Diastasis Rectus Abdominis (DRA) is a term that is becoming more common in discussions about pregnancy, postpartum fitness, and core strength. This is a condition, which involves the separation of the rectus abdominis muscles (the "six-pack" muscles), is prevalent among pregnant and postpartum women, but it’s also something that can be managed effectively with the right strategies.
The problem that’s seen in so much social media is a fear based approach when it comes to what we should and shouldn’t do. More and more research is coming out and we are understanding DRA better in regards to why it happens, is it something we should even worry about? Should we be doing specific exercises to prevent it or manage it if we have it?
What is Diastasis Rectus Abdominis?
Diastasis Rectus Abdominis occurs when the two sides of the rectus abdominis muscle separate due to the stretching of the linea alba, the connective tissue that runs down the center of your abdomen. This is a natural occurrence during pregnancy as the uterus expands and accommodates the growing baby, creating increased tension on the abdominal wall.
The extent of the separation can vary from woman to woman, and it is typically most noticeable in the postpartum period. While some degree of separation is common, a non-functional diastasis can lead to lower back pain, hip pain, and pelvic floor dysfunction. A large worry for most mommas is the aesthetic perspective of a visible "pooch" or bulging in the abdomen in some cases. BUT, it’s critical to know is this an actual separation of the abdominal muscles or is this just a normal and healthy degree of fat and stretched skin that we can expect in the postpartum period.
We expect >99% of Moms at 9 months pregnant to have a DRA and we should be normalizing a small degree of separation after a baby as our tissues had to stretch to their maximum capacity to grow a human! The biggest worry is if the DRA is causing more issues that affect our ability to live life, be a mom, and exercise how we want to.
Why Does Diastasis Rectus Abdominis Happen?
During pregnancy, the body undergoes significant changes to support the growing fetus. The hormones estrogen and relaxin play a critical role in loosening ligaments and connective tissues to allow for the expansion of the uterus and the pelvis. As the baby grows, the abdominal muscles stretch to accommodate this growth, and in some cases, the pressure on the linea alba can cause it to thin and widen, leading to DRA.
Factors that can contribute to the development of DRA include:
- Genetics: Some women may have a genetic predisposition to weaker connective tissue, making them more susceptible to DRA.
- Number of pregnancies: Multiple pregnancies can increase the likelihood of developing diastasis due to repeated stretching of the abdominal muscles.
- Size of the baby: Larger babies, multiples, or higher amounts of amniotic fluid can exert more pressure on the abdominal wall.
- Type of delivery: A cesarean section can sometimes exacerbate DRA due to the trauma to the abdominal muscles during surgery, making them have a more difficult time engaging.
- Pre-pregnancy fitness level: Moving into pregnancy and throughout pregnancy with less overall strength can make our deep stabilizing muscles of our abdominal wall not coordinate in a way that best manages our intra-abdominal pressure as our belly is growing. This can place more tension on our linea alba and can cause more doming and coning around our midline throughout pregnancy and into the postpartum period.
Understanding these factors can help in managing DRA effectively. Knowing there are certain things out of our control such as genetics, # of pregnancies, size of baby, and delivery type can at least take blame off of ourselves and start to work on those things that are controllable like our strength moving forward.
What to look for with a DRA:
Many tests can be completed when assessing for a diastasis, but the most common test is the curl up test where we lie flat on our back, legs straight out, and we feel from under our chest bone all the way to our pubic bone. We can do a small sit-up as we lift our shoulders and head off of the ground. We want to feel from our chest bone down to our pubic bone again and notice how that tissue has changed in the curl up. DRA is most commonly found around the belly button.
There are a series of things that can happen throughout that tissue and they can be described in multiple ways:
Invagination: dropping/ sagging of linea alba (this feel like we can press down into our insides)
Doming: pressure throughout the midline (looks like a loaf of bread and is typically the 6 pack muscles doing TOO much work)
Coning: Linea alba is pushing outward, looks like a cylinder tube between the 6 pack muscles
Tenting: Pointed and triangular shaped pressure in the area between the 6 pack muscles (kind of looks like a toblerone candy)
If you feel like you are noticing any of these, don’t panic! It is difficult to really assess ourselves and seeing a professional who can do the most functional test for you to see if you are able to functionally or non-functionally manage this pressure in a way where you can do your exercise and live your life without future issues is so helpful in easing your worry.
