“Mommy Tummy” – Evidence-Based Techniques for Treatment and Prevention of Diastasis Recti

One of the biggest shockers that every woman experiences after having her first baby is that her stomach still looks 6 months pregnant for quite a while. I remember taking my 1-month old twins for a walk and several “caring” women asking me when I was due.

Before I had my first set of twins I thought that getting rid of “mommy tummy” was a simple matter of a balanced diet and sit-ups. Boy, how ignorant and naive I was! (I was not a Pilates instructor back then.)

Seven years, another twin pregnancy and Pilates teacher training later, I know that getting back in shape after pregnancy is not just about looking good (get a full scoop on what I did to get my perfect post-baby body here.) It is about regaining full control and function in your body (yes, incontinence issues are something that all women have to deal with after pregnancy.) Flat stomach is just a tip of an iceberg that many women notice and become self-conscious about.

One of the conditions that most women never hear and think about before pregnancy is Diastasis Recti – separation of the rectus abdominis muscle that makes stomach look 5-6 months pregnant postpartum. There is little research on this condition; Boissonnault & Blaschak (1988) found that 27% of women have a DRA in the second trimester and 66% in the third trimester of pregnancy. 53% of these women continued to have a DRA immediately postpartum and 36% remained abnormally wide at 5-7 weeks postpartum.

If as an instructor you are working with pre/postpartum women or if you are trying to get rid of the “mommy tummy” yourself then it is extremely important to be aware of this condition. Today I am talking to Diane Lee, PT – a leading expert, researcher and advocate for women’s health from Canada. She is the author of several books and publications including The Pelvic Girdle: An integration of clinical expertise and research(aff) and The Thorax: An Integrated Approach (aff) I was fortunate enough to find her work and lectures a little before my second pregnancy. She offers the most comprehensive and clinically-proven strategies for treating Diastasis Recti and Pelvic Girdle Disorders in postpartum women.

Here are topics that we will focus on in this interview:

Resources mentioned in the video:

• Diane Lee & Associates website
• Diane’s Blog
• The Baby Belly Belt – look at free videos and exercise protocols
• Connect on Facebook
• Dr Demianczuk – plastic surgeon in Vancouver, CA

Video Transcript

(please note, this transcript has been edited very lightly.)

Interviewer: Today I’m talking to Diane Lee, a physical therapist from Canada. She’s well known for her clinical work on thoracic, lumbar and pelvic floor as well as pelvic disorders and pain symptoms. And she is also one of the pioneers in the diastasis recti research and as well as an author of several books that we will mention in just a little bit.
Diane can you just mention a little bit about who you are, what you work with, and how did you get started with the DRA research?

Interviewee: I’ve been passionate about women’s health for a long, long time and what I started to see in the clinic is an increasing incident of women who weren’t able to get their core function back by traditional training, whether it was in the gym or yoga, or Pilates. It doesn’t matter how hard they worked they still had this protruding abdomen, and with or without back pain or incontinence or prolapse. There is one woman in particular, Christine, who had a fairly high loaded job. She worked as a cable man installing cables for a TV company here, and she had a diastasis and we just weren’t able to help her get better. It was in 2006, and at the time the questions were all about what does the evidence say about when we should give up and go for an abdominal wall repair.

So we started to wonder what were the best ways to close the diastasis assuming that’s what need to happen in order for forced closure and stability to happen in the abdomen, and how wide could her diastasis be before we should consider surgery? Those were the key questions we had in 2006. And I happened to be at the conference in the United where Paul Hodges was also presenting, and I showed him some of Christine’s ultra sound video clips. And he basically looked at me and said, “What’s that?” And because he’d never seen a woman with a significant DRA and the whole doming during a curl-up task.

When you look at her linea alba in the ultrasound it just looked like there was nothing there. So he got very interested in the topic and he gave me a grant from a clinical center of research excellence at the University of Queensland, and over the next six or seven years we started to develop some protocols for investigating the behavior of the linea alba. And it was in the middle of this gathering the data, some of the women were getting better, but I started to realize as they were getting better linea alba was getting wider. And it really confused me because it was supposed to close to get better, why is it getting wider?

And of course the women always wanted to know what’s my distance? What’s the measure? I’m feeling good, my peeing is going away, I’m not leaking as much, I can do more, this is awesome, and your number is getting wider. And it was like it’s a whole paradigm shift to realize that it wasn’t about closing, transversus and the lateral abdominal muscles don’t close the linea alba, they tense it, and so as long as you can generate tension, it feels like it’s closed because you can’t feel the gap anymore, but in fact for a lot of these women, it’s actually wider.

