Everything You Need To Know About Abdominal Separation
Confused about abdominal separation? The dos and don’ts? Well, rightly so! There is a serious lack of good quality research in this area and plenty of
differing views, leaving women feeling confused and disempowered.
My mission is to turn this around…to educate and empower you with the available evidence, what has consistently worked in my clinical practice to date and my expert opinion.
But, before we get into the management, it’s really important that you understand what is going on in your body if you have abdominal separation.
What is Abdominal Separation?
Abdominal separation is technically termed Rectus Abdominis Diastasis (RAD) or Diastasis Recti Abdominis (DRA).
RAD is the abnormal separation of the rectus abdominis muscles (the “6-pack” muscles) at the front of the abdomen. The muscles are divided right and left by a central connective tissue called linea alba. It is the stretching or weakening of the linea alba that causes an increase in separation between the rectus abdominis muscle bellies.
The degree of separation that is classified as abnormal is >2.7cm. This is translated to approximately >2 finger width, and is best assessed by a specialised Women’s Health Physiotherapist. http://www.thewholemother.com/consults/
What Causes RAD?
RAD is very common in pregnancy, with 66% of pregnant women having RAD in the third trimester (Boissonnault & Blaschak 1988). This is due to:
Hormonal elastic changes on the linea alba.
Stretching of the abdominal wall to accommodate the growing baby.
Displacement of abdominal organs.
How Do You Know If You Have RAD?
During movements, such as a sit up or getting straight up out of bed, you may notice a bulging or doming along the vertical line of your belly button. This indicates RAD and a possible hernia of the abdominal organs.
This bulge may be evident during pregnancy and postpartum, and is something to be aware of and avoid! I will go into this more below.
Other times, RAD may not be as noticeable, which is why having an assessment by a Women’s Health Physiotherapist is a must.
What Other Symptoms May Accompany RAD?
RAD can be linked to low back pain. This is because there is reduced abdominal strength and stability anteriorly, so as a result the lower back and pelvic muscles/joints may be strained, and imbalances occur.
It has also been shown that there may be a correlation between RAD and pelvic floor dysfunction, such as stress incontinence http://www.thewholemother.com/9-successful-strategies-treat-stress-incontinence/and prolapse http://www.thewholemother.com/prolapse-all-your-questions-answered/ (Spitznagle et al 2007).
Can You Prevent RAD?
Whilst there are many factors that we cannot control during pregnancy, such as the hormonal and mechanical changes that take place, the size of your baby and your genetics, there are also many factors that we can control.
These include your posture, the way you move during your pregnancy, the type of exercise you do and excessive weight gain. Avoiding any movements or exercises that cause straining of the abdominal muscles or a bulge/doming as described above, is imperative.
My advice to help prevent RAD:
Learn how to activate your core (deep abdominal and pelvic floor muscles) correctly by seeing a specialist Women’s Health Physiotherapist in your second trimester of pregnancy.
Perform these core exercises daily.
Learn neutral posture.
Roll onto your side to get out of bed and use your arm strength to sit you up rather than using your abdominals to pull you straight up.
Use your arm strength to pull yourself up from a low chair.
Avoid sit ups/crunches, double leg lowers, planks or other advanced abdominal exercises.
Avoid lifting anything heavy that causes you to strain and hold your breath.
Exercise regularly and safely during your pregnancy following my safe exercise guidelines here. http://www.thewholemother.com/all-you-need-to-know-about-safe-exercise-in-pregnancy/
Remain fit and active pre-pregnancy with a focus on core stability and function.
Can RAD Resolve On Its Own?
Natural resolution of RAD is possible, and has been shown to be most prolific in the first 8 weeks postpartum (Coldron et al 2008). In saying this, one study reported that 32.6% of women had a RAD at 12 months postpartum (Sperstad et al 2016). This is one of many reasons why postpartum recovery and core rehabilitation should be a priority from day 1 postpartum rather than waiting to see if dysfunction persists down the track.
Can RAD Improve with Conservative Management?
Yes, absolutely! Your focus needs to be on restoring stability and function, so you can eventually get back to doing the activities and exercise you want without dysfunction or pain. Remember, the aim of the game is not about achieving complete closure of the muscles, as this is anatomically impossible.
Important to know that every BODY is different and therefore no two cases of RAD are exactly the same. Just because your friend or a mum you follow on Insta recovered quickly, doesn’t mean your recovery will be the same. There are multiple contributing factors to the development and restoration of RAD, and therefore it is not as simple as doing one or two exercises and then Bob’s your uncle.
How Do You Treat RAD?
1. See a Specialised Women’s Health Physiotherapist
A specialised Women’s Health Physio will assess your RAD, your posture, how you move, and discuss your birth and any other symptoms you may have. They will provide you with individualized exercises and advice.
