The deal with diastasis…

Diastasis Recti is a topic that seemed bang on trend a year or two ago. Since then, while recognition has certainly increased surrounding it, health trends have somewhat evolved and progressed and moved on to the next big culprit affecting the health and well-being of our population.

As a physiotherapist who regularly treats diastasis I STILL feel that there is a need to ensure that all women, men, medical professionals and fit pro’s understand and recognise diastasis and its implications. Who could believe that I still have face-palm moments when a client repeats how their consultant/GP/health professional said that there was nothing wrong or that it is purely cosmetic. Even worse when a health professional has appeared to recognise it and prescribe abdominal crunches to fix it….the more the better being the take away message!!!!

So what is it and what is the big deal anyway?

Diastasis Rectus Abdominis (a.k.a. Diastasis Recti, DRAM, Divarcation Recti, mummy tummy, tummy gap) is a separation of the 2 bellies of the rectus abdominis at the Linea Alba (LA), with widening and fibrous division of the LA. It is commonly seen in pregnant and postpartum women but can also present in newborn babies, men and high level sporting men/women.

100% prevalence of diastasis was recorded in pregnant women at gestational week 35, with 35-39% prevalence recorded at 6 months postnatal (Moto et al 2014). This suggests that some widening/diastasis can be expected as normal in pregnancy, however it should resolve postnatally.

The issue with diastasis is multi-factorial. Firstly, and perhaps most significantly for some people is the effect it can have on body image, self confidence and overall mental health. We all know the importance of considering the biopsychosocial model of care and understanding that physical conditions can have a detrimental impact upon our psychological well-being. The largest group that we associate diastasis with is pregnant and postnatal women. These women are already coming to terms with a changing body shape and potential weight gain, and the presence of diastasis lingering into the postnatal period can be distressing in terms of body image, strength and capability. 

Other issues that have been associated with diastasis include predisposition to pelvic floor dysfunction (Spitznagle et al 2006). A more recent study by BØ et al 2016 found no link between diastasis recti and pelvic floor dysfunction at 6 weeks, 6 months and 12 months post-partum however I wonder if predisposition to pelvic floor dysfunction with those who have unresolving diastasis occurs over a longer period postnatal. Anecdotally I do find a link between diastasis and pelvic floor dysfunction. And if we consider the anatomical relationship between the diaphragm, abdominal wall and pelvic floor we can appreciate how dysfunction in one of these can impact upon the others. (Bordoni & Zanier 2013).

Several studies have supported the link between diastasis and lumbopelvic dysfunction(Parker et al 2008; Whittaker et al 2013).

Umbilical and epigastric hernias involve protrusion of intra-abdominal contents through connective tissue in the linea alba at umbilical area or upper abdominal area above the umbilicus. Risk factors for these hernias include pregnancy and my own clinical experience and understanding would lead me to hypothesise that this risk is associated with diastasis and therefore widening and thinning of the linea alba which would leave it more susceptible to being compromised. 

Then there is the overall spiral into non-optimal muscle recruitment strategies which may eventually lead to further issues and dysfunction. I find that when people have diastasis their body learns to continue doing the activities and functions required of the abdominal wall by adapting and using compensatory strategies. These can include over activity and bracing in the oblique muscles, over recruitment of the muscles in the neck, clamping down with the jaw, and over bracing with the hip and lower limb muscles to name a few. While the additional recruitment of muscle groups can facilitate to get the task at hand done, they are not ideal.

It should not require THAT much effort to lift your head off your pillow that you have to clamp down and brace at your jaw. Your rib cage should not excessively flare or compress while you attempt a simple abdominal exercise. If they do, this demonstrates an imbalance in abdominal wall muscle recruitment where either the internal oblique (ribs flare) or external oblique (ribs compress) muscles are over-dominant. This can lead to changes in posture/how we hold ourselves or even how we breathe e.g. tendency towards a swallow breath. Flared ribs also present an obstacle to diastasis recovery. If we consider the superior attachments of the rectus abdominis muscle at the the costal cartilages of ribs 5-7 and xiphoid process, we can understand how flaring or widening and elevation of the ribs could encourage stretch and widening at the linea alba.

Over-activity in the abdominal wall can also encourage over-activity in the pelvic floor and alas we enter into symptoms of pelvic floor dysfunction, which links to my hypotheses above regarding predisposition to pelvic floor dysfunction with diastasis. 

Assessment of diastasis recti is not just all about the gap! Assessment should involve a whole body approach including the issues we have already mentioned e.g. posture, breathing, pelvic floor function, pain, discomfort, functional ability, core recruitment strategies etc. When assessing the actual diastasis we want to understand the width, depth and length of the diastasis as well as the ability to generate tension and transfer load across the linea alba. We want to individually assess what happens when clients attempt different exercises/movements/activities/functional tasks. Are they recruiting their core muscles optimally? Are they doming? Is the connective tissue sinking in? Do they need to improve their activation patterns? This topic of assessment of diastasis is really justification for a blog of its own which I will get round to soon. In the mean time check out this video by Canadian and world renowned physio Diane Lee demonstrating part of her assessment for diastasis by clicking here.

