Nov 1

Diastasis Recti – what you need to know

Diastasis Recti
Diastasis Recti (DR) stands for the separation of the rectus abdominus muscles along the linea alba which during pregnancy occurs under the influence of relaxin and other softening hormones. DR is not exclusively a pregnancy or postnatal condition but highlights, or may be the end result of, excessive strain and pressure placed on the lines of connective tissue (fascial lines), poor movement technique and breathing coordination resulting in an increase in abdominal pressure. It is usually during and after pregnancy that women become aware of it and want to make changes.

A two finger gap is a normal separation postnatally and not every gap is a DR if the fascia appears healthy and springy. Apart from poor movement technique/posture there are other factors that may cause DR such as pregnancy, abdominal surgery such as c-section where the fascia is being ‘clamped’ and pulled apart, hypermobility, excessive exercise and even belly button piercings. During pregnancy, DR can occur as early as the start of the second Trimester. Some women with consecutive pregnancies, hypermobility or any of the other factors mentioned, might start their pregnancy journey with an existing DR.

With the current knowledge of the fascia and the fascial lines, DR needs to be looked at from a wider perspective rather than just focusing on the abdominal muscles. There is a fascial sheath that attaches into the linea alba and posteriorly into the thoracolumbar fascia. This sheath encompasses the transversus abdominis, internal and external obliques and the rectus abdominis. Other posterior muscles we need to consider part of this system are the psoas major, quadratus lumborum and the erector spinae.

The function of this whole network needs to be addressed when we are trying to restore the synergy of this fascial sling. Carolyne Anthony (The Centre for Women’s Fitness) has developed a programme for Diastasis Recti Recovery which I have trained in and highly recommend for rehabilitation of a Diastasis. Carolyne says that ‘it is thought that when this fascial line is tight, the rectus abdominus may hang loose’ and that ‘releasing this area may have the effect of changing the tone of the rectus abdominis by offering more structural support’. Her programme is based on releasing, realigning and restoring. Especially postnatally, there is often the perception that women need to strengthen to ‘get back into shape’ and it feels great to be able to share a different insight into postnatal recovery and that actually we will start by releasing, breathing, realigning and the coordination and flow of it all together – all of which should feel lovely!

As mentioned, DR may be caused by lack of ability or technique to handle Intra-Abdominal Pressure (IAP) and excessive loading of the abdominals and fascia. Pregnancy does not cause the separation but can heighten the underlying issues such as poor posture, over-intense exercise regimes and exacerbate issues due to multiple pregnancies. Diastasis Recti and pelvic floor dysfunction tend to occur together due to the failure to cope with increases of IAP. In pregnancy, the growing uterus adds to the internal pressure on the fascial sheath/ linea alba when performing loaded flexion.

Many women are very upset by the aesthetics of DR as it can lead to doming of the abdominals and a ‘crepey’ look in the skin due to the poor quality of the fascia. Deep loaded flexion (sit ups), oblique work (twists), rotation and lateral flexion, taken beyond the functional range, are all contraindicated for anyone with Diastasis Recti. Dealing with IAP is crucial and will help you to reduce the impact of movement and daily strain on the separation. This means that exercises such as planks are also contraindicated as a postnatal women is unlikely to be able to control the IAP that this movement creates. The recovery from Diastasis Recti is helped significantly by doing the correct exercise but it is important to be aware that nutrition, posture and movement habits are just as important as the exercises themselves and no matter how much a client commits to the programme, their day-to-day habits need to be considered too.

Some women use an abdominal support, brace such as the Tupler technique to help “bring the abdominals back together”. Traditional postpartum body-binding also involves the thighs, pelvis and ribs and with it supports the whole unit. Although these techniques can be useful in the short term, they should never be considered a substitute for learning correct muscle function and addressing the issues that caused the DR initially.

How To Check For Diastasis Recti
Starting lying on your back with the knees bent up and the spine in neutral. One hand should support behind your head, the other finding the bellybutton, then sliding one finger just above it to lie on the linea alba pointing downwards to the pubic bone. Exhale to come forward into a small sit up, keeping the neutral spine. As you wriggle your finger right and left, check for the width, how many fingers you can fit into the gap and how soft/ deep or firm/ shallow it feels. Release. Then repeat checking for the gap below the belly button. A two finger gap is considered a normal separation but if the tissues feel very spongy and soft then you may be able to make improvements to this.

It is important to get a sense of the health and elasticity of your fascia and how deep the gap feels and take a look at the skin and belly button where the fascial pull is often noticeable with wrinkles and creases in the skin. For some women it feels that there is no resistance at all in the area between the muscles of the RA. Our goal is not necessarily to “close the gap” but to regain good fascial health and create better connections in this area so that the tissues are functioning more efficiently. Many women are overly worried about “closing” the gap in the abdominals but there is nothing wrong with having some separation of the RA if the tissues are functioning well. Good movement habits, good nutrition and a safe exercise programme will help the healing and reconnection of the abdominal wall – daily alignment is crucial as well as safe transitions and which exercises to avoid. DR is a normal side effect or structural adaptation of pregnancy and that with awareness of movement, fascial release, nutrition, rest and sleep (!) and the correct strengthening exercises, you can make a huge difference to her abdominal function and skin texture. In the first postnatal year and further on there may be changes as to how the gap feels and the texture of the skin due to the postnatal and as postural demands increase with your growing baby/ toddler/ child as well as hormonal changes of the (underlying) menstrual cycle.

