Still Having Issues Getting that Flat Belly? Part III: Diastasis Recti Q&A

I’ve had some really great questions come my way since starting this blog series. I was not able to address all the questions within my past two entries, so I decided to dedicate one post to responding to questions and concerns of our readers. I hope this addition is helpful and informative. If you continue to have any questions or concerns, please email me at stephanie@beyondbasicspt.com or visit our clinic website to schedule an appointment: http://www.beyondbasicsphysicaltherapy.com/

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Question

I just had my first baby 9 weeks ago and think I may have a Diastasis Recti. How can I check if I have one? 

            – D.M., FL

Answer:
A small separation is normal for everyone. Although standardized norms are still yet to be determined, generally a 2 cm separation at and above the belly button and a 1 cm separation below the belly button is considered typical. Most people don’t have a caliper for an accurate measurement and using a ruler to measure on yourself can be tricky. An easy cheat is to use your fingers. Two finger widths above and at the belly button is average and 1 finger width below is average. It can be hard to feel the edges of the muscles when relaxed, so measuring first while lifting your head and bringing your ribcage towards the pelvis is often easier. You want to measure at three different locations along the linea alba: At the belly button, 3-4 inches above the belly button and 3-4 inches below the belly button. The separation is often different at each location and knowing where your separation is can help direct where you should be splinting your abdominals during the exercises.

Start by lying onto your back with both knees bent. Take one hand and place your fingers at your belly button aligned horizontally (see picture below). Press into the tissue with moderate pressure so that your fingertips are past the depth of the skin. Lift your head off the floor and slowly bring your ribcage towards your pelvis. When you feel your muscles start to pop into your fingers, stay in that position and take note of how many fingers fit within the gap. If you do not feel the muscles either move more into the crunch, press until the tissue with more pressure or increase the number of fingers (The separation may be wider). Lay your head back down and repeat at 3-4 inches above and below the belly button.

DRA Measurement

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Question

Is a diastasis recti the same thing as a hernia?

-          J.R., NY

Answer:

Great question. A hernia and a diastasis recti are not the same thing. The lina alba consists of multiple fascial layers and while one layer may be overly stretch, the others may still be intact. With a diastasis recti, the rectus abdominis muscle separates from a widening of the linea alba, but the stretched and thinned linea alba still holds in all the abdominal contents. A hernia is when there is a hole in the abdominal wall and the abdominal contents are pressed outwards through the hole. The below picture is a great example of an infant with both a diastasis recti AND a hernia. You can see the separation of the muscle in the front (football shaped bulge) as well as a hernia (circular bulge above belly button) coming through the diastasis.

DRA with Hernia

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Question:

I had surgery a while ago for ulcerative colitis. I had an incision from just above the belly button to about 3 inches below. I used to have good abs but I’m struggling to get them back especially towards to lower abs.  I can feel some separation in the middle of the muscles of my core and am wondering if that’s part of the problem. I was hoping you might have some advice. I’m desperate to get my flat tummy back. I don’t need a 6 pack but I do miss having a flat tum. Would really appreciate your thoughts. 

            – A.H., UK

Answer:

Having any surgical incision along the linea alba definitely compromises the integrity of the closed canister and often leads to a diastasis recti. Studies have shown that almost 100% of women with laparoscopies (just a small hole) through the belly button or along the linea alba are left with a separation, so a longer incision line would almost definitely leave you with one. The separation could definitely be contributing to your difficulty with getting your flat tummy back. I would stay away from crunches right now, but start introducing some TA (Transversus Abdominis) exercises with abdominal splinting that I discussed in part 2 of this blog. Make sure you have support for all abdominal exercises you do – meaning a sheet wrapped around your abdomen or you can just grab the edges of the rectus abdominis and make sure they stay together with the exercises.

If the muscles are not coming together in 6-8 weeks, I would visit a women’s health physical therapist. Scar tissue is laid down anytime a surgeon cuts into the body, and especially with abdominal surgery, the scar tissue may be preventing the muscles from coming together in the front. The fiber orientation of scar tissue is disorganized and laid down in a random manner, meaning it can attach to anything around it – skin, muscle, bone, organs, etc. This can result in adhesions that inhibit normal gliding of the surrounding organs and normal contraction of abdominal/pelvic/hip musculature.  Without manual intervention to break up the scar tissue, it may be difficult for the muscles to return to a better resting position.

