Welcome to part two of Mind the Gap: Improving the look of Mommy Tummy. For Part one and more background, check out Mind the Gap: Diastasis Recti Abdominis and What We Don’t Know: Part I. Joanna Hess, PT, DPT, PRC, WCS (practices at our down town office) So, about that flat tummy. I want it. Our bodies can be amazingly resilient and are constantly adapting if given the opportunity. Think about an ankle sprain—in order for the overstretched ligaments to heal, the ankle needs be in a position without excessive strain. Conversely, limiting motion over a long period decreases the body’s signal to rebuild the area. We need the Goldilocks treatment—just enough movement and challenge without too much strain. We can use these same principles for understanding the self-resolving diastasis recti. The strained linea alba and loose skin associated with diastasis, like so many other parts of the body, will produce fibroblasts to improve collagen and elastin (the building blocks of skin and other connective tissue), if it is given appropriate mechanical load. Here are some tips for dealing with diastasis: 1. Patience. 100% of women have a diastasis recti (DRA) at the end of the third trimester. Postpartum, 52-60% of women have a diastasis at 6 weeks, 39-45% at 6 months (1, 7) with effects on abdominal strength and endurance (10), and 33% at 12 months. Most improvement happen before 6-12 months, but can continue to 24 months without specific intervention (10,11). 2. Nutrition. This is out of my league, but understandably important, particularly early post-postpartum. Consult your favorite integrative nutritionist. But for starters, bone broth and vitamin C are widely touted to help collagen production. Also, make sure to stay hydrated. Don’t waste your time on the creams. The body needs internal signaling and cellular level building blocks to increase collagen production. 3. Dance, laugh, live. Regular and progressive 3D movement that requires the abdominal system to stabilize, to lengthen, to contract, to work is an easy way to load the system. This translates into activities like laughing really hard, reaching up for things on the top shelf, lifting a child, twisting to grab a cookie, or walking really fast with arms swinging. With some exceptions for pain and loss of the ability to do everyday tasks, limit abdominal bracing techniques such as taping, belly binding, and second skin Spanx. These push pressure elsewhere in the system and decrease the signal for the body to rebuild. We want as much motion that the body can handle without losing its stability. 4. Managing abdominal pressure. The abdominal canister—the multifidus muscles of the back, the respiratory diaphragm at the top, the pelvic floor on the bottom, and abdominals in the front—contains most of the body’s organs and manages fluctuating intra-abdominal pressures. Adopting better posture and movement patterns help manage intra-abdominal pressures taking off excess strain and help resolve DRA. 5. Breathe and wiggle the ribs. Sigh and drop those ribs. A rib flare (thank you baby, and organs that relocated into the rib cage real estate) adds a strain on the linea alba. An easy way to safely challenge the system may be as simple as raising your arms over your head while keeping your ribs down. Or spend some time doing diaphragmatic breathing adding gentle twisting on the exhale. 6. Battle of the ab exercises: Transverse abdominis vs. Rectus abdominis (RA). Women who do specific transverse abdominis exercises are less likely to have a DRA during pregnancy and postpartum as compared to women who have a general exercise program (6, 12, 13). These exercises are focused on a phrase that I like to use, coined by the Institute of Physical Art, “keeping the baby in the bucket”. Cautiously get excited about a very small study that found women who exercised during pregnancy (pelvic tilts and transversus abdominis) had a lower rate (12.5%) of significant postpartum DRA vs non-exercisers (90%) despite DRA during pregnancy (13). A systematic review notes how little we know about exercise for prevention of DRA. A prenatal abdominal exercise program will prevent 1 in 3 women from developing DRA, but unclear as to which exercises should be included (14). Almost 90% of physical therapists use transverse abdominis and pelvic floor training with their patients, and up to 63% of physical therapists use the Noble method which combines the physical approximation of the muscle bellies while doing an abdominal crunch (3). What happens with a transverse abdominis contraction? The transverse abdominis (TrA) is typically cued with the drawing in of the abdomen keeping the