So it took us about five to six years to actually develop correct research questions. We needed more clinical experience before we could ask the right questions, and so it’s been quite an interesting journey, but my interest in helping moms after pregnancy goes back a long, long time.

Interviewer: Most women learn about DRA because they don’t like their mommy pooch. What are some of the functional changes that DRA causes in the body? Why is it important to fix it?

Interviewee: So a couple of reasons, most of the research for back pain and pelvic girdle pain has focused on the world of the abdominal wall and the thoracolumbar fascia, relationships between the abdominal muscles, the diaphragm, the pelvic floor, but it has given the assumption that there is anatomical integrity in the front that connects the left and right recti. And so the whole theory about forced closure of the abdominal canister have worked in the intention that you can connect the left and right side of the abdominal walls together. And no one’s really looked at well, what happens into pelvic lumbar pain to back pain to control when you can’t.

Now the diastasis is really interesting because you can have parts of the linea alba that are still quite functional and that’s usually the lower part of the abdomen. Around the umbilicus is where it tends to be more lax and softer and then for about, I don’t know–two, two and half inches above the umbilicus. And so parts of it can be functional, and parts of it can be non functional and though there is no data to actually support this. My clinical experience suggests that depending on where the lack of tension is, those are the joints in your system you are going to have difficulty controlling.

So if it’s a hard diastasis, your lower thoracic ring, so ribs on left and right side plus the vertebrae they’re attached to we call that a ring. So the lower part of your thorax and the thora-columbar junction is where you are going to have difficulty to control. If it’s around the Umbilicus it will be in mid lumbar spine.
So say for example you are doing a short spine exercise where you are doing a roll up, roll down, you may find that the woman with the diastasis is unable to eccentrically blank them or to relax their back muscles in that area. So they kind of volt over that they can’t get a nice sequencing action of their spine because they are using a bracing strategy to try and stabilize that area, because the brain has learned that it can’t rely on the abdominal wall.

Now unfortunately this whole condition is thought to be cosmetic by most medical plans or insurance plans, and there is not a lot of coverage in any country that I found to help living with it. And yet there is an incredible amount of evidence, research evidence that shows the abdominal wall is important for

• Muscular-skeletal health
• gynecological health,
• continence mechanisms
• pelvic organs support.

So it isn’t just about peeing, it’s about the future control of urinary continence control, pelvic organ support, it’s related to all of that. There is only been one study that I know of that has looked at the incidence of prevalence or correlation between the diastasis and pelvic floor dysfunction, and that’s one Theresa Spitznagle in 2007, where she showed that 66% of women with diastasis also have a pelvic floor associated dysfunction of either incontinence, painful intercourse, or loss of pelvic organ support. So little data, but clinically it really appears to correlate and the thing that drives women for help is often not pain, it’s when they start to leak. When they start to leak or they start to have pain with intercourse, or they start to feel more pressure in the perineum that they start to get a bit worried about.

Interviewer: Prevention: can you go over with us some of the basic factors that can prevent or minimize the chances of developing DRA, especially in women who’ve had separation during previous pregnancies?

Interviewee: Yes, so again the proper answer is it depends because there are many reasons. We have to figure out first of all what is putting the excessive tension on the linea alba and causing it to stretch. And it’s not just the linea alba that stretches, it’s the whole abdominal wall, so those are some studies that have shown that the width of rectus abdominis gets wider, linea alba gets wider, the whole thing gets distended.

So there is no data, there is no evidence, so this is a question the million dollar question everybody wants to know, so let’s start with if you don’t have one at all, how do you not get it?

If you don’t have DRA at all, how can you prevent it:

It seems to be that the longer your diaphragm to pelvic floor ratio is, the more space you have vertically to accommodate the extending uterus, the less the abdominal wall has to go anteriorly. That makes sense from a physics perspective that you are not going to have as much stretch. So that doesn’t mean that tall women are exempt from having diastasis, we see them in tall women, but women who tend to brace with their diaphragm like really bear down with their diaphragm, so this whole imprinting of the rib cage excessive activation of the external oblique where the diaphragms sort of gets pushed down into the abdominal canister is not a good thing.

So anything we can do to lengthen the trunk, to get the trunk nice and long and to have the diaphragm and the pelvic floor creating space, but not shutting off, I think is going to be helpful. Shorter women, women who don’t have a lot of space and they are married to big tall guys, so I saw somebody yesterday, she’s five foot tall, and her husband is 6.7. The first baby was ten pounds, now five foot tiny girl is not meant to have a ten pound baby, and she is going to stretch. So it depends again on compliance of the abdominal wall, how well can it stretch, how well can your soft tissue accommodate the stretch, and that’s going to really toss us to things that I’m not sure we can address in terms of Pilates. There is going to be cellular physiology things, the genetic makeup.