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Question

I had a cesarean section and am having difficulty engaging my abdominal muscles. I think I also may have a diastasis in my lower abdominals. Does having a cesarean section affect which exercises I should be doing and my recovery rate? Thank you so much!

-          E.K., CA

Answer:

I am so glad you asked this question as there is a huge population of women who have had cesarean sections. Scar tissue is also an issue with this population and can restrict the abdominal muscles from gliding normally. The abdominal muscles and fascia are sewn back together following the operation and it takes 6-8 weeks for the muscles to heal – meaning you should not begin an abdominal exercise program for 6-8 weeks (you must receive clearance from your Obstetrician first). Scar tissue will be laid down along the entire depth of the incision line and will decreased tissue glide unless the issue is addressed. This may prolong or prevent correct muscle activation and can therefore affect proper closing of the diastasis recti. The exercises for women with cesarean sections are the same, but if you notice that your muscles are not coming back to midline within 6-8 weeks following the start of the exercises, then you may want to consider seeing a women’s health physical therapist.

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Question:

I had twins 6 months ago and am still struggling with looking pregnant. I have a moderate separation above, at and below my belly button. I have being doing exercises for diastasis recti for a month now and I think my muscles are slowly coming back together. Should I be wearing an abdominal binder to help with the process? Also – I think my TA, the muscle on the inside of my hip bone, is starting to hurt from working it so hard. Is that normal? Thanks for your help!

            – R.M., NY

Answer:

For a moderate to significant separation (> 6 cm separation at rest), an abdominal binder can definitely be useful. The binder helps with preventing further separation of the abdominal muscles during functional activities, such as lifting your child and pushing a stroller, by providing external passive splinting of the muscles. You should wear the binder during the day when you are doing physical activities and only if you are also doing abdominal exercises without the binder. If you rely on the binder, the muscles will become weak and your separation will not come back together. While wearing the binder, you don’t have to actively hold in your abdominals. The splint should bring the two ends of the muscles together so that when you need to engage your abdominals (lifting, pushing) they are in a good, safe position. The muscle just inside your hip bones are either your obliques or Transverses Abdominis – neither should be getting sore with the exercises. Make sure you are not constant holding in your abdominals throughout the day with the binder and that you are only lightly contracting the TA with the exercises (your buttocks and superficial abdominals should not be contracting).

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Question:

What does “women’s health physical therapy” mean and how does it differ from regular physical therapy? If I have issues surrounding my pregnancy, can’t I just go into any physical therapy clinic?

            – C.W., FL

Answer:

Great question! To be honest, “women’s health” is an outdated term since many of these clinics also treat men and children. The term is now shifting to “pelvic floor physical therapist.”  I specifically used the term women’s health because many general orthopedic PT clinics that don’t treat pelvic floor issues do treat pre- and post-partum women. If you are interested in physical therapy services, be sure to call the clinic and ask if there is anyone there who specializes in pre- or post-partum care.

I specifically work as a pelvic floor physical therapist treating varying orthopedic conditions, women’s health issues and bowel, bladder and sexual dysfunction in men and women. Typical diagnoses that I treat are painful sex, painful urination, urinary frequency, urinary urgency, urinary incontinence, interstitial cystitis, endometriosis, pre/post-partum, rectal pain, constipation, fecal incontinence, lower back/coccyx/pelvic/sacral pain and any post-op abdominal, back, hip, pelvic or bowel/bladder/vaginal surgery. Pelvic floor refers to the group of muscles that sling from your pubic bone in the front to your coccyx bone in the back. Since three different systems (Bowel, Bladder & Sexual) go through these muscles any pelvic mal-alignment, weakness, tightness or dysfunction in coordination can disturb any or all three systems. If you remember back to the analogy of the core as a closed canister, any dysfunction in these muscles can affect breathing, abdominal organ function, trunk stability and in turn the extremities that rely on the trunk for stability.

