Diastasis Recti: Can you really close the gap?

Diastasis Recti: Can you really close the gap?

The answer is yes! It’s not all about closing the gap… but it can be accomplished with a combination of visceral manipulation (a gentle manual therapy that moves your organs) and strengthening the abdominal muscles.

What is a Diastasis Recti (DRA)?

It’s a separation of the two muscles that give you a six pack, Rectus Abdominis.  A little separation is normal and during pregnancy the line alba (fascia connecting all the abdominal muscles at midline) is naturally stretched to accommodate a growing baby. This fascia frequently becomes overstretched, leading to abnormal widening of the rectus muscles and loosing it’s supportive ability.

Diastasis occurs in 66% of women in their third trimester and 36% remain abnormally wide at 5-7 weeks postpartum.(1) After delivery, the separation naturally closes as the body heals during the first 8 weeks, however left untreated it’s has been shown to remain the same one year later as it did at 8 weeks postpartum. (2)

A space of more than 2-2.5 fingers (2.7cm) at the level of the belly button is considered abnormally wide. (3) In the morning when you're getting out of bed or when you bend forward to pick up your child you may notice bulging around your belly button, this could be a diastasis...

Don’t be alarmed if you do have a separation, it can be treated! 

The internet provides a lot of information that is both helpful and questionable. It is valuable to have a pelvic floor physical therapist fully evaluate your abdomen, ribcage and pelvis before you start an exercise program.


How to treat a DRA?

It’s common practice to retrain the deepest abdominal muscles, Transversus abdominis (TA). These muscles play an important role stabilizing our trunk, supporting the breath and preventing leakage. (4, 5)

TA contracts like a flexible corset, facilitating a gliding of fascia towards the front and back of our abdomen, flattening our tummy and narrowing our waist. Clinically, I’ve found that postpartum women tend to loose this gliding action…

Frequently, there is an asymmetrical TA contraction, one side may engage and the other may pull backwards or there is no activity at all. And commonly I feel the other abdominal muscles pop into my thumb pads... those are the obliques, which we do not want to initially fire! (5)

Potential reasons why this may happen:

Pain decreases communication between the central nervous system and TA (6, 7)

There are physical restrictions preventing the gliding movement of fascia

A recent case study series (kirk and Elliot-Burke, 2017) has suggested that restrictions of our abdominal organs and fascia attaching to the back, can cause a diastasis recti (8).

The theory is based on understanding anatomy: all of our abdominal muscle layers are connected to each other towards the back, and the inner most layer called peritoneum is directly attached to our organs. (9) In this study the diastiasis present in all 3 cases was resolved within 3 sessions of visceral manipulation and remained intact between 6-11 months. (8)

This is obviously a very small study, however I’ve been using the same techniques on all of my diastasis patients, and the results are quite amazing…within 3-4 sessions, I've seen the gap fully close and patients can correctly engage their TA. (4)

What about abdominal crunches?

In general women with DRA are advised not to do crunches, increased abdominal pressure during sit-ups pushes down and through, widening the gap…

A contrasting research report by Mota et al, 2015 has demonstrated that a crunch actually reduced the size of the gap during pregnancy and at 3 different stages postpartum. Interestingly, they also found a "TA contraction generally created a small widening." (10)

This study only shows the immediate effect of the 2 exercises, so it doesn't give you permission to start doing crunches, but it does highlight that we shouldn’t avoid them! Coordinating the breath with correct TA and pelvic floor muscle activation, during a modified crunch is a safe way to rehabilitate diastasis recti… combine it with visceral manipulation and say goodbye to your gap!


References

  1. Boissonnault J.S., Blaschak M.J. Incidence of diastasis recti abdominis during the childbearing year. Physical Therapy. 1988; 68:1082-1086
  2. Coldron Y., Stokes M., Newham D., et al. Postpartum characteristics of rectus abdominis on ultrasound imaging. Man Ther. 2008; 13:112-121
  3. Rath A.M., Attali P., Dumas J.L., et al. The abdominal linea alba: an anatomo-radiologic and biomechanical study. Surg Radiol Anat. 1996;18:281-288.
  4. Lee D.G., Lee L.J., McLaughlin L. Stability, continence and breathing: the role of fascia following pregnancy and delivery. J Bodywork Move Ther. 2008;12:333-48 Lee
  5. Diane, Lee Linda-Joy (Major Contributor), Vleeming Andry (Contributor), The Pelvic Girdle. An Integration of Clinical Expertise and Research. 4th Edition, Elsevier 2011.
  6. Cowan, S.M, Schache, A.G, Brukner, P., et al., 204, Delayed onset of transversus abdominis in long-standing groin pain. Med. Sci. Sci. Sports Excerc. 36 (12), 2042
  7. Hodges, P.W., Moseley, G.L., 2003. Pain and motor control of the lumbopelvic region: effect and possible mechanisms. J. Electromyogr. Kinesiol. 13, 261
  8. http://www.barralinstitute.com/docs/articles/effect-of-visceral-manipulation-on-diastasis-recti-abdominis--dra--a-case-series.pdf
  9. Paoletti, S. The Fasciae. Anatomy, Dysfunction & Treatment. Eastland Press. Seattle. 2006
  10. Mota, P., Pascoal, A.G., Carita, A.I., Bo, K., 2015. The immediate effects on inter-rectus distance of abdominal crunch and drawing-in exercises during pregnancy and the postpartum period, J. Ortho & sports PT, Vol 45, 10, 781