Intra-Abdominal Pressure (IAP) Management
Intra-abdominal pressure (IAP) refers to the pressure within the abdominal cavity, which plays a key role in stabilizing the core and protecting the spine during movement. We need IAP in order to brace our core muscles and protect our back when we pick up heavier objects or are doing a strenuous physical task. This may mean picking up our toddler and grocery bags, moving a heavy couch, or even getting out of a chair holding our new born when we are immediately postpartum. Properly managing IAP can be so helpful for people with DRA, as excessive or mismanaged pressure can exacerbate the separation of the abdominal muscles and strain place more strain on the pelvic floor muscles, low back, and other pelvic muscles.
Effective DRA management involves understanding how to regulate IAP during everyday movements and exercises. When IAP is not well managed, it can push outward on the abdominal wall, placing pressure on the linea alba causing coning, doming, or any of the other descriptors mentioned above. On the other hand, proper IAP management can help stabilize the core, reduce the separation, and support healing or a diastasis.
Techniques for Managing Intra-Abdominal Pressure:
1. Breathing Techniques:
Diaphragmatic Breathing: Learning to breathe into your diaphragm, rather than shallow chest breathing, helps reduce pressure on the abdominal wall. This type of breathing encourages the diaphragm, pelvic floor, and core muscles to work together harmoniously.
Exhale on Exertion (if you can): Exhaling during the effort phase of an exercise (e.g., when lifting or pushing) can help regulate IAP and prevent unnecessary pressure from building up in the abdomen
Don’t Hold on a Max Inhale (if you need to hold your breath): Using a partial exhale instead of a full max inhale breath hold can help prevent excessive IAP that just places unnecessary strain on a DRA. Try a large inhale with a small exhale prior to a breath hold if you need to use a breath hold to lift something heavy or do something strenuous.
2. Alignment and Posture:
- Maintaining a neutral pelvic and spinal alignment by keeping your ribs stacked over your pelvis can help distribute pressure more evenly across the core. It can help allow your core, pelvic floor, and diaphragm to work harmoniously together to avoid excessive strain on one or another. Avoid excessive arching of the lower back or tucking of the pelvis, as these positions can increase strain on the abdominal muscles.
- Good posture throughout daily activities, such as standing, sitting, and lifting, can also play a role in managing IAP effectively.
3. Engagement of the Deep Core Muscles:
- Activating the transverse abdominis (TVA), the deep core muscle that acts like a corset around the abdomen, prior to and throughout a movement can provide support to the linea alba. Exercises that focus on engaging the TVA without causing outward bulging of the abdominal wall are key to DRA recovery.
- Pelvic floor engagement is also critical. The pelvic floor and the TVA work together as part of the deep core system, and ensuring both are functioning properly can help with overall pressure management.
4. Exercise Modifications:
- Certain exercises have been victimized when it comes to DRA, such as full sit-ups, crunches, or heavy lifting. The problem is, all of these are things we have to do daily such as getting our of bed, off of the ground when playing with our baby, or even when picking up our baby in their carrier with their diaper bag. The important thing is to assess how we are feeling and noticing if we are getting that doming or coning with any of these movements. If we are, we may need to modify these exercises and gradually build into them as we are recovering or struggling with a DRA.
- Learning how to properly brace through our TVA and pelvic floor muscles while maintaining a good alignment through exercises can be incredibly helpful to start gradually reconnecting to these deep core stabilizers so we can gradually progress. Gradually progressing to more challenging exercises as the core becomes stronger and better able to manage IAP is essential.
Resistance training, when done with proper form and IAP management, can actually be beneficial for DRA recovery. We want to shift away from fear-based avoidance of exercise and towards empowerment through education and technique.
We want to adapt exercise programming to each mommas needs and ensure that movements are performed with optimal alignment and pressure management. Rather than avoiding all challenging movements, understanding your body’s limits, gradually progressing in intensity, and always prioritizing proper IAP management is key in recovery.
Exercise Strategies for Women with DRA
Now that we've covered the basics of DRA and IAP management, let’s dive into some specific exercise strategies that can help women recover from DRA while maintaining a strong, functional core.
Good exercises to begin to learn how to connect to our deep core muscles:
1. Bridges:
These exercises help engage the deep core muscles and the pelvic floor without putting excessive strain on the abdominal wall. Start with small, controlled movements and focus on exhaling during the exertion phase. You can place a Pilates ball between your legs to squeeze to better encourage your deep core and pelvic floor muscles.
