Diastasis Recti Abdominis

It would be hard to dispute that the human body changes in many ways during pregnancy. Most of the changes happen for reasons of a biological nature, and are an expected and often welcomed part of the process of bearing a child.

There is a category of changes that are often neither expected nor welcome, though. This includes complaints such as back pain and pelvic floor disorder, and a lot of other issues in between. Unfortunately, many of us will experience one or more of these issues during or after pregnancy.

Among the list of complications is Diastasis Recti Abdominis (‘DRA’), sometimes referred to informally as abdominal separation. For someone with DRA, a pot-belly will remain weeks or months after pregnancy, and a trademark ridge or dome typically appears in a vertical line on the abdomen when we cough, or get up from lying down. The condition is relatively easy to diagnose; your doctor, midwife or OB can perform a quick and very simple test, and there are short video tutorials online for self-testing[i]. It is widely accepted that it is caused by pregnancy, with a woman’s chances of having DRA increasing with every successive pregnancy.

DRA is not only a problem of muscle separation, however. The muscles and tissues of the abdominal cavity necessarily come apart during pregnancy to make way for the growing baby; our abdominals are not one wall of muscle for this very reason. A stretchy fibrous tissue called the linea alba connects the two sides of the abdominal musculature. The linea alba, as well as the abdomen’s fascia (connective tissue) is what is part of what has been compromised in those presenting a DRA. If you have been diagnosed with DRA, chances are your healthcare provider has then suggested, if you asked about the cause, that your muscles have simply “not come back together”, or that “the linea alba/fascia has failed”. The current level of knowledge within the healthcare system is patchy when it comes to DRA, and midwives, ob-gyns, doctors and physiotherapists often cannot explain why a DRA is present, nor what exactly has caused it, other than pregnancy. Research in the field is woefully minimal, despite the high proportion of women who show symptoms; one study[ii] found that 66% of women had a DRA by their third trimester of pregnancy, and of these women, over half still had it after they had delivered their babies.

Current treatment of the condition will normally focus solely on muscle (and, less frequently, fascia) health, with an emphasis on bringing the muscles back together. Many physiotherapists and other health professionals seem to work on the assumption that once the muscles are brought back together, through exercise or surgery, the DRA will no longer present a problem. This approach might at first appear to solve the problem, but it does not speak to the question: “What causes DRA?” The treatment, either via exercise, binding[iii] or even surgery, is often ill-advised, as we could expect it to be with any condition that has not been researched sufficiently.

Let’s move on to the cause, then. Simply put, DRA is caused by excessive intra-abdominal pressure (too much pressure within the abdominal cavity), which results in the contents of the abdomen being squeezed outwards and forwards. In order to explore why the abdomen has been placed under excessive pressure, we need to know that DRA is what we could call a modern disease of our modern environment. Biomechanist Katy Bowman points out that current lifestyles and lack of natural movement mean that our bodies are adapting in a negative way; she states, effectively, that we are how we move (or don’t move). We sit for many hours a day, wear heeled shoes, are often in a state of stress, and move our bodies in restricted ways and for less time than at any other point in history[iv]. Our bones are no longer held in the places they should be by our muscles, tendons and ligaments, which have become shortened and compromised by our habits and practices.

Now let’s explore the subject of pressure. The abdominal cavity should be a well-functioning cylinder lined with muscle and healthy fascia. By wearing heeled shoes (which affect the alignment and position of the pelvis), sitting too much and generally under-using our bodies, the cavity becomes deformed and squashed, especially with the addition of a growing baby, or by extra weight gained around the abdomen. We thrust our ribs up and out, both intentionally for masking purposes and unintentionally due to shortened muscles (shortened muscles and their attendant problems could make for an entirely new article!), and suck in our stomachs to try and hide our bellies. Our insides are then pushed outwards under the pressure[i], and all too often, skin and loosened fascia end up holding in the weight of the contents of the abdomen[ii]. A DRA now appears, though it’s been a lot longer than nine months in the making!

Hopefully, what I have written above helps you to understand why most health professionals are not currently able to answer our questions about DRA: the research is insufficient, the condition is relatively new, the causes are numerous and fairly complex, and much of the information and training given within the healthcare system pre-dates what is happening now to our bodies. The good news is that the most common width of a DRA (measured in finger-widths: around three or four) should be pretty easy to heal if the right information and support is given.

It is also worth knowing the following:

– Although many women are diagnosed with DRA during or after pregnancy, it is also possible for DRA to appear in women who have not borne a child, as well as babies, children and men. It is clear that pregnancy, with the extra mass and weight of a baby adding extra pressure, is a catalyst for a DRA, but pregnancy is not the cause.

– When performed correctly, core abdominal exercises can help a DRA to diminish, though many regular abdominal exercises are not helpful and may hinder healing. Any exercises that cause the stomach to bulge (eg: planks, boat pose) or that force you to hold your breath should be avoided. However, the problem is neither simply of a muscular nature, nor does this solution take account of the disconnect that many of us experience with our own bodies in the post-partum period. This disconnect can manifest itself in an emotional way (“It upsets me to look at my body”), and/or a physical way (“I have lost the ability to recruit my core muscles” – this is one cause of our inability to self-heal). Many of us with DRA end up using alternate muscles to compensate for a lack of core strength or to “protect” our insides, which are moving forward and outwards, instead of being packed safely behind layers of muscle and firm, strong fascia. To take account of this, the solution should incorporate both finding the core connection and all-body wellness.

– If you decide to visit a physiotherapist, be prepared ahead of time. A good physiotherapist has an excellent understanding of muscle health and knows exactly what your abdominal muscles should be doing. They can also, by way of ultrasound and palpation (using hands to feel), tell what your muscles are actually doing. However, in my experience, physiotherapists often overlook the disconnect between the brain and core muscles of a DRA patient (or, possibly, they find it difficult to apply a practical solution in the face of this disconnect), and visits can be frustrating and unproductive. It is most certainly worth finding one’s core connection, and learning more about the cause of a DRA, in preparation for a visit.

– Surgery is becoming a popular solution, and is often prescribed as “the only course of action”, particularly for those of us with a wider DRA. However, this route still fails to address the cause of the issue. Once we can stop thinking of DRA as a single ailment, and more of a symptom alerting us to other issues, we can move towards finding solutions that work. Surgery can be a game-changer for those with a wide DRA who are experiencing one or more of the afflictions that can develop alongside when the condition is extreme and remains untreated: hernia being a common associated risk. However, for those who are not experiencing complications, it makes sense to find the cause before treating the symptoms, particularly with such an extreme step.

If you have discovered that you have DRA, and would like to learn more about how your core (and every other muscle) is affected by the way you move throughout your life, there are some excellent resources springing up now. Some are exercise programs specifically designed for healing DRA[iii] and others, such as Bowman’s writing and teachings, deal more broadly with natural movement and alignment (the adjustment of each part of the body to provide optimal functionality and eliminate wear, tear and pain) and how to avoid the health risks associated with modern life in general.

And if you would like to start right now with some simple, practical changes, my recommendations are to start moving more and stretching, walking more, and in flat footwear, and to spend less time sitting in chairs. Strengthening and re-aligning the body can start before or during pregnancy in order to avoid conditions such as DRA, though adopting natural movement and alignment work (otherwise known as Restorative ExerciseTM) at any time will be beneficial.