Some women who have DR who also have an umbilical hernia – this occurs when the weakness along the linea alba allows internal parts to push through the fascia. If you are concerned that this may be the case, always see a GP and Women’s Health Physio. In our experience an umbilical hernia can be improved upon by following the Diastassis Recti Recovery exercise programme but in the long term you may decide to have surgery as this is the only guarantee of “fixing” the problem. If you have had the surgery, you still need to be treated as if they still have a significant DR as you will still have the same postural and breathing habits that caused the issue. This also applies to women who have had their DR surgically brought together; focusing on breathing and connecting the DFL is equally useful here. The abdominals and fascia may be tightened like a corset and their natural movement and sliding may be altered through surgery.

So what can I do?!
The first advice I would give is to go and see a Women’s Health Physio. She will be able to assess you and give you specific advice as to the function of your pelvic floor and abdominals and hopefully will teach you some exercises that will be useful in your recovery.

In an ideal world, daily practice of good breathing and abdominal connections will help to kick start the recovery of the abdominal muscles but homework should not the be a priority – the amount of time spent doing exercises is offset by the way you are using your body for the other 23 hours and 45 minutes of the day! So if you miss a day because the kids are ill and you have a crazy day at work and you barely have time to go to the toilet – don’t feel bad! Make sure you are eating good nourishing food and using good movement habits and that will be enough.

Here are some simple tips to try and include in daily movement that will help postnatal bodies just as much (and possibly more) as the exercises. Key things to be aware of are keeping the ribs released, keeping the pelvis in neutral and weight evenly distributed in the feet.

Daily Tips:
- sit with your pelvis elevated above your knees to allow your tailbone to untuck
- don’t do a “sit up” to get out of bed/on and off the floor – always roll onto your side when you are getting up and down from lying down
- avoid loaded rotation
- hold car seat and other weights close to your centre of gravity
- try to swap sides when carrying the baby
- be aware of the position of your pelvis in relation to the feet and the ribcage
- raise your feet when you are sitting on the toilet (if you have a toddler step theses are ideal for keeping the feet elevated) – this also allows the tailbone to untuck and reduces strain on the pelvic floor when you are on the loo
- try to use your arms to carry children rather than balancing them on your hips to take their weight. Even if you can’t manage this all day, just 5 minutes will help in the way that 5 minutes of exercise is useful.
- Pick things up by squatting not bending at the waist
- When you reach up to kitchen cabinets etc be conscious of what is happening in your ribcage

For anyone who DOES have time to exercise, here are some useful exercises to kick start your movement practice but in an ideal world I would find a local pregnancy and postnatal specialise trained by Carolyne Anthony or Jenny Burrell as there is no substitute for good teaching!

These exercises should only performed after you have had clearance from your GP to exercise again. I would recommend that you also see a Women’s Health Physio before starting any exercise postnatally.

Sidelying Ribcage Rock
* Lie on your side with both arms extended forwards at chest level with the palms together
* Inhale to rock the ribcage forward while at the same time rocking the pelvis back
* Exhale to rock the ribcage back as you rock the pelvis forward
Repeat then change sides

Breathing With Awareness
Sitting on the floor/chair/Swiss ball with your feet in parallel. Make sure you can feel your sit bones beneath you.
Place your hands on your belly. Inhale through your nose and try to breathe down into your belly for 10 breaths. Try to feel how your belly moves outwards as you inhale.
As you exhale feel your abdominals move inwards towards your spine. Try and have an awareness that as you breathe in your pelvic floor and diaphragm naturally move downwards and as you breathe out they recoil back up again.

It might take a while before your can really feel your breath moving down into your abdominals. Sometimes the breath gets a bit stuck in your ribs so really focus on bringing it down. This breath can be used during labour to help you relax and ease the strength of the contractions. Learning to relax with the breath can really help you during labour and can be used alongside visualisation techniques to teach your body how to let go of tension.

For the next 10 breaths, try to focus on breathing into the back and sides of your ribcage and feeling your ribcage expand as you inhale and soften every time you exhale. You can try this breathing in a small side bend to help open up the ribcage. In lateral breathing the abdominals lift and flatten upward on on the inhalation and release down and out on the exhalation, which is opposite to a diaphragmatic breath. Both have their place. The lateral and posterior breath can be really helpful when the uterus expands and lifts in the second trimester and can help make more space for the diaphragm that may be squeezed upward.

Breathing and Connecting Sequence
Lying on your back in a neutral spine with your knees bent up and your feet in parallel with an awareness of your sit bones. Inhale to send your breath down to your sit bones. Exhale to let your belly relax towards your spine, feel your pelvic floor recoil then gently contract the muscles to draw your sit bones together. Remember this is a very subtle and internal contraction and shouldn’t cause any external movement as such but will act on the viscera/ abdominal content and will be felt as a lengthening of the spine. Repeat 5 times.