Again, if you continue to have any questions or concerns, please email me at stephanie@beyondbasicspt.com or visit our clinic website to schedule an appointment: http://www.beyondbasicsphysicaltherapy.com

Prevention: Diastasis Recti, Part II

By Stephanie Stamas

So now that you’ve learned how a Diastasis Recti (DR) can be created during pregnancy, how can you prevent it from happening to you? There is currently a lot of available information on the positive benefits of aerobic exercise for the pregnant mother and the fetus, but little research focuses on the effects of exercises on abdominal muscle strength, function during pregnancy and exercises to prevent linea alba separation. While studying at Columbia University I had the privilege of conducting research with Dr. Cynthia Chiarello, who is a pioneer in examining the relationship between diastasis recti, exercise, function and prevention. A research article published by Dr. Chiarello, “The Effects of an Exercise Program on Diastasis Recti Abdominis on Pregnant Women” found a significant difference in the presence of a DR between women involved in an abdominal exercise program (12.5%) versus non-exercising women (90%)1. This conflicted with results reported in an article by Gillard & Brown that found no difference between the exercising and non-exercising groups2. Dr. Chiarello argues that the key difference between the two prescribed exercises protocols was the purposeful activation of the transversus abdominis (TA), a deep abdominal muscle that acts as the body’s natural corset (the circumference of the Coke can discussed in part I), and promotes continued linea alba approximation throughout pregnancy.

Transversus Abdominis

Activation of the TA is implicated in the prevention and resolution of a DR for several reasons. First, contraction of the TA acts like an internal splint, helping to stabilize your core and decrease the width of the linea alba from the inside out.  Secondly, because the linea alba is made of two fascial layers (deep & superficial), targeted strengthening for separation prevention of both layers is required. Typical abdominal exercises – crunches, curls, etc – target the rectus abdominis and oblique muscles which only strengthens the superficial fascial layer. The deep fascial layer and inner abdominal wall, which is mainly formed by the TA, is not addressed with these exercises and is under the most tensile stress with a growing uterus. The inclusion of rectus abdominis and oblique exercises should only be introduced once the TA has become adequately strengthened. In summary, strengthening the TA first should be the foundation of any pre-natal or post-natal exercise program (also, an added bonus – the TA aids in the pushing phase of labor!).

To help you begin strengthening your TA, I have created a two-phase abdominal exercise program. The first phase focuses on isolated TA activation (week 1-2) and the second phase begins to add dynamic activities on top of TA stabilization exercises (week 2-6). Click on the links below and then enter the corresponding codes to gain access to the exercise programs.

Phase 1TA activationCODE: W9KNTZK

Phase 2TA activation with dynamic activitiesCODE: HDQ7JN2

Adaptions for Pregnant Mothers
For those in their second trimester – It is recommended that you don’t lie onto your back more than 5 minutes at a time as there is a (low) chance of decreased blood flow to the uterus. So either do the exercises with your back elevated on a wedge, in modified squat position against a wall or take breaks lying on your back by switching to another exercise in a different position. If you notice that you are starting to develop a diastasis recti, be sure to splint your rectus abdominals during all exercises – cross your arms around your waist as if you were hugging yourself and pull the muscles towards midline in sync with the TA contractions.

Adaption for post-natal mothers with DR
Start with the phase I exercises all supine (lying on your back), making sure to splint your abdominals with either the sheet wrapped around your abdomen (See Part I), using your hands to manually bring the edges of the muscle bellies together or while wearing an abdominal binder. These are by no means the only exercises out there, but are foundational stepping stones required to return to crunches, planks, bicycles, etc diastasis-free and pain-free!

I’ve had great feedback from Part 1 and a lot of excited expectation for this post on prevention. I knew a lot of my friends would benefit from this series, but I couldn’t not have imagined how hungry people were for this information. I have received some excellent questions that I was not able to address in these two posts, therefore you can now look forward to Part 3! I will be answering questions that I have received and have not been able to address. Feel free to reach out to me if also you have any questions: stephanie@beyondbasicspt.com

*While abdominal exercises are generally safe during normal pregnancies, it is important to observe the ACOG precautions for exercise & consult with your physician prior to starting a new exercise program.

 

References
Gilleard WL, Brown J Mark M. Structure and function of the abdominal muscles in primigravid subjects during pregnancy and the immediate post-birth period. Phys Ther. 1996; 76(7):750-762

Chiarello CM, et al. The Effects of an Exercise Program on Diastasis Recti Abdominis on Pregnant Women. J Women Health Phy Ther. 2005; 29(1):19-24

Why Do I Still Look Pregnant?!: Diastasis Recti, Part I

By Stephanie Stamas

Is it just me, or does it seem like everyone is having a baby this summer? My Facebook feed is filled with pregnant belly time lapses and newborn pictures. I’m at the age where a lot of my friends are starting families and knowing that I am a pelvic floor therapist, I have been getting a lot of phone calls. One of the top questions that I have been asked is – I’ve had my baby, so why do I still look pregnant?