It’s not just about hypermobile women, I’ve seen stiff women with diastasis, it’s not about ethnicity, I’ve seen it in every ethnic group you can imagine, you see it in children, you see it in men, you see it obviously most common in postpartum women. And so I know that doesn’t really answer the question, but I think one of the things across the board that is common with both the yoga and Pilates and good training is that we are going for length, we are going– we don’t want to shorten the system as we strengthen it, we want to lengthen system, and that’s going to be helpful.

The other thing that’s helpful is being able to support the extending abdomen through a good co-activation strategy using transverse system and the pelvic floor, allowing space in the diaphragm.

Transversus does not close the diastasis, in fact it pulls it open, so the whole Julie Tupler is off the mark because you can do 500 TA contractions a day and it won’t close your diastasis. It just doesn’t do that, it pulls it wide and that’s what you want it to do. So the transverses muscle inserts into the very posterior erector spinae sheets and they’re very longitudinal, very linear fibers. So what we think is that transverses can help to prevent diastasis of the linea alba from opening, but it doesn’t close it. So if you just hang out on your belly when you are pregnant, if you just let your belly hang maybe you are going to be in more trouble than if you support it. All of this is just hypothesis, and so we don’t know, there are no studies, there is no data yet.

Interviewer: How prevalent is diastasis recti?

Interviewee: So my research doesn’t actually look at prevalence, but there is a girl in Australia right now who is doing a study looking exactly at that. All the women coming through the maternity ward in the hospital, and having are having their linea alba (the inter-rectus distance) measured.
Everybody opens and it makes sense, so we don’t want to freak women out and thinking oh, you know what, I’ve got separation here, this is a diastasis, it’s just a normal accommodation of the abdominal wall. Everyone does. Up to eight and even up to six months that distance can be wider, it is not an elastic band, it doesn’t just snap back the moment that you deliver. The key thing to watch for in Pilates when women are coming back, is not just whether they can group transverses in the deep muscle system, it’s what’s the balance between the EL (the external obliques) and the IL (internal obliques.) So if you put your thumbs on the infrasternal angle like this, and they do a short head-and-neck curl-up task, if that infrasternal angle is widening like this, the rib cage is widening, the internal oblique is dominating the external oblique, one is puling harder than the other. I’ve seen women with the IL, it perpetuates, keeps pulling apart.

So if we give them cues to maintain that angle– so don’t let your rib cage widen, so imagine the lower ribs like Venetian blinds slowly closing each blind, so don’t widen them and so your are working the synergy in all the abdominal muscles. I’ve seen women being able to narrow their 3.5 centimeter diastasis down to normal diastasis. So it’s all about being able to retrain optimal synergistic activation of all the abdominal muscles. Some women are EL- dominant and they are pulling it apart with their external obliques.
So we can’t say ever that there will be a recipe or a protocol for a woman or a man or a child who has diastasis. The cause can be:

• Excessive inter-abdominal pressure,
• excessive myofascial tension, pulling,
• insufficient activation of the abdominal wall totally.

So in children we will see it, some of these kids have never really learned how to use their core muscles properly, and they live in their back, they also often have hyper lordosis, their little bums stick out, their bellies protrude and slowly the pressure of the organs just starts to stretch things.
You see the same thing in an older man who has a lot of fat in the omentum.

So the little kid, the child we have to do neural training and teach them how to use their abdominal wall better, that takes longer than the postpartum woman who has just forgotten how to use it well because of the nine months of the stretch. And then there is the guy with the big fat omentum that’s never going to go away until he loses the internal abdominal fat, all right?

So if you have a diastasis after your first pregnancy and you want to get pregnant again, you need to take a good four to six months to get the patterns of activation of the abdominal wall and pelvic floor and diaphragm better. So you go into your pregnancy with better patterns and then support the second pregnancy perhaps in a better way. And I have seen women who have maintained their diastasis so it hasn’t gotten worse through the second pregnancy, we’ve also had one woman who rebuild the linea alba through pregnancy because of the constant tension that the increasing pressure emitted on the linea alba.

It fits in beautifully with the tendinosis research, so if you want to repair Achilles tendinosis or Gluteal tendinosis, you have to progressively load it, you don’t want to offload it.

So we don’t want to be putting these women into belts, you want to load it and that’s why good progressive abdominal training will load the linea alba and will build– lay down more collagen. It’s not inflamed, there isn’t any inflammation here, so the whole premise of “let’s offload the abdominal wall” (close it, brace it) so it can heal, is totally wrong thinking, there is nothing to heal, you want to load it to strength it, does that make sense?

Interviewer: Diane, can you explain a bit more about the point of no return? At what point can we say that surgery is the only solution to regain abdominal wall function?

