As a team, we have spent an enormous amount of time and brain power learning during 2022! Dr. Becca and I have completed over 50 hours of training specific to pelvic health in the year. The demands of staying up to date with research to provide the best client care is one thing we pride ourselves on. The world of PT has changed dramatically in the last 11 years in general, but so has the world of pelvic health. Pelvic therapy is no longer about clamshell exercises, kegels and recommendations from a specialist to go to pelvic therapy 2-3x/week for 4-6 weeks. No! This generation of 30 to 40 year olds are done with leakage, pelvic pain, pressure and are no longer patiently “waiting to see '' what happens during pregnancy, postpartum and perimenopause transitions. They are committed and ready to take on these challenges with grace and strategic planning!
We covered a multitude of topics, therefore the 2023 blogs and information we share will provide you with the most up to date info! This month’s topic is diastasis recti aka a split or gap in the abdominal wall. Read on to learn the facts about what it is and how we can support healing the abdominal wall.
Diastasis Recti- What is the gap all about?
At full term, 100% women will have diastasis recti. This naturally occurs for women during pregnancy due to hormonal and physical changes allowing the linea alba, a thick fascial connection between the left and right sides of the abdomen, to make room for the growing uterus and baby. Think of the “stretching or “gap” as the second zipper on your suitcase that you can unzip to allow for a bit of extra room to pop in your favorite heels. Because you know a girl’s gotta have options!
At 6 months postpartum, 1 in 5 women will experience persistent DRAM (diastasis of the recti abdominal muscle) or gapping in the abdominal wall greater than 2.2 cm as noted by ultrasound.
For reference, 2.2 cm is a little over the width of your pointer fingers. This gapping is found mainly in the linea alba expanding from under your ribcage to the pubic bone. The most expansive area of the gap is found:
59% above the umbilicus
8.5% at umbilicus
1.2% below umbilicus
The average gap or separation width is 22 mm (About 2 of Dr. Amanda or Dr. Becca finger widths) of space above and/or below the umbilicus. This is all considered normal physiological changes for postpartum people. Somehow we have turned it into a “thing” we must close, heal, shape or surgically correct. It is difficult to say what exact recipe is necessary to heal, but what we do know is every woman is different, but is not alone in her journey to heal herself.
“I am afraid exercise will make my DRA worse. How can I close the gap in the abdomen?”
The social media jury of “how to heal a diastasis” is completely all over the board. Charging postpartum people to do planks, do not do sit ups, lift weights, or do not do anything for 6 weeks. But there is research noting best practice for closing the gap. Here is what we learned regarding exercise and DRAM:
To assist in closing of a DRAM at 6-8 weeks postpartum, women who performed crunches versus performing a transverse abdominal (TVA) drawing in action of the abdomen noted significant closure of DRAM around 15 weeks PP. Performing core activities focused on “drawing in the belly button to the spine” (aka the transverse abdominals) with a coordinated pelvic floor muscle contraction was found to lead to an increase in the gap! It is no longer about kegels friends. Based on the biomechanics of the abdominal muscles and the ability to create tension along the linea alba, we need to focus movement strategies that protect and close the gap!
“My OB/midwife checked me for diastasis with her fingers and said I’m fine. Is that enough?”
The goal standard of assessing a DRAM is to use ultrasound. An ultrasound has always been on my Christmas list, but calipers, tape measures and finger measurements have a similar reliability for ultrasound. Calipers have the strongest correlation to ultrasound, so they will make an appearance in 2023 in the office.
Many women will become obsessed with checking “how many fingers of a gap” they can palpate. However the amount of resistance felt between the gap in the direction of depth is more relevant and provides a better sense of how much stretch the muscles and fascia have endured.
Imagine feeling the space between your muscles. In some areas you may notice there is more “give or mushy” sensation verses a trampoline like tension. We like to feel a trampoline-like tension between this space. The more “give or mushy” the tissue or the more depth we can feel between the gap, signals the more challenging it is to create tension throughout the linea alba. Ultimately requiring more time for healing and a challenge to the overall prognosis of closing the gap. Learn how to self check your diastasis here with Dr. Amanda
“What do I do about the Mom Pooch? I hate looking at myself in the mirror.”
One of the biggest calls we receive is to find out if my belly shape going to return to its previous self after I have my baby. Our answer is always it depends! This depends on genetics, health, nutrition and hydration, athletic abilities before, during and after the baby. It is unrealistic to expect our bodies to transform back into social media influencer washboard six-packs. When you think of the prolonged, low load of pressure pushing the belly wall and fascia for over 9 months, you realize you did an amazing thing. It takes anywhere from 1-2 years for women to feel “back to their bodies.”
Best part is- research shares there is spontaneous healing in the first 6 weeks regardless of exercise, baby size, and breastfeeding or non-breastfeeding. How amazing! In reality, we know the effects of DRAM can negatively affect one’s body image. The visible changes to the physical body also lead to a decrease in quality of life. When you do not feel good about yourself, you just do not feel good about many other aspects of life. This is a universal effect seen and felt by women worldwide. There is research to back this and you are not alone.