Here is the scoop – When you are pregnant, your abdominal muscles expand in length by the addition of more muscle fibers (sarcomeres) to accommodate your growing belly. After birth, it typically takes 6-8 weeks for the muscles to re-organize and shrink in length to a size that best supports your abdominal contents. This is how the body is designed to adjust to the changing abdominal circumference. Some women, however, grow very quickly and the muscles are not able to expand quick enough. When this occurs, the linea alba (the vertical line of the much-desired six-pack) stretches and the abdominal muscles move away from the midline. This is a more common occurrence in women with more than one pregnancy, multiples (twins, triplets, etc) or a non-exercising lifestyle prior to pregnancy. The stretched linea alba does not typically return to its previous length in a 6-8 week time frame and can allow the abdominal contents (your organs) to bulge through the thin tendonous structure, leading to the look of being pregnant.

Having a diastasis recti may not only result in the mother continuing to look pregnant, but it can also lead to low back pain, pelvic pain, constipation and pelvic organ prolapse. I like to compare the core to a closed canister (you can think of a Coke can) – The diaphragm is on top, the pelvic floor muscles are the bottom and the abdominal musculature – specifically the transversus abdominus and multifidi – are the circumference of the can. These muscles create a tight-knit closed environment that allow for proper support of the viscera (organs), stabilization of the spine with functional activities, and normal function of the bowel, bladder and sexual systems. Having a diastasis recti is similar to having a split along the side of the coke can, and therefore can compromise all systems that rely on that closed environment.

Great, so I think I have a diastasis recti – now what do I do?
Most separations can return to normal with progressive exercises. First off – stop all crunches and abdominal exercises you are doing.  If you have a separation, doing crunches will actually contribute to the muscles being pulled away from the midline and worsen the diastasis. We need to promote approximation, not separation. Some women benefit from wearing an abdominal binder to counteract distraction forces across the linea alba with physical activity. This is helpful for active mothers who are required to use their abdominal muscles, specifically the rectus abdominus, throughout the day (lifting, carrying, etc). The abdominal binder often gives mothers immediate abdominal support, but should not take the place of strengthening. Below is a basic foundational exercise that will begin to allow the rectus abdominus muscle to return to midline.

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If the muscles are not coming together within 4-6 weeks of starting the exercises, see your local women’s health physical therapist (like us!). Sometimes abdominal scars, muscle tightness (especially internal & external oblique) and thoracolumbar fascia tightness can prevent the muscles coming together in the front because of adhesions elsewhere in the core. Also, if you are experiencing low back pain, pelvic pain or dysfunction with bowel, bladder or sexual function, then seeing a women’s health physical therapist is highly recommended.

Just found out you were pregnant or trying to get pregnant soon? Stay tuned for Part 2, where we will discuss preventative measures to prevent a diastasis recti!

Stimulating Science: Next on The Pelvic Messenger!

By Riva Preil

Get excited for the next episode of The Pelvic Messenger, Stimulating Science with Dr. Kenneth Peters, on August 21, 2014 (1:30 PM EST).

Dr. Kenneth M. Peters is Professor and Chair of Urology at Oakland University William Beaumont School of Medicine in Rochester, Michigan. He is also Chair of Urology at Beaumont Health System in Royal Oak, Michigan, and Medical Director of the Women’s Urology Center in Royal Oak, a unique multidisciplinary center dedicated to women with chronic pelvic pain and voiding dysfunction. He graduated with honors from the University of Michigan in Ann Arbor and earned his medical degree from Case Western Reserve University School of Medicine in Cleveland, Ohio. Dr. Peters subsequently completed his training in surgery and urology at William Beaumont Hospital, where he also completed a fellowship in female urology and urodynamics.

Widely recognized as a leader in research, Dr. Peters is internationally known for his work on interstitial cystitis, neuromodulation for voiding dysfunction, nerve rerouting surgery to restore voiding in spina bifida patients, and adult human stem cell injection for stress urinary incontinence.