2. Modified Planks:
Traditional planks can be too difficult for those struggling with a DRA, but modified versions, such as planking on the knees or against a wall, can help build core strength gradually. Remember to maintain proper alignment of your rib cage over pelvis and keeping your TVA draw inwards by imagining zipping up your pubic bone to belly button will help preventing pressure outwards. Work on this both front planks and side planks.
3. Bird-Dogs:
This exercise challenges core stability and coordination while allowing you to focus on managing IAP. Keep the movements slow and controlled, and ensure that your spine remains neutral throughout the exercise. Work on keeping your TVA wrapped by pulling your belly button into your spine and use your exhale to lift your arms and legs away from each other
4. Side-Lying Leg Lifts:
These are great for targeting the glutes and obliques, which can help provide additional support to the core and pelvis. Avoid twisting or arching your back as you lift the leg. Focus on keeping belly button in towards spine and using your exhale to lift your leg up.
5.Paloff Press
Anti-rotational exercises are helpful in learning how to better coordinate our deep core muscles while encouraging our obliques and other trunk muscles to work. Using your exhale to zip up your pubic bone to belly button and press a band or cable column away from your body while your prevent yourself from rotating can help in encouraging strength throughout your trunk.
5. Progressive Strength Training:
Once core stability and IAP management are improved, gradually introduce more challenging strength exercises, such as squats, deadlifts, overhead presses, and sit ups. The key is to ensure proper form and breath control, deep TVA and pelvic floor coordination prior to and throughout a movement, and exhaling on exertion when possible to manage intra-abdominal pressure.
So…..Sit-Ups?
The golden question! What if I was to tell you that sit-ups and crunches can actually help HEAL a DRA? WHAT?! Yes. More research is coming out about how strengthening our 6-pack muscles can actually narrow the distance between them and reduce the width of our DRA, but this is only really done with co-contraction of our transverse abdominis muscles (TVA.) Learning how to properly engage our TVA prior to and have the strength to hold it throughout a motion is crucial in DRA recovery. If we don’t have the coordination in these muscles for a sit up, we may want to regress the movement and learn how to better coordinate these deep core muscles with other exercises first. If we don’t have the strength in these muscles, we may need to regress the movement and work on building up strength gradually before going straight into a sit up.
Other ways we can start strengthening our 6 pack muscles while learning to coordinate our deep core muscles can be with learning to draw in our TVA and holding it with pelvic tilts lying on our back or on all 4’s, holding our TVA and working into a supported and then unsupported boat pose, beginning eccentric support sit ups with TVA coordination and control, gradually building up to sit ups, hanging knees to chest, and learning how to gradually pike with a physioball.
Lastly
Diastasis Rectus Abdominis is a common condition among pregnant and postpartum women, but with the right knowledge and approach, it can be effectively managed. By focusing on intra-abdominal pressure management techniques, coordinating deep core and pelvic floor muscles, modifying exercises as needed, and gradually building strength, women can heal and regain core function and strength!
Avoiding sit ups and lifting forever is just not realistic and being fearful of movement is detrimental in our daily lives as mommas. Let’s celebrate our body by strengthening it, learning more about it, and reconnecting to it through movement! Whether you are early postpartum or years into your recovery, remember that healing from DRA is a journey, and with the right strategies, you can achieve a strong, functional core.
Resources:
- 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 Jul;46(7):580-9. doi: 10.2519/jospt.2016.6536. PMID: 27363572.
- Sperstad JB, Tennfjord MK, Hilde G, Ellström-Engh M, Bø K. Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. Br J Sports Med. 2016 Sep;50(17):1092-6. doi: 10.1136/bjsports-2016-096065. Epub 2016 Jun 20. PMID: 27324871; PMCID: PMC5013086.
- Kaufmann RL, Reiner CS, Dietz UA, Clavien PA, Vonlanthen R, Käser SA. Normal width of the linea alba, prevalence, and risk factors for diastasis recti abdominis in adults, a cross-sectional study. Hernia. 2022 Apr;26(2):609-618. doi: 10.1007/s10029-021-02493-7. Epub 2021 Oct 5. PMID: 34609664; PMCID: PMC9012734.
