WHAT YOU NEED TO KNOW ABOUT DIASTASIS RECTI ABDOMINIS (DRA)

Image DRA © 2017 YogaSpine/Christa Powell

Image DRA © 2017 YogaSpine/Christa Powell

Postnatal separation of the Rectus Abdominis muscles was rarely talked about in public some years ago. It briefly came up in my professional training, and even then seemed to get brushed away on one lecture slide. My granny, who gave birth to six children, had never heard about the condition. Over the past few years, however, the term has gained traction, and an increasing number of body-conscious mums come to me asking if a Diastasis Recti Abdominis (DRA) is the reason why their abdomen looks so different than before their pregnancy. For many the postnatal changes they experienced have caused grief, loss of confidence, and it’s not uncommon for women to feel like they are living in a body that they no longer recognize. So the purpose of this blog is to shed some light on what a DRA actually involves, how to test for it, and where to go from there.

 

Understanding The Anatomy

The Rectus Abdominis (RA) muscles are the vertical muscles that lie either side of the midline. Commonly known as the ‘six pack’, they run from the xiphoid process at the apex of the ribcage down to the pubic bone. The Linea Alba is the taut, white band of connective tissue that runs down the midline of the RA muscles, anchoring the muscles to one another and to the deep abdominal wall. In addition, there are two layers of oblique muscles (picture these as a huge X across the ribcage and abdomen) that help us breathe, side-bend and rotate. Finally, the Transversus Abdominis muscles are the deepest and are like a huge corset that wraps all the way around our waist, attaching on the back. It is important to understand that all the above muscles work in collaboration to draw in, support, move and stabilize the waist and trunk. 

  

What We Know

Diastases are common in pregnancy. In fact, not only are they common, but in the third trimester all women will have some degree of separation as the belly grows (1). Postpartum prevalence is much harder to pinpoint, partly due to inconsistent study methods and because good research is scarce. Sperstad, J. et al. (2016) estimated in their study that at six months postpartum two thirds of mums have a DRA greater than before they got pregnant, compared with only one third at 12 months. This shows us that time itself plays a role, and that actually most mums will see a noteworthy reduction in their DRA at one year postpartum regardless of what exercise they have done.

For the most part, the factors that play a role in severity are often the ones that we can't do so much about. For example, we know that having more babies will result in a more severe DRA, and that after the age of about 25 the body tissues are already less able to cope with the physical changes  of pregnancy (3) (harsh, but true!). In fact perinatal heavyweight lifting is the only manageable factor that has been linked with a more severe DRA. But even here the effects have not been studied long-term, nor do we really know how heavy those weights need to be per individual to make a difference. 

Studies have also failed to consistently link DRA to other common postnatal complaints, such as lumbopelvic pain (4,2), pelvic floor dysfunction (5), and the presence of protrusions or an abdominal pouch (6).  It is possible to have a DRA without dysfunction, pain or visible distortion, but also to have all the above without a DRA. This is not to say that they cannot coincide, but it is important to remember that a DRA is just the visible element of a greater problem, and that all of the muscles must be addressed. Separated RA muscles may contribute to instability, but when there is pain or the waistline is unstable postpartum, the entire support system of the trunk is weakened. All the abdominal muscles are put under great stretch during pregnancy, not just the RA.

To have a tangible concept of how important this relationship is, try this: Lie on your back with your knees bent and perform a curl-up. Notice that your six-pack muscles pop out as they tense to lift the torso off the floor. Now while you hold this, suck your belly button down towards the spine and notice that not only is the abdomen flatter overall, but there is more stability and the pose feels easier to do. You have now activated your Transversus Abdominis muscles (TrA). If you look at the images above you will see that the TrA muscles consist of horizontal fibres. These lie deep to the RA muscles, and literally anchor the RA muscles down and flatten the stomach by pulling laterally.

Unfortunately the relationship between the abdominals if often lost in resources readily available online. One quick Google or Pinterest search will show up a multitude of quick-fix articles with promises, claims and ab exercises that target the six-pack muscles. This is perhaps because some earlier studies focused on which abdominal exercises would be the most successful at narrowing the width of the Linea Alba while performing the exercise. Studies looked at the width of the gap during a curl-up (which mainly activate RA muscles) vs hollowing, pilates-type exercises (stronger focus on TrA). It was suggested that because activation of the TrA muscles creates a lateral pull from the midline, reverse curl-ups that tense the RA muscles without co-activation of the TrA should be favoured (7,8).