Move your hands to your hip bones. Inhale to send the breath between your hip bones. Exhale to let your belly relax towards your spine, feel your pelvic floor recoil then gently contract the muscles to bring the hip bones together. This should not cause the abdominals to bulge outwards. Repeat 5 times.

Move your hands to your lower rib cage. Inhale between your hands. Exhale to let your belly relax towards your spine, feel your pelvic floor recoil and your ribcage relax downwards then gently contract the muscles to bring the rib cage together. Repeat 5 times.

Now bring it all together. Inhale to send the breath to your sit bones, hip bones and ribcage. Exhale to let everything relax then gently draw sit bones, hip bones and rib cage towards your midline. Everything should feel relaxed and like it is drawing into the centre. Your abdominals should never feel tense or bulging. Repeat 10 times.

Pelvic Tilts
Lying on your back in semi-supine. Make sure that the feet are parallel to each other and be aware of the big toe joint connecting into the floor. Feet are a little further away from the pelvis so that hamstrings and glutes will activate functionally. Exhale to gently connect tailbone to pubic bone and pubic bone to chest so that your lower spine softens into the floor (rolling your pelvis under and thinking of bringing your pubic bone and your rib cage towards each other). Inhale and release back into neutral, allowing your hip flexors to release, the pelvic floor to open. As a variation, you can hold the pelvis in the tilt (if you can, try not to fully release on the in breath, keeping some connection), exhale to connect again, visualising the abdominals drawing back into the middle. Have an awareness of your pelvic floor connecting as your ribcage is softening and the pelvic floor connecting the sit bones into the inner thighs and big toe joints with every out breath. Repeat the breathing 5 times. Release the pelvis back to the floor.

Pelvic Lifts
Lying in semi-supine with your knees bent up and your feet in parallel. Feet are a little further away from the pelvis so that hamstrings and glutes will activate functionally. Exhale to release then tailbone to pubic bone, pubic bone to chest rolling through the spine, sit bones, hip bones ribcage to lift your spine away from the floor one vertebrae at a time. Make sure that you don’t over extend your ribcage at the top so the lower spine does not go into extension. Inhale into the lungs (or posterior ribs), exhale to soften your ribcage then slowly peel the spine back down inhale to release back into neutral.

Double Knee Openings
Lying in neutral spine with your feet together. Exhale to allow your abdominals to soften then draw sit bones, hip bones and rib cage together and open both knees out to the side – focus on keeping the pelvis still as the legs move. Inhale to hold the legs there, exhale to connect and pull the legs back together again. Think of the legs being heavy and using your abdominals to pull them back to the middle.

When working in neutral spine many postnatal women benefit from a higher head position (cushion/ block) to allow the back of the ribcage to stay released into the mat whilst the lumbar spine can maintain its neutral arch. If neutral spine is uncomfortable for the client look at the positioning of the head into the thoracic spine.

Single Knee Openings
Lying in semi-supine, exhale to allow your abdominals to relax then draw your sit bones, hip bones and rib cage together and open one leg out to the side, inhale and hold it, exhale to bring it back to parallel. Repeat with the other leg. Focus on keeping the pelvis and especially the supporting leg still and releasing as the other leg moves.

Single Leg Slides
Lying in semi-supine. Exhale to allow your abdominals to relax then connect your sit bones, hip bones and rib cage, then slide one leg along the floor. Inhale when it is straight. Exhale to connect then slide the leg back towards you.

Knee Floats
Lying in semi-supine. Exhale to allow your abdominals to relax then draw your sit bones, hip bones and rib cage together, then lift the leg to a 90 degree angle with a bent knee. Inhale and hold the leg there. Exhale to connect then lower the foot to the floor. Make sure you always have the feeling of the abdominals lifting and connecting together. Start with Heel Lifts – all the same thoughts but just lifting the heel from the floor – if the hip flexors are too active or the abdominals are wanting to dome.

Awareness of Posture, Awareness of Even Weight Placement Through the Feet
Standing with your feet in a parallel position. Have an awareness of your foot alignment and try to line the middle toes up with each other. Lift all of your toes off of the floor and try to place them back to the floor one toe at a time, from the little toe into the big toe. Feel how this changes the weight placement within your feet. Hopefully you will get a sense of the arch of the foot lifting slightly. Continue to feel that lift through the arches and find a sense of weight through the big toe joint at the same time. Visualise your thigh bones widening within your hip sockets to give you a sense of space between the sit bones and connection into your pelvic floor. A typical pregnancy posture means that the hips will swing forwards. Try and feel that your pelvis is stacked on top of your ankles and your ribcage is stacked on top of your pelvis. Think of lengthening the back of your neck and bringing your ears in line with your shoulders.

This article is an edited version of work from my ‘Pregnancy and Postnatal Pilates Training Manual’ which I wrote alongside Anja Schall for our Teacher Training workshops.


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