the muscles of the abdominal wall by doing exercises that involve flexion, extension, and rotation of the trunk. We want to be doing exercises that challenge the TA in more upright positions to help create tension through the core that reaches the linea alba! Like I said above, it's not always about what exercises you do, but how you do them. The abdominal muscles need to be loaded and challenged above what they normally are in your day to day to produce changes and improve strength! If an exercise starts to feel easy to you, it's likely time to progress to a more challenging version!


I hope you found this information helpful! My hope is that you will not fear diastasis! Our body and our cores need movement, exercise, and load to get stronger! If you feel lost in rebuilding your postpartum core or maybe its been years since having kids and you still don't feel strong in your core, please reach out! I'd love to help you in creating a program that works for you and your body and your goals! An individualized assessment helps us determine an individualized program!


Feel free to contact me here through my website or send me an email: restore.physicaltherapy614@gmail.com



Kaitlin Hartley, PT, DPT, PPCES





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