The problem is that focusing on narrowing the gap itself isn’t enough to create tension across the whole trunk. Diane Lee and Paul Hodges (9) demonstrated recently that perhaps we should steer the focus away from the width of the Linea Alba and instead look at its quality and appearance during abdominal exercises (9). What they found was that when there is pre-activation of the deeper muscles (TrA) during curl-up exercises, the Linea Alba becomes a taut, smooth band. Without this activation the gap is narrower, but the Linea Alba is rendered unhelpfully distorted. They concluded that what we should be aiming for enhanced tension across the entire trunk rather than narrowing of the muscles. Not only will this create a flatter appearance, but the entire trunk will have more support as the muscles are toned in synergy. 

 

Do I Have a DRA?

Checking for a DRA is a quick and easy manual test which, though not as accurate as an ultrasound measurement (10), will give you some indication. Lie on your back with your knees bent and lift your head off the floor as though to look at your pubic bone. You should see your RA (‘six-pack’) muscles pop up and an indentation down the midline between them. This is your Linea Alba. Place one or two fingers right here just above the umbilicus. There are many variations of DRA’s. Some are greatest at umbilical level, others above or below. As such, ‘normal’ width has been found to vary significantly, but more than approximately 2 cm or two finger widths is considered to be positive for a DRA (11).  

Know that even if your gap is two finger widths or wider, conservative treatment is still the way forward. Rarely, and as a last resort, surgery can be an option, but this is usually only indicated where a) there has been no improvement at one year postpartum, b) abdominal content can actually be felt through the skin and fascia, and c) there is impaired movement function (11,12). In fact, surgery is most commonly opted for due to cosmetic reasons (13). Many confuse a DRA with an abdominal pouch, and  patients are sometimes surprised at how narrow their DRA is, compared with the appearance of their abdomen. Understanding that a pouch can exist without a significant DRA (and vice versa!) is helpful. An abdominal pouch, especially in the absence of dysfunction or pain, is usually a consequence of extra abdominal fat, loose skin and muscle weakness. Unfortunately skin does not have the elastic recoil property that muscles have, though again time will help, as will a good diet and healthy lifestyle.

 

So, What Can I Do About It?

Below are three easy steps to get you on your way. Please note my blogs are for educational purposes only and are never meant to replace advice or consultancy with a medical professional in person. 

 

1. Get to know your deep abdominal muscles: 

Lie on your back and find your frontal hip points (those bony points on your pelvis). Slide two fingers just medial to this point and cough. You will feel the deep the lower TrA muscles contracting below your fingers. Now take a big deep breath and relax. As you exhale, gently imagine you are drawing the belly button to meet the spine, and simultaneously drawing the pelvic floor up into your pelvis. As you do this, see if you can feel the activation of those TrA muscle points. This simple breathing and deep abdominal muscle activation exercises gets the brain – trunk support connection working well again and is an integral part of moving forward. I often spend a while doing these exercises with patients, so it’s worth visiting a professional who can work on breath and deep abdominal work with you in more detail to make sure you are doing it right.

 

2. Restore muscle recruitment during movement:

Understand how to move this way in everyday situations. It’s great that you learn to breathe and move well on the floor, but now it’s time to transfer those new skills to your regular movement patterns. Yoga sun salutations and standing yoga sequences are useful because they allow you to intelligently consider your use of breath and trunk during conscious movement. Eventually this will start to translate into your subconscious movement habits too. For the same reasons it is best to avoid belts that give support to the trunk throughout the day. If they are used for pain relief, they can be helpful every now and then, but they certainly will not tone your muscles nor tighten your ligaments, and will in due course lead to more weakness and instability.

 

3. Make your  lifestyle choices work for you:

Thirdly, it is so very important to incorporate lifestyle changes, and perhaps even more important to be honest about whether or not that is something that may be helpful in the long-run. People often find this the hardest to do, and frankly, it’s hard to talk to people about this because most of us believe we are doing enough, eating well, challenging ourselves. The truth is we probably aren’t. I’d like to refer to a blog written by the author of the website, and host of the podcast Stop Chasing Pain, Dr Perry Nickelston, on habits. I find it to be a well-written, honest text on how good and bad habits form our day to day life, but which can actually live our lives if we pay attention to them. Read it here!

About The Author:
 Christa Powell is a London-based osteopath and a registered yoga teacher. She has been teaching yoga, movement anatomy and working with the body in London and New York City for nearly 15 years. She is a mum, a wife and lives in London where the pulse is contagious and the parks are beautiful. She writes blogs for her clients and for her sanity.

 

REFERENCES

1. Gilleard W, Brown J. Structure and Function of the Abdominal Muscles in Primigravid Subjects During Pregnancy and the Immediate Postbirth Period. Physical Therapy. 1996;76(7):750-762.

2. Sperstad J, Tennfjord M, 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. British Journal of Sports Medicine. 2016;50(17):1092-1096.

