Ever watch a movie where someone has a baby? It’s so calm and blissful (well, after the pushing). But it’s as if you are watching a dream – a few pushes, a cry and a beautiful baby is handed over to mom. 2 days later she goes home and aside from a lack of sleep it’s like nothing other than that new child has changed. “That’s funny,” you think. “What about the bleeding? What about the leaking? Why does she have a perfect 6 pack right after giving birth?” Meanwhile you just sold all of your bikinis in an online yard sale, discontinued your gym membership and purchased stock in Depends. Clearly these movie people have it wrong. “Have they seen my mummy tummy?”
Do you ever feel like this is you? Surely you are not the only woman dealing with these issues. Every week there is another article on your timeline about post-natal fitness, a new incontinence product, or a different type of compression garment to make you look forever 21.
The volume of articles and statistics speak for themselves. One of the most underserved populations is post-natal women. Just because it is not widely known that there is help for these problems does not mean it does not exist. There are physical therapists all around the country ready and willing to help.
This blog series is going to address a number of issues that women face after giving birth. We will talk about incontinence, prolapse and return to exercise. The goal is to dispel some of the myths surrounding these subjects and give you renewed hope that you can get back to the activities you have been missing due to these problems.
The topic this week is diastasis recti (DRA). Yes, that sounds like a mouthful and for those of us with a slight lisp is sort of hard to pronounce. People even pronounce it differently, but thanks to merriam-webster.com I can say the correct pronunciation is Die-AS-tah-sis REC-tie. The meaning is far simpler: it is a split in the abdominal muscles that occurs in pregnancy. The abdominal wall is made up of several layers of muscles that are all interconnected through fascia, a type of connective tissue. The muscles and fascia are meant to stretch and lengthen as the abdomen expands in pregnancy. While all tissues can handle a certain amount of stress it’s important to remember that pregnancy is a special time (for many reasons but especially physically). Pregnant women secrete hormones, namely progesterone and relaxin, that serve to loosen all connective tissue in the body. This is to help the mom’s body adapt to pregnancy and prepare for childbirth. Rapid stretch, coupled with lax tissues makes the abdominal muscles and fascia more likely to tear. In fact, up to 2/3 of pregnant women experience some degree of abdominal separation by the third trimester of pregnancy.
(photo courtesy of www.people.com)
If so many women experience this, and the laxity is normal, what’s the big deal?
Well, the tearing affects the abdominal muscles and makes it more difficult to establish tension across the abdominal wall, at the area known as the linea alba, or the mid-line fascial anchor of all of this connective tissue. When someone loses the ability to tension the fascia, this may affect her overall core control.
What does this have to do with my core?
Good question. Let’s take it back to anatomy 101. The core is made up of 4 muscle groups: the diaphragm superiorly, the pelvic floor muscles inferiorly, the lumbar multifidus posteriorly and the transversus abdominus (TA) anteriorly. All of these muscle groups work together to produce core control, or control of intra-abdominal pressure with physical activity. More severe DRAs affect the ability of the TA to effectively tension the abdominal fascia. When this occurs, the core muscle team can no longer function efficiently. Things may start to occur in the body, such as adapted postures like a “mummy tummy” or other physical changes. Some studies link DRA to things like urinary incontinence, pelvic organ prolapse and low back pain. At the very least, weak abdominal muscles may impact physical function in many capacities, including difficulty with everyday tasks such as home care, child care, and exercise.
If I have DRA can it be fixed?
Conventional medical thought is that the only way to fix DRA is through surgery. While in some cases, surgery may be necessary it is not always the only option. Many women can overcome DRA through non-invasive interventions such as physical therapy and exercise. Physical Therapists who are trained to identify and manage DRA use many techniques, including manual therapy and targeted muscle training to help restore the ability of the core muscles to work as a team. To read more about this click here. What is important to recognize when managing DRA is that function must come before aesthetics. The goal of any good program to treat DRA is that the exercises focus on restoring the ability to tension the abdominal fascia. A recent study by Hodges and Lee describes this phenomenon. Depending on the severity of the fascial tearing, learning how to use the core muscles appropriately can improve the tension across the abdominal fascia and allow women to perform activities such as lifting babies, pushing a stroller, running, lifting weights and even participating in fitness programs like CrossFit and Pilates.
It’s also important to know that not all interventions are created equal. Be wary of people or programs who claim to “close the gap” in an attempt to heal DRA. While some of the splits may close partially or completely, the most recent evidence is pointing more toward the depth of the split v. the width in terms of function. In fact, some separation between the rectus abdominus muscles is completely normal! The abdomen needs room to expand. For more on this topic, check out this recent post by my colleague Julie Wiebe here .
While not all women with DRA will be able to heal completely with physical therapy and exercise, many will. A post-natal physical therapy screen can help identify whether DRA is present and how much capacity there is to improve. It’s been months or years since your last pregnancy? That’s okay too! One of the most amazing things about the body is its capacity to heal and change, even years later. Don’t be afraid to reach out and get help. Restoring normal core function and teaching the core how to function within the body as a whole is important whether or not a DRA is present.