Interviewee: There is a point of no return, but it’s not a number. Well, there is actually. I can tell you that a woman at 18 months that has a nine inch DRA, is not likely going to get that much better. But women with an inch or an inch and a half, two inches separation can sometimes generate enough tension in the midline to be quite functional, they never have a flat tummy again, so it’s never really cosmetic, but they can be functional, right? Other women with the same distance they can’t, and this is where I’ll use the ultrasound a lot to sort of help me guide this, but you will just be relying on your fingers.

If you’re pretty sure that they are activating their transverses and their internal oblique quite well, and yet you still can’t feel any tension in the midline, and they still have difficulty controlling the middle of their lumbar side, and their upper limit, when you do resistant rotation, so if you put a resistant load in rotation, low back goes all over the place, they can’t stop the lower thorax from moving, and yet you’re pretty sure that they are activating their core as best as they can, it means that they’re not going to be able to. So at that time that’s the time for a referral to a plastic surgeon. I am working with Dr Demianczuk here in Vancouver and he has changed his procedures based on our work together.
What a lot of plastic surgeons will do is they’ll just use non absorbable sutures, which is what you want. I mean you don’t want this thing to come apart, so why put something absorbable in there? Non absorbable sutures and they only tuck the ventral sheets together, so they don’t cut out the bit in the middle, it’s still there, but they often only attach the ventral sheets. So transverses is still not attached, it’s still detached deep in there, and it’s only the EL and the IL that are there.

So what Dr Demianczuk has been doing now is taking off the tension of both posterior rectus sheets and the anterior rectus sheets, so really doing more of an anatomical repair of the whole thing. You don’t want it over lapped. I’ve seen two women where the recti have been overlapped, they had a heck of a time breathing. They really can’t extend enough, right? So just the posterior sheet is important, the ventral sheet is important. It’s a big surgery, but the end results of it look good, it functions well too.

And we have to stop calling it a “tummy tuck”, because the “tummy tuck” has such negative connotations for both women and for other people. We have to call it what it is, it’s a recti plication, and the abdominoplasty. So the abdominoplasty is the skin repair and the recti plication is the muscle repair. So if we start using terms and the words that it really is then it sounds– it’s more accurate, right?

Interviewer: Do you recommend using any type of binders postpartum?

Interviewee: I do actually and– but it’s meant to be as an adjunct, so the belt has nothing to do with the linea alba of the diastasis. The belt has everything to do with using intra-abdominal pressure to help support your back. So if a woman is really having a considerable back pain or a pubic symphysis dysfunction or say if they really have joint pain, sometimes adding a little bit of support through a pelvic belt such as the baby belly belt can be helpful. The baby belly belt, my new product, is really intended for pubic symphysis dysfunction and not for DRA.

The general abdominal binders that come up a little bit higher, can be really helpful when you’ve got three kids and fourth on the way, or two kids and a third on way, and you got to run around as you go get groceries, and your job requirement, your loading requirements for the day are just more than your back can handle. So the support just gives you that extra little bit of intra-abdominal pressure, that will help to lift and separate the thorax off the pelvic floor, and will help your back.
In the immediate post partum phase I do believe in binders. I think that in that first two to three weeks, as everything is starting to shrink down, the pelvic is healing, it’s just nice for your brain to have some kind of knowledge as to where is my thorax supposed to live over my pelvis. With a little bit of support and help to get your viscera back up into your thorax. Because you deliver your baby, your guts drop down and your diaphragm goes with it. Often postpartum women have a diaphragm that’s too low. That’s why I love Downward Facing Dog, or inversions, or getting your bum up. Start training your pelvic floor with your butt up higher than your diaphragm, get upside down on Cadillac.

The intention and the purpose of a brace doesn’t replace exercise or training by any means, but it can help.

Interviewer Where can people learn from you? What resources can they use?

Interviewee: On babybellybelt.com I have a whole section there on diastasis, exercises for diastasis and how you assess for it, so that’s where you find some resources at least on what I have been doing. The research that Paul Hodges and I have done over the last six years is currently in the submission phases to journals, and so we haven’t got accepted yet. But if you follow me on Facebook you will certainly hear about it when it gets accepted, and so there will be the evidence for that.

There’s a couple other researchers, people who are doing some research on diastasis, so we’ll see some evidence coming on in the next five years, but as far as an online place to go where you’ll get advice that’s consistent with what we feel is what really linea alba should be doing, other than that, there isn’t one. I’m really not a believer in some of the work of what the Julie Tupler program, it’s not evidence based. The premises don’t make sense with respect to the evidence, and I’m not saying women don’t get better with that program, but it is the antithesis of what we’re trying to educate women with.