3. Fitzgerald C, Segal N. Musculoskeletal Health in Pregnancy and Postpartum. Cham: Springer International Publishing; 2015.

4. Mota P, Pascoal A, Carita A, 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;20(1):200-205.

5. Bø K, Hilde G, Tennfjord M, Sperstad J, Engh M. Pelvic floor muscle function, pelvic floor dysfunction and diastasis recti abdominis: Prospective cohort study. Neurourology and Urodynamics. 2016;36(3):716-721.

6. Brauman D. Diastasis Recti: Clinical Anatomy. Plastic and Reconstructive Surgery. 2008;122(5):1564-1569.

 7. Chiarello C, McAuley J, Hartigan E. Immediate Effect of Active Abdominal Contraction on Inter-recti Distance. Journal of Orthopaedic & Sports Physical Therapy. 2016;46(3):177-183.

 8. Mota P, Pascoal A, Carita A, Bø K. The Immediate Effects on Inter-rectus Distance of Abdominal Crunch and Drawing-in Exercises During Pregnancy and the Postpartum Period. Journal of Orthopaedic & Sports Physical Therapy. 2015;45(10):781-788.

 9. Lee D, Hodges P. Behavior of the Linea Alba During a Curl-up Task in Diastasis Rectus Abdominis: An Observational Study. Journal of Orthopaedic & Sports Physical Therapy. 2016;46(7):580-589.

10. Mendes D, Nahas F, Veiga D, Mendes F, Figueiras R, Gomes H et al. Ultrasonography for measuring rectus abdominis muscles diastasis. Acta Cirurgica Brasileira. 2007;22(3):182-186.

11. Beer G, Schuster A, Seifert B, Manestar M, Mihic-Probst D, Weber S. The normal width of the linea alba in nulliparous women. Clinical Anatomy. 2009;22(6):706-711.

 12. Lee D, Lee L, McLaughlin L. Stability, continence and breathing: The role of fascia following pregnancy and delivery. Journal of Bodywork and Movement Therapies. 2008;12(4):333-348.

 13. Akram J, Matzen SH. Rectus Abdominis Diastasis. Journal of Plastic Surgery and Hand Surgery. 2014;48(3):163-9

 

 

Yoga With a Bump

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The second trimester in pregnancy can be a different experience from one woman to the next, as can yoga. As rule of thumb - listen to your own body, your instincts and do what feels right. You will know if you are pushing yourself too hard, a pose feels wrong, uncomfortable (or even physically impossible!) to do. At this point you are beyond the scare of the first trimester, and the chances of a miscarriage are significantly reduced, so if you already have a regular practice and enjoy working up a bit of a sweat in an intense yoga class - don’t be afraid to carry on doing as you were. Having said that, now is probably not the time to learn new tricks like balances and jumping between poses. Although research now overwhelmingly supports the importance of exercise during pregnancy, there are justifiable concerns linked to the risk of falling, causing injury to mum, or in the worst case scenario placental abruption. That’s why arms balances, headstands and jumps are often discouraged. Below are nine areas that are valid for consideration when embarking on or continuing with yoga practice when there are two of you on the mat. 

1.     Avoid unnecessary jumping and jarring movements – it’s uncomfortable and not great for your placenta. Placental abruption is an uncommon, but serious complication defined as the placenta separating from the uterine wall. It can essentially deprive baby of nutrients and cause bleeding in mum. Step back into planks instead of jumping – and practice letting your ego go at the same time!

Image 2: Diastasis Recti, where the Rectus Abdominis muscles separate laterally    

Image 2: Diastasis Recti, where the Rectus Abdominis muscles separate laterally

 

2.    Crunches and poses that work on the abdominals are pointless…Consider that your superficial abdominal muscles are already under huge stretch – now is not the time to increase the stretch resistance in this area. This is especially true if you’re concerned about Diastasis Recti (Image 2), a phenomenon that often isn’t, but can be permanent. However, maintaining core strength is important, instead of crunches, practice moving slowly through standing poses such as high lunge or chair pose. These will help your core by challenging your balance. As an alternative to Boat pose – try Dandasana (staff pose). It stretches your hamstrings and works your back, while it gently tones the abs. After the pose it is easy for you to join back into the sequence again with the rest of the class.

3.     Generally practice with a wider stance than normal. Trust me, it will naturally need to get wider and wider as you get bigger and bigger! Your balance will be challenged as the weight of your baby pulls the (now more flexible) lumber spine forward into a deeper curve than normal. Standing postures such as the Warrior poses, Trikonasana, Side Angle Pose etc help to maintain a healthy, strong and supple Iliopsoas muscle, open the hips and maintain important leg and core strength. Remember to think about lifting and lengthening the fronts of your hips in these poses as much as possible, avoiding temptation to cave into over-arching the lower back.

