Let's talk Diastasis Rectus Abdominus (DRA), what some people refer to as "the belly bulge, mummy tummy, and the momma pouch". I get a lot of concerns from women about their new (or not so new) momma bellies. Everything they tell me seems to stem from fear or worry.
Here is what women are saying
Do I have a separation?
How bad is my gap?
What can I do to heal it?
If I do {fill in the blank} will I make it worse?
There is so much information on the internet that women feel stuck, don't know what to do or where to start!
If this sounds like you, hear me out.
The internet is full of information
This is lovely because at the drop of a hat or a click of a button we can quickly access answers to important life questions such as what was the theme song to "The Wonder Years?" I actually had to look that one up the other day to confirm my memory hadn't failed me. But sometimes the answers are not simple and they are down right confusing. This is what happens when you google DRA. The internet fills you with contradicting information which is frustrating, I get it, because I am frustrated too. Worse is the hidden fear behind the wording.
Some internet searches may lead you to believe: {sit ups, planks, twists, crossfit, running, lifting, carrying} are the devil and you will "make your belly worse!" Some sites may advise to: remain in one "perfect" posture, stop lifting your new baby {yea, right}, only hold your baby this way {can people realistically do that?}.
After days of googling (that's a word now, right), people end up freezing. A rush of fear takes over, they stop all activity and come to me in search of clarity. They feel broken, doomed, a mess and completely confused.
Let me the first to tell you that if you have a gap in your belly, you are NOT doomed, broken, or a mess. Now repeat this a thousand times.
How do you know what you should do?
What is the best way to exercise or carry your baby? Can I do normal daily life things without worry of my belly bulge getting bigger? The answer is, it depends.
In this blog I am not going to tell you how to assess for DRA (I can do that in a quick video on another day). I am also not going to give specifics about what should you do in terms of exercise. (Sorry ladies, but that will have to be a separate blog). I am just opening up the conversation around DRA and fear of exercise or movement that many women come to me with.
Evidence is scarce in the area of DRA
Some of the statements you read on the internet are hypotheses created by beliefs and biases despite studies to back it up. I am definitely guilty of letting my biases and beliefs dictate my course of action. But I am living and learning to release judgments and maintain a higher level of curiosity. Some women come into the office with a large gap. Initially, I may jump to the conclusion that they may require surgical intervention. {these are thoughts in my head, aka judgement} Others may present with a small 1-2 finger space, leading me to assume this will be a simple rehab and interestingly, these beliefs have been proven wrong.
I am not saying everything on the internet is bullocks, but what to do or not to do for women with DRA is difficult to stereotype into a group. Everyone has different desires, goals, and needs. Everyone is at different fitness levels, has different connective tissue quality, medical histories, and genetics. DRA is not a one size fits all. Ultimately, an individual assessment is important to know your baseline of function so that a progressively loaded program can be fit for you.
With all that said, lets get a little into what a diastasis recti is and what it is normal.
It is a separation between the right and left sides of the abdominal muscles. Here is a picture of the normal anatomy of the superficial rectus abdominals. I hope this helps you understand how the muscles are arranged.
You should be able to see that the right and left sides of the abdominals are not touching in the picture on the left, there is a normal, I repeat, normal space between them. The tissue that connects them together is the linea alba which is a connective tissue. This connection between the two sides allows them to communicate and function together.
A study by Beer et all in 2009, showed that nulliparious (never had a baby) women have a normal gap size varying from 0 to 35mm (that's about 3 fingers width). This means many women may think they have a DRA, but it is really their normal gap that was present pre pregnancy, but never checked to know their baseline.
During pregnancy our miraculous bellies grow to accommodate our growing baby.
The abdominals stretch front, side and back. Our bellies expand like a balloon, the skin, muscles and connective tissue all must lengthens as the baby and uterus continue to grow. During this growth, the pressure inside our abdomen increases and there is nice tension throughout our core system. Then after childbirth, the balloon has "deflated" and we are left with loose squishy belly tissue. {Why don't people tell us that after we have a baby our bellies feel like a jello mold} The internal abdominal pressure has reduced and the muscles and connective tissue are wondering, " What just happened here? Where did my support go that was keeping me secure?" The muscles have no idea how to support this new shape and change in pressure. And our abdominals have a hell of time trying to function in the postnatal phase. It has to figure out how to create tension in its new shape.
Creating tension through the abdomen gives our central core system strength for movement. Having a gap between the right and left sides of the abdominal muscles is fine and sometimes it is totally normal. The gap may be the same width as pre pregancy, but the inability to access muscular control and function of the abdominals is the obstacle. The tension can be felt along the linea alba at rest and with various movements. The tissue tension (firmness in the gap) may be considered more important than the size of the gap.
So why do women care that they have a DRA?
For some women, they just don't feel strong in the belly, period. They want to be able to accomplish simple daily tasks such as getting up from bed easier, lifting their kid, carrying groceries {more like carrying a kid, 2 jackets, a blankey and 3 bags of groceries} from their car to their house and feel strong doing it. In this case, daily function is the motivator.
It may be aesthetics that drives them to train their belly. For others, it's returning to higher level activities such as crossfit, running or sports. No matter what the driver is to heal your belly, hopefully it is for POSITIVE goals such as feeling strong doing the things you love and NOT FEAR of DRA worsening or possibly causing other symptoms down the road.
Remember, research is scarce and somewhat contradictory.
Are women with DRA more likely to get symptoms such as low back pan, urinary incontinence (UI), fecal incontinence (FI) or pelvic organ prolapse(POP)?
Although Spitzngle et al (2007) found that 66% of women with DRA had at least one other pelvic floor support dysfunction (UI, FI, POP), there is limited evidence to suggest cause and effect. Parker et al (2009) did not find a correlation between DRA and back pain. However, some of his subjects may not have actually had a wide enough gap to be classified as DRA. A more recent study by Kari Bo et al (2016) measured vaginal resting pressure, pelvic floor muscle (PFM) and POP in women at 21 weeks gestation, 6 wk, 6 mo and 12 mo postnatal. They found that women with DRA did not have weaker PFM or POP. {But what about long term 2+ years later}. Also by one year postnatal, there was not a significant difference between women with vs without DRA and their report of UI. {Again, we don't know if this holds true in the longer term} It is also interesting that they found women with DRA to have stronger pelvic floor muscles at 21 weeks gestation compared to those without DRA. {That is some food for thought}
What I am trying to say is, please DO NOT BE AFRAID of having a DRA!
You may want to work on the belly muscles for reasons I mentioned above, but until more research is done, don't let fear be your driver.
What to do and how to exercise is for another blog. Diane Lee has done some great research where she describes it isn't about closing the gap, but creating tension through the abdominal wall for improved functional strength.
P.S. If you skimmed this blog and came down here, I basically cover some reasons why you shouldn't fear having a DRA!
P.P.S. Find some positive goals to strive for when working on your belly muscles such as: "I want to feel strong when I carry my sweet baby for a hike outside"
P.P.P.S. You CAN get stronger and have improved function of those belly muscles. Some women can do that through physical therapy and a great program and others ultimately will need a surgical intervention. Either way, our bodies are resilient and adaptable. You got this mama!
In wellness,
Dr. Ashley