By Lindsay Mumma,
DC
As a chiropractor, I see many
pregnant and postpartum women in my office.
The topic of diastasis rectus abdominis (DRA) comes up fairly regularly,
as many of the women I treat present with this condition. I also serve as a Regional Director for the
organization BIRTHFIT,
and we’re working to educate women about their bodies during the preconception,
prenatal, and postpartum period, so I end up talking DRA quite frequently.
I first heard about DRA from a
Dynamic Neuromuscular Stabilization course in 2009. It actually had nothing to
do with pregnancy, but was demonstrated via videos regarding poor loading
techniques in those with Cerebral Palsy or simply folks who could not
effectively manage their own intra-abdominal pressure system. DRA is a stretching of the connective tissue
that holds the two rectus abdominis (six-pack) muscles together; it occurs from
repetitively using poor loading techniques (not stabilizing your body when
lifting an object), but also in rapid expansion of the abdominal tissues, as in
pregnancy. There are some thoughts on
how to prevent/correct/heal DRA, but there isn’t a lot of consistency. It can be hard to sift through the info,
especially when you’re a new mom. Since
I’ve been studying DRA, I’ve learned quite a bit about it, and have seen which
methods work and which have been less than ideal. While some of this will be a little
science-heavy, I’ll try to keep it relatively concise.
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| Image courtesy of momsintofitness.com |
To keep things simple: if the diaphragm is not stacked on top of
the pelvic floor in all postures, then the body is set up for some amount of
dysfunction. This occurs when posture
isn’t ideal, but also when a person sucks in their stomach or holds tension in
their abdomen. This prevents ideal
diaphragmatic breathing, wherein the diaphragm lowers and the abdomen expands
360 degrees, which would set the diaphragm on top of the pelvic floor easily. This is unfortunately where most fitness
programs regarding DRA are currently failing.
They’re missing the big picture when it comes to stability of the torso
being established by the diaphragm.
In the ideal breathing and
postural pattern, the abdomen is solid and stable without having excess tension
of the musculature. Stability is created by the diaphragm. The diaphragm rests parallel to the pelvic
floor (relatively speaking considering both are rounded structures), which
gives an almost piston-like stabilization of downward motion of the diaphragm
resulting in eccentric activation of the pelvic floor. (Eccentric contraction means a muscle is
lengthening under load rather than shortening, as it does in concentric
contraction. An example would be in a
typical bicep curl: bringing the weight towards your body would concentrically
activate the bicep; lowering the weight would eccentrically activate the
bicep.) With this type of breathing,
intra-abdominal pressure (IAP) creates a stable environment and the transversus
abdominis muscle (TrA) gets some eccentric
contraction with every breath. This type of breathing also helps improve
pelvic floor functioning. Most
programs are encouraging participants to concentrically
activate TrA, which destabilizes the IAP system and does nothing for the pelvic
floor (1).
I see coaches and other
healthcare professionals posting on their social media accounts and blogs about
engaging the TrA by pulling them in. (Some even recommend physically pulling
the rectus muscles together and doing small crunches! YIKES!) They encourage
their clients or patients to bring their belly button toward their spine or
hold their stomach tight or pulled in. This does, in fact, engage the TrA, but
it isn’t the best way to stabilize the abdomen, and doing so won’t heal a
diastasis.
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Diastasis during pregnancy -
this picture was taken during a
curl-up/crunch type move (not recommended in
those with DRA)
|
So why is that advice so bad? First, it's based on flawed research
that's outdated. Second, it doesn't allow for proper use of the diaphragm.
Third, it actually contributes to poor loading techniques of the entire
abdomen, which can lead to (or worsen) a diastasis. DRA has very recently become a buzzword that
nearly every coach, yogi, fitness professional, PT, or chiropractor who works
with women is talking about. Unfortunately, most of them don’t have great
information, and they’re spreading around the bad info like wildfire.
Why doesn’t everyone agree? In comes the outdated research. A 1999 study by Hodges and Richardson
concluded that in subjects with low back pain, they did not activate TrA as quickly
as those without low back pain. The
conclusion was drawn that we therefore must train people to activate TrA in an
effort to decrease low back pain (2). But the opposite was true. Subjects were trained to activate TrA prior
to loading their spine, but they still had low back pain. People obviously got better at activating
TrA, but still couldn’t functionally stabilize, because they’d simply isolated
one muscle in a broken series. Further
studies have gone on to show that multiple
muscles do not engage properly in those with low back pain (3). This is because
the body works as a unit, made up of many parts that need to function
together. If one or more parts isn’t
working, the entire system falters (4).
Fixing the individual muscles doesn’t actually fix the system. The same is true for healing DRA: simply activating TrA won’t fix it.