4.    Avoid twists (unless they are comfortable, which they probably aren’t). Again, a wider stance is key if you want to continue with standing twists, but a nice option that allows room for the bump is to always rotate into an open twist instead of one that crosses the body. If you’re in a general yoga class and the teacher brings you all into a twist, play with an alternative that works for you, or try a side bending movement instead. Your teacher will be able to guide you if you’re not sure.

5.    Forward folds - If you do not have much hip flexibility and find yourself rounding your back, a forward fold from a standing position with bent knees is likely to benefit you more than the seated equivalent. It is important to bend the knees just enough for your back to be able to remain relatively straight, and for you to feel a stretch in your hamstrings where they attach onto your sit bones and not in the lower back! Doing forward folds with a round back places a lot of strain on the lumbar (lower) spine at a time when your ligaments are likely to give excessively, rendering you vulnerable to long-term instability in the spine. Be careful.

6. Pregnancy is a great time to work on squats, which promote pelvic mobility, thigh and gluteal strength - again great for the delivery. Unfortunately there is a likelihood that you will end up on your back and asked to hold your knees to push regardless of what your perfect birth plan states, and having extra flexibility and strength in the lower body can make that much easier. If your heels don’t reach the floor as you go deeper into the squat, place a book under your heels so that you can stretch your calf muscles, or hang on to a bar with your arms so you can lean back into the squat. Think ‘booty out’ rather than ‘under’ to allow the hips to do the movement rather than your spine.

7.     Walk to class (walking a lot while pregnant is soooo important!). If you can, walk to and from class. Walking helps to maintain muscle tone and strength across the sacroiliac joints – those large diagonal joints on the lower back that unite the base of the spine (sacrum) and the two bones either side, making up the pelvic bowl. Because the sacroiliac joint needs to be able to move freely during a vaginal birth, pregnancy hormones render its (normally) stiff ligaments loose and mobile. In turn the surrounding muscles have to work harder and support the (increasingly heavier) weight of the upper body as its weight is transferred down and into the legs. This frequently results in gluteal muscle spasms, which can pinch nerves, cause symptoms of sciatica down the leg. Generally, if the pain is of muscular nature, it should be relieved by heat, movement and massage.

 

8.    Going upside down…Personally, I did the odd head and arm balance throughout my pregnancy until I started to show significantly around week 27 and my balance really changed. However, these have been part of my practice for over 15 years, and I never stayed there for more than a few breaths. Some people stress that inversions (defined as feet, pelvis or heart over heart or head – depending on who you ask) are contra-indicated because they place pressure on your already overworked heart, may cause you to feel lightheaded or nauseous, and pose the risk of falling. Critics may even erroneously suggest that inversions can bring the baby into breech position. The truth is that if it were that simple we would all be doing positional corrective poses for breech babies, the effectiveness of which unfortunately remains unproven. As many pregnant women struggle with swelling in the legs, inversions can actually provide significant relief if practiced safely by someone with a normal and healthy cardiovascular system. 

Nevertheless, I would normally not suggest head – or handstand to a pregnant woman who isn't confident in her practice, or at least has a person supporting her in the pose. If this is you, try mild inversions such Downward-Facing Dog, Viparita Karani(legs up the wall pose) or Bridge Pose instead to help with leg swelling and to give you that rosy cheek feel. 

Image 1: Inferior Vena Cava compression illustration in woman lying on her back

Image 1: Inferior Vena Cava compression illustration in woman lying on her back

9. Pregnant women are often advised to avoid spending too long lying on their back because the growing uterus can compress the Inferior Vena Cava (the main vein returning blood to the heart from your body) and in turn compromise oxygen to the foetus. The truth is that a few minutes upside down or on your back is unlikely to do harm to either of you, and you would probably faint before your baby is affected. However, it is still best to opt for a side lying position if you have the choice. Savasana can be easily done lying on your side with a couple of blankets under your head and a thick yoga brick between the knees to keep the hips in alignment. 

There is a lot of conflicting prenatal yoga advice online. However, the bottom line is - if something makes you feel physically (or even mentally) uncomfortable, take a break or replace it with something that feels good. Likewise, if your body is craving a pose that is contraindicated and you feel confident in your abilities, don't be afraid to have a go. 

About the Author:
Christa Powell is an Osteopath from the UK, and has been teaching yoga and yoga anatomy for nearly 15 years. She is a mum, a wife and lives in New York City where the pulse is contagious and the sunsets breathtaking. She writes blogs for her clients and for her sanity.