“Is my diastasis also why I have lower back pain, leakage and a prolapse? I guess everything works together.”
Your body is a fascinating system, but there is no relationship between the amount of gapping and related pelvic dysfunctions like prolapse, leakage and lower back pain. They may co-exist, however one does not cause the other. However DRA in 2-3 places along the LA is correlated with weakness abdominal muscles, endurance and dynamic function! So yes, you will need to give yourself time, patience and learn appropriate strategies to rebuild your core post-baby. Even though there is no association between these two, having a gap is correlated with fear avoidance behaviors, like remaining sedentary, not lifting baby or pushing a stroller and fear to return to walking and fitness.
We have found in our office that the lack of knowledge (and lack of research) is what most likely drives this fear! It is well known that fear of movement leads to lower back pain and more disability, but if we bust the myths of the changes of postpartum life, we can ultimately encourage positive body image, healthy return to movement and less back pain!
To encourage you to move more with a DRAM, the gap was NOT associated with BMI changes, age, weight changes during pregnancy, baby birth weight or type of birth (vaginal vs cesarean). It was also not associated with exercise training customs! Exercise like Olympic weight lifting and CrossFit did not affect the amount of gapping someone may experience.
“Is there anything else I can do to heal my DRAM?”
Since 100% of women will have diastasis recti at the end of their birth, we need to create a plan to support women after giving birth. During the initial postpartum time frame starting at day 2, women would benefit tremendously from using a belly binder. I'm not talking about a waist trainer or spanx! The use of binder like an ace bandage, taping or even belly scarves (If you are interested in belly binding ceremonies see Janelle of Foi en La Femme) are encouraged for use for about 1 month postpartum. Believe it or not, research shows belly binding alone is most beneficial to change the appearance of the belly and core muscle endurance for the first month PP. I know, I totally just put physical movement, therapy and myself out of a job! But it is true! Your body has innate spontaneous healing that occurs during the first 4-6 weeks whether you do something or not.
But let’s say you want to do something! Research shows belly binding and exercise are beneficial together. Exercise alone actually can have a negative effect on the width of the gap, core muscle endurance and also body image, especially if performing exercises not specific to your body. Check out our must have Postpartum Recovery Kit to see what else can support your postpartum recovery
Movement with belly binding does allow a greater support for the belly to promote greater closure of the gap. Specific movements like trunk twists including movement like targeting the oblique muscles was found to improve DRA closure more than “pulling the belly button the the spine”. Exercise focusing on transverse abdominis (TVA) only is found to have negative effects on closing the gap. Long gone are the days of thinking “draw the navel to your spine” while exercising. The forces of the TVA alone can pull the linea alba wider, ultimately decreasing core endurance and challenging the appearance of the “mom pooch”. From our perspective, it is best to provide abdominal wall support AND activate the entire core system together starting at 2-4 weeks postpartum for the best outcomes with professional guidance to support your body!
“Should I just get a tummy tuck or a “mommy makeover”?”
Cosmetic providers in the region are using high intensity focused electromagnetic and electro-frequency techniques to firm, tighten and lift facial wrinkles. There is a similar technology known as Emsculpt that has shown to assist in closing larger DRAM. There was a 20% change in DRAM width by 3 months postpartum which was also maintained by 6 months. We typically see a 14-16% reduction in DRAM after 8 weeks of prescribed exercise. While this technology is not cheap, this is another option we could not pass up sharing. As PTs we are familiar with electrical stimulation for lower back pain and strengthening the muscles around the knee. E-stim can also be utilized for DRAM starting at 2 months PP. Along with 30 minutes of exercise and the use of E-stim, there is a significant improvement in waist circumference, core power and strength. Estim units are also portable and far more accessible compared to Emsculpt.
In all honesty, we learned a lot and most of the research did confirm what we see, feel and do everyday in the office! Albeit research is generally 5-10 years behind, there is a consistent trend to improve not just the outcomes of strength, mobility and function, but the client/patient’s perception and mental health associated with the changes occurring throughout the childbearing years. Exactly why we love seeing our clients and walking the path to pelvic wellness with them.
GRATITUDE SIDE NOTE: We were privileged to be a small part of the 10% of American physical therapists who participated in an international conference hosted by the incredibly brilliant and exceptional pelvic physiotherapist Taryn Hallam. Taryn is an Australian physiotherapist and research guru. The international cohort opened our eyes to learn that Australia, New Zealand, Ireland, England and our northern neighbors, Canada, are well ahead and forward thinking about care for pelvic health. Doing our part to move pelvic and women’s health forward, we are committed to providing excellent care, resources and exclusive one-on-one support to you and the South Jersey community! Let’s do this together.
Want more? Learn what is or is not normal with Dr. Amanda's Postpartum Healing workshop. Get instant access now and start your path to pelvic wellness.
Dr. Amanda Heritage, PT, DPT, PRPC is the owner of Breathe Life Physical Therapy & Wellness, LLC located in Collingswood, NJ. She has been practicing physical therapy for 11 years with a strong focus on pelvic health. She enjoys encouraging women about pelvic therapy as a treatment option for those suffering with pelvic pain, incontinence or constipation.