A little more science-y stuff for
you nerds to salivate on: statistics show that 30-70% of all pregnant women will
have some amount of diastasis; it’s practically considered a normal variant of
pregnancy (5). However, what’s NOT
normal is when the diastasis stays beyond 8 weeks postpartum, which can occur
in as high as 60% of cases (5). Unfortunately, many health professionals
completely disagree about what to do with this separation. Surgical intervention is risky, and doesn’t
boast superior outcomes to conservative treatment in the literature. A large part of that is because there isn’t a ton of literature on the
subject. Here is the conclusion drawn
from a systematic review in 2014 in the Journal of Physiotherapy: “Based on the
available evidence and quality of this evidence, non-specific exercise may or
may not help to prevent or reduce DRAM during the ante- and postnatal periods”
(6). It doesn’t sound too promising, does it? There’s junky information out
there, and no studies seem to come to any obvious conclusions. Non-specific exercise may help, but it may
not. And one of the most common things
that practicing clinicians can agree upon is that DRA contributes to various
ailments such as low back pain, urinary incontinence, or pelvic pain. But a study from 2015 showed that there was
no correlation between women with DRA and a higher incidence of lumbopelvic
pain (7).
So if the evidence is
inconclusive, and more research needs to be done, then where do we go from
there? Well, my vote is to go where the
research is sound.
While it isn’t specifically associated with pregnancy
or postpartum, there is a decent amount of research coming out of the Prague
School regarding the use of Dynamic Neuromuscular Stabilization and improving
the functionality of the core, which includes conditions like DRA. The exercises in the studies are all based on
developmental kinesiology (something else that’s been studied immensely), which
means they’re based on how babies learn to move. You know what babies have? Relaxed muscles, no low back pain, and a
stable midsection (after they’re 4.5 months old, because babies are born with diastasis that they learn to heal through stabilizing
their midsection through breathing and movement - learn more about that in
this blog series).
What the studies conducted by
those implementing DNS have discovered is that patients without a properly
functioning diaphragm have aberrant movement patterns and low back pain
(8). They’ve also discovered that the diaphragm
doesn’t just function in breathing, but also plays a huge role in stabilization
of the trunk (1). And they’ve discovered
that improving the stabilization and respiratory function of the diaphragm
leads to improvement throughout the body (9).
Given this information, I start
all of my patients with simple breathing exercises. Getting their breath out of their chest and
into their abdomen requires that they relax their belly. This is easier for pregnant women, but much
harder for postpartum women to do. Relaxing your belly means you can’t suck it
in anymore. This means that others
can see any extra weight you’re attempting to hide, which is hard for a lot of
people. But it’s the only way to fully
utilize the diaphragm, which is the beginning of stabilizing the abdominal
system.
Additionally, I give women (and
men, because you’d be surprised how many men are walking around with DRA and
don’t know it until they come into my office) exercises similar to movements you’d see a 7.5 month old baby doing
- stabilizing on their side and beginning to move toward turning. (Check out the full functional
progression by Dr. Erica Boland from BIRTHFIT WIsconsin. )
The hardest thing for people to
do is to let tension go from their belly.
But that’s the fastest way to begin to stabilize the midsection, which
is unstable in the event of DRA. It
allows you to naturally stack your diaphragm on top of your pelvic floor, which
gives you a stable base as well as naturally better posture. This is also a great starting point for
improving pelvic floor awareness and function. Given that the pelvic floor is
the base of the core, it’s pretty important to get the entire system working
well together rather than just isolating a few muscles.
Citations
(1) Kolar P, Sulc J, Kyncl M,
Sanda J, Neuwirth J, Bokarius AV, Kriz J, Kobesova A.
Stabilizing function of the
diaphragm: dynamic MRI and synchronized spirometric assessment, J Appl Physiol.
, 2012;42(4):352-62
(6) Benjamin DR,
van de Water
AT, Peiris CL.Effects
of exercise on diastasis of the rectus abdominis muscle in the antenatal and
postnatal periods: a systematic review. Physiotherapy. 2014
Mar;100(1):1-8. doi: 10.1016/j.physio.2013.08.005. Epub 2013 Oct 5.
(7) Fernandes da
Mota PG, Pascoal AG,
Carita AI,
Bø K.
Prevalence and risk factors of diastasis recti abdominis from late pregnancy to
6 months postpartum, and relationship with lumbo-pelvic pain. Man Ther. 2015
Feb;20(1):200-5. doi: 10.1016/j.math.2014.09.002. Epub 2014 Sep 19.
(8) Kolar P, Sulc J, Kyncl M,
Sanda J, Cakrt O, Andel R, Kumagai K, Kobesova A.
Postural Function of the
Diaphragm in Persons With and Without Chronic Low Back Pain. , J Orthop Sports
Phys Ther, 2012;42:352-362, Full text displayed with permission of the Journal
of Orthopaedic and Sports Physical Therapy, and the Sports Physical Therapy
Section and the Orthopaedic Section of the American Physical Therapy
Association.
(9) Kobesova A, Dzvonik J, Kolar
P, Sardina A, Andel R.
Effects of shoulder girdle
dynamic stabilization exercise on hand muscle strength. , Isokinetics and
exercise Science. , 2015;23:21-32, 0959-3020