It is ideal to have your first postpartum appointment at 6 weeks and from there the Physio will guide you on how to safely return to exercise. Whilst returning to exercise after having your baby may be different for every woman, there are some fundamental principles and guidelines to be aware of that you can access for free here. http://www.thewholemother.com/freebies/
2. Core exercises
Learning how to activate and isolate your transversus abdominis and pelvic floor muscles http://www.thewholemother.com/freebies/ (core muscles) CORRECTLY is key to rehabilitating your RAD. We teach you this using a real-time ultrasound machine so you can see your muscles moving on the screen and learn how to contract them via biofeedback.
It’s important to note that “core” activation in the fitness industry is often misunderstood and explained as “sucking in your belly button to spine”. However, this movement does not actually activate your deep core muscles in isolation, and instead may cause intra-abdominal pressure and breath holding. The correct activation is actually very subtle.
As “boring” as you may find these exercises, they are fundamental to restoring the function of your abdominal muscles due to the fascial links between the deep abdominal muscles and the rectus abdominis and linea alba. It has been shown that activating transversus abdominis, brings the rectus abdominis muscle bellies together and increases fascial tension of the linea alba (Lee et al 2008).
3. Posture and alignment
Correcting your posture and alignment is an important step in rehabilitating RAD. Your Women’s Health Physio will guide you through this and will give you strengthening exercises for your postural muscles. You can then incorporate postural awareness and strategies into your everyday life.
4. Lifestyle modification
The way you move, bend, pick up your baby/toddler, put the pram in the boot and all the other many actions mums do, are important to do in a way that supports your abdominal recovery. Your Women’s Health Physio will teach you how to activate your core muscles during these movements and how to move safely.
5. Support garments
I am an advocate for SRC Recovery shorts, which provide medical grade compression to the abdominal muscles postpartum. They are designed to support the abdominal, pelvic floor and back muscles, whilst facilitating recovery by giving the muscles biofeedback to assist with their activation.
When one part of our body changes structure or weakens, such as with RAD, it can influence other areas, causing muscle/joint imbalances, tightness or tension. Releasing and stretching these areas will help to restore normal alignment and facilitate recovery. Your Women’s Health Physio will guide you on this based on their assessment findings.
7. Progress core exercises/Pilates
Your core exercises can be progressed as your technique, alignment and control improve. This may be in the form of home exercises and/or a postnatal Pilates class.
Pilates is a great form of exercise to strengthen the muscles around your trunk, pelvis and hips in a controlled and safe way, whilst still working on postural alignment and core activation.
I recommend going to a Pilates class run by a Physio who has knowledge of RAD. If the instructor is not a Physio then make sure you have a discussion with them about your RAD and they are aware of your Physio’s recommendations.
Let’s not forget about the essential role nutrition plays in recovery and healing. Make sure you are eating an abundance of wholefoods (vegetables and fruit) and good quality proteins and fats during pregnancy and postpartum. Eating more protein increases the production of collagen, which is important for tissue repair. Good sources of this are bone broths and slow cooked stews, soups and curries that incorporate animal foods.
Supplementing your diet with a collagen powder such as vital proteins https://www.vitalproteins.com/collections/best-sellers/products/collagen-peptides is a worthwhile addition to smoothies.
Anna Scammell is a Masters-trained Women’s Health & Pelvic Floor Physiotherapist, and Founder of www.thewholemother.com. Anna offers online consults, home visits around Sydney and sees clients out of Sevenways Health Centre in North Bondi. She combines her 10+ years of clinical experience, evidence based knowledge, and passion for health & wellbeing. Anna’s mission is to educate, empower & inspire as many women as possible to be the best version of themself during their childbearing years and beyond.
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Benjamin et al (2014) Effect of exercise on the diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy 100: 1-8.
Lee and Hodge (2016) Behavior of the linea alba during a curl-up task in diastasis rectus abdominis: an observational study. J Orthop Sports Phys Ther 46: 580-9.
Michalska et al (2018) Diastasis abdominis recti - a review of the treatment methods. Ginekologia Polska 89: 97-101.
Mota et al (2015) Diastasis Recti Abdominis in pregnancy and postpartum period. Risk factors, functional implications and resolution. Current Women’s Health Reviews 11: 59-67.
Sperstad et al (2016) Diastasis recti abdominis during pregnancy and 12months after childbirth: prevalence, risk factors and report of lumbopelvic pain. British Journal of Sports Medicine 50: 1092-1096.
Spitznagle et al (2007) Prevalence of diastasis recti abdominis in the Urogynecological population. International Urogynecological Journal 18: 321-328.