upper abdominal soft. You can feel the difference in the contraction just inside the front of the inside hip—trampoline tension for TrA and hard bulge for the obliques/RA. For most people contracting the TrA will increase the space between the abs (1, 8, 15, 16) while linea alba distortion decreases (8). The decrease in linea alba distortion corresponds with an increase of tension of the linea alba. Based on a small research sample and case series, progressive pelvic floor and TrA exercises decrease the space between the abs (13, 17), possibly by vertically aligning the rectus abdominis muscles, increasing mechanical strain and increasing fibroblast activity for collagen synthesis. What happens with rectus abdominis contraction? The abdominal crunch activates the rectus abdominis muscle. Usually when people with DRA do a crunch, the space between the abs decreases (1, 8, 15, 16), but the linea alba distortion increases as the tension is decreased (8). The RA muscle length increases during pregnancy and immediately postpartum, but not enough to decrease the ability for the muscle to generate forces vertically (18). As pregnancy and DRA progresses, the change from vertical orientation to diagonal insertion of the RA muscle fibers likely decreases the ability to generate forces effectively. Perhaps, the decrease in force transfer at the linea alba with RA contraction is more related to the orientation of the muscle fibers instead of the movement of abdominal crunch itself. The winner is transverse abdominis! Based on what we know so far, the exercises that include recruitment of the TrA are most effective at improving the force tension and closing the DRA over time. Passive external supports can be used as part of a progression if the TrA is unable to activate on its own. The TrA needs to be trained to turn on and off which allows for the intermittent tension and internal signaling required for the linea alba and abdominals to adapt to a new position and for collagen synthesis. There are many ways to do this, but here’s a suggested progression: 1. Standing arms overhead with ribs down and diaphragmatic breathing (Irene, our personal trainer, shows a variation lying down)
2. Noble technique with diaphragmatic breathing
3. Sahrmann transverse abdominis progression
4. TrA brace with quadruped alternating arm/leg lift
5. TrA with squat to single leg squat with diaphragmatic breathing
6. TrA with Turkish get-up
7. See a specialized physical therapist. Postpartum pelvic floor therapy is the norm wellness program for most of Western Europe. Like I mentioned before, the variability of why some people do better than others is not well understood. However, a specialized physical therapist will assess how you uniquely go through everyday life and can suggest ways to improve the efficiency of your abdominal pressure system, to give more input in places that are sleepy, and to quiet the overloaded parts. We teach, monitor and appropriately progress your exercise program and functional integration to appropriately challenge without overloading deficient muscles. On a blog, it’s easy to talk about the transverse abdominis, but actually recruiting and integrating this muscle without overloading others, often requires extensive cues, sometimes manual techniques, and adjustments at other parts of the body. 59% of physical therapist use some type of manual technique to treat DRA including 21% using visceral mobilization. A case series demonstrated that the mobilization of the jejunoileum can help to resolve DRA (19). Postural education, exercise progression, abdominal pressure management, and visceral mobilization are part of our regular program for diastasis recti at Beyond Basics Physical Therapy.
We know that the body and linea alba are highly adaptable. The research is unclear regarding the risk factors of DRA, the important measures for DRA regarding function and resolution, and why the TrA seems so important for healing DRA even though its contraction temporarily widens the gap. We do not know how to best nudge the body to produce new collagen for DRA, but if it is anything like the rest of the body, it responds well to intermittent contractile loads and responds poorly to static underloading or overloading. In the meantime, we can hope to see America’s next top model with a real-life mummy tummy that shifts our cultural ideas of beauty and health.
Thank you so much for reading our blog, if you think physical therapy can help you. Please give us a call at either our midtown location 212-354-2622 or our downtown location 212-267-0240. We are offering free phone consultations at both offices for a short period!