Dr. Peters is an active and well-respected clinician, educator and researcher. He specializes in the treatment of voiding dysfunction and female urology. He has written numerous peer-reviewed journal articles and book chapters on incontinence, interstitial cystitis and neuromodulation. He has twice won the Society for Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) clinical research award.

Dr. Peters is an active member of the American Urological Association, the North Central Section of the AUA, the Society for Urodynamics & Female Urology, the Michigan Urological Society, the International Continence Society and served on the Research Council of the American Urological Association. Dr. Peters has a private practice in Royal Oak, Michigan.

If you have any questions for Dr. Peters, please feel free to submit them in advance! Please message them to the Beyond Basics Physical Therapy Facebook fan page. Thank you!

Do Older Moms Live Longer?

By Riva Preil

According to NPR, a recent study published in the journal Menopause revealed that women who gave birth to their last child after the age of thirty three are twice as likely to live until the age of ninety five (or beyond!) when compared to women who birthed their last child before age twenty nine.

Thomas Perls, a geriatrician at Boston Medical Center, hypothesizes that the ability to conceive at more advanced ages is correlated with a SLOWLY AGING BODY, including the reproductive system.  Other research suggests that there may be a genetic connection between longevity and the ability to bear children later in life.

However you slice it, it would be incorrect to state that there is a direct cause and effect relationship between birthing at later ages and living longer.  After all, there is a degree of CHOICE involved with conception.  Older women may choose to use contraception even if they theoretically have the ability to conceive.

Therefore, a different and possibly more accurate factor to consider is the age of menopause.  This component accounts for the length of an individual’s reproductive ability, and it would be fascinating to explore whether or not there is a connection between this process (which is NOT in the woman’s control) and longevity.

Time will tell…let the research begin!  Until then, may ALL pregnant women have happy, healthy, and safe pregnancies and long happy lives!

Fancy Pants

By Mary Hughes

We all know Victoria’s Secret has always supported and lifted our “girls,” but who knew that there is a company out there to support and lift the “fellas”?  Enter Frigo RevolutionWear AKA “Tempur-Pedic Banana Hammocks.”

We just discovered an article in Market Watch reveals “the key to the product is an interior mesh pouch that separates a man’s “package,” as Matthew Butlein, president of underwear retailer Freshpair.com, delicately puts it. (Freshpair is the exclusive online source for the $100 pair.) Not only does that help prevent sweating — by virtue of avoiding “skin on skin,” says Butlein — it also offers more support. (And its adjustable support, too — there’s an elastic band that controls the degree of lift and separation.)”

What do you think, dear readers? Would you try it? Let us know in the comments!

Live (Yesterday) from New York!

By Riva Preil

Even if you snoozed, you DIDN’T lose your chance!  If you missed yesterday’s live episode of The Pelvic Messenger, May the Floors Force Be With You with Diane Lee, you can STILL listen to it and enjoy her knowledge and wisdom. I feel blessed to have had the opportunity to interview such a renowned clinician and educator, and I am pleased to share my reflections on the experience with you.

Diane opened the conversation with a description of her professional journey and telling us about her role models.  She then described the Integrated Systems Model and explained the difference between form closure, force closure, and motor control.

Diane also elaborated upon various postpartum issues that mothers may face, and she shared helpful hints with listeners regarding how to address those problems.  (I don’t want to spoiler alert y’all and ruin the excitement for you, but I WILL give you a hint: Baby Belly Belt. Listen to the show, link below, for more details!)

Diane proceeded to discuss some of her most rewarding experiences as a physical therapist, and she whet our appetite for her upcoming International Pelvic Pain Society presentation (October 22-26 in Chicago, Illinois).  She also described her upcoming exciting trip to South Africa, where she will work with other PTs to educate health care providers and treat underprivileged women. One of my favorite parts was when Diane extended a PERSONAL INVITATION to me to join her on her medical mission!

It was an honor and privilege to (virtually) meet one of MY role models, and I encourage you to sit back, relax, and enjoy the show.  Comments and feedback are warmly welcome- this was my first show (!) and I would love to hear your thoughts :)

http://blogtalk.vo.llnwd.net/o23/show/6/640/show_6640983.mp3

P.S. The interview starts 1 minute and 13 seconds into the show, so don’t be alarmed if you don’t hear anything for the first minute or so. ENJOY!    

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