Joanna Hess is a treating therapist at our downtown locationReferences: 1. 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. Manual therapy. 2015 Feb 1; 20(1):200-5. 2. Lee DG, Lee LJ, McLaughlin L. Stability, continence and breathing: the role of fascia following pregnancy and delivery. Journal of bodywork and movement therapies. 2008 Oct 1; 12(4):333-48. 3. Keeler J, Albrecht M, Eberhardt L, Horn L, Donnelly C, Lowe D. Diastasis recti abdominis: a survey of women's health specialists for current physical therapy clinical practice for postpartum women. Journal of Women’s Health Physical Therapy. 2012 Sep 1; 36 4. Spitznagle TM, Leong FC, Van Dillen LR. Prevalence of diastasis recti abdominis in a urogynecological patient population. International Urogynecology Journal. 2007 Mar 1; 18(3):321-8 5. Parker MA, Millar LA, Dugan SA. Diastasis Rectus Abdominis and Lumbo‐Pelvic Pain and Dysfunction‐Are They Related?. Journal of Women’s Health Physical Therapy. 2009 Jul 1; 33(2):15-22. 6. Bø K, Hilde G, Tennfjord MK, Sperstad JB, Engh ME. Pelvic floor muscle function, pelvic floor dysfunction and diastasis recti abdominis: Prospective cohort study. Neurourology and urodynamics. 2017 Mar 1; 36(3):716-21. 7. Sperstad JB, Tennfjord MK, Hilde G, Ellström-Engh M, Bø K. Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. Br J Sports Med. 2016 Jun 20:bjsports-2016. 8. Lee D, Hodges PW. Behavior of the linea alba during a curl-up task in diastasis rectus abdominis: an observational study. journal of orthopaedic & sports physical therapy. 2016 Jul; 46(7):580-9. 9. Axer H, Keyserlingk DG, Prescher A. Collagen fibers in linea alba and rectus sheaths: II. Variability and biomechanical aspects. Journal of Surgical Research. 2001 Apr 1; 96(2):239-45. 10. Liaw LJ, Hsu MJ, Liao CF, Liu MF, Hsu AT. The relationships between inter-recti distance measured by ultrasound imaging and abdominal muscle function in postpartum women: a 6-month follow-up study. journal of orthopaedic & sports physical therapy. 2011 July. 11. Coldron Y, Stokes MJ, Newham DJ, Cook K. Postpartum characteristics of rectus abdominis on ultrasound imaging. Manual therapy. 2008 Apr 1;13(2):112-21. 12. Boissonnault JS, Blaschak MJ. Incidence of diastasis recti abdominis during the childbearing year. Physical therapy. 1988; 68(7):1082-6 13. Chiarello CM, Falzone LA, McCaslin KE, Patel MN, Ulery KR. The effects of an exercise program on diastasis recti abdominis in pregnant women. Journal of Women’s Health Physical Therapy. 2005 Apr 1; 29(1):11-6. 14. 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 1; 100(1):1-8. 15. Pascoal AG, Dionisio S, Cordeiro F, Mota P. Inter-rectus distance in postpartum women can be reduced by isometric contraction of the abdominal muscles: a preliminary case–control study. Physiotherapy. 2014 Dec 1; 100(4):344-8. 16. Sancho MF, Pascoal AG, Mota P, Bø K. Abdominal exercises affect inter-rectus distance in postpartum women: a two-dimensional ultrasound study. Physiotherapy. 2015 Sep 1; 101(3):286-91. 17. Litos K. Progressive therapeutic exercise program for successful treatment of a postpartum woman with a severe diastasis recti abdominis. Journal of Women’s Health Physical Therapy. 2014; 38(2):58-73. 18. Gillard S, Ryan CG, Stokes M, Warner M, Dixon J. Effects of posture and anatomical location on inter-recti distance measured using ultrasound imaging in parous women. Musculoskeletal Science and Practice. 2018 Apr 1; 34:1-7. 19. Kirk B, Elliott-Burke T. The Effect of Visceral Manipulation on Diastasis Recti Abdominis (DRA): A Case Series.