Rehabilitation for diastasis needs to be individualised, informed and active. While I don’t advocate any passive treatments no matter what the complaint, I certainly do not advocate passive treatments in the conservative rehabilitation of diastasis recti. A client looking to succeed with healing after diastasis needs to commit to rehab and actively take on board the activity and lifestyle modifications advised, the individualised exercise program and postural re-education.

The ideal environment for improving diastasis comes to effect when we shift the pendulum on the amount of times we do activities involving excessive intra-abdominal pressure/poor recruitment strategies/non-optimal pressure management….to carrying out optimal abdominal recruitment strategies/ less frequent high pressure activities/ improved pressure management strategies. It is the repetitive activities that we carry out everyday that are often overlooked in the management of diastasis despite having significant influence.

Take for example something as simple as opening our bowels. Opening our bowels is a regular activity  that we often take for granted….or at least it should be! Diastasis clients can complain of a new onset of having to strain or difficulty evacuating even though their motions are not necessarily hard and typical of constipation. A variety of factors may play a part here including potential overactive pelvic floor muscles which do not relax fully on desired evacuation and/or decreased pressure control strategies.

By decreased pressure control strategies what I mean is that instead of having an eccentrically stable abdominal wall during attempted evacuation, clients with diastasis present with a weak point in their abdominal wall. This means when they attempt to bear down, the pressure finds the direction of least resistance, i.e. the anterior abdominal wall and not the rectum. This results in regular excessive pressure against the linea alba as well as decreased efficiency and satisfaction with emptying the bowel. 

I educate all my clients about the importance of optimal defecation techniques and position. First and foremost, position is key. Having our knees higher than our hips when sitting on the toilet and forming a squat like posture creates the optimum position for opening the bowels. It enables further relaxation and lengthening of the puborectalis muscle and therefore opens the rectal outlet. 

Then I teach clients how to use their hands to support their diastasis, similar to providing wound support after abominal surgery or c-section. This position and the reinforced abdominal wall facilitates improved strategy for controlled bearing down in which the pressure directs towards the rectum as intended and not elsewhere. Check out this video by “Squatty Potty” (by clicking here) which was created to explain the importance of optimum posture for opening the bowels. Please note I am not affiliated with Squatty Potty in any way and just genuinely appreciate the concept and how this illustrates it. Any step/stool/upside down basin which will safely help you achieve this posture will achieve the same outcome.

Other factors to consider include dietary influences such as reducing the foods which make clients bloat or are difficult to digest. Ideally reducing processed foods and refined sugars is recommended as the environment they can create in our bodies is not one in which healing and repair flourish. Ensuring that we eat a well balanced diet which includes water for hydration as well as food sources such as fruit, vegetables and protein to provide the nutrients needed for the body to adequately recover and repair. A balanced diet will also reduce your risk of constipation and the issues it can cause.

More recently there has been interest in collagen and gelatin supplements to facilitate collagen repair. It isn’t that our bodies cannot generate their own collagen in the repair process, however it is proposed that if your diet is lacking in the sources necessary to support the body with rebuilding collagen perhaps taking a supplement can boost the repair process. This isn’t an area that I am well schooled in and would like to research further before I recommend or disagree with the concept. There is certainly a lot of contradictory advice out there so I think it is important that health professionals and clients alike ensure that they are following the most accurate and evidenced based dietary advice from suitably qualified professionals.

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Q+A with Julie Tupler

In November 2016 I spoke with Julie Tupler, founder of the Tupler Technique, to hear the answers to the questions that I know many physiotherapists have surrounding her approach. I have a lot of respect and admiration for Julie and the work she has done to bring awareness to diastasis.

While I may not entirely agree with all of the concepts of her approach I do appreciate and value what she has to say and look forward to reading the upcoming research she is involved in. Apologies, the video is a “longie but a goodie!!!” For ease of navigation through it I have written out the questions I asked below:

1. The Tupler Technique appears to be a set protocol of exercises. How can this address each individuals specific needs?
2. I have had many physiotherapists complain that the Tupler Technique is not a holistic approach as it just focuses on closing the gap. Why do you not broadcast all the components of your approach?
3. What if the technique patients use to carry out your seated exercises causes increased pressure on their pelvic floor?
4. Many physiotherapists question the rationale of splinting as they think it will unnecessarily increase abdominal pressure and also encourage weakening of the abdominal muscles. Do you agree with this and why is it an essential step in Tupler Technique?
5. You promote your technique as being “evidence based”. Can you clarify how the Tupler Technique was involved in research?
6. Paul Hodges and Diane Lee’s research challenges how we understand diastasis recti and tension across the linea alba, including whether we should open or close the gap. What are your thoughts on this and do you solely focus on closing the gap? 
7. I would love to hear more about your upcoming research for Diastasis?
8. Would you advise women to get an individual assessment by a pelvic health physiotherapist prior to or in conjunction with starting the Tupler Technique?

I have so much more I could and would love to say regarding diastasis recti, however this blog is becoming all too long as it is. If anyone has anything in particular they would like to know more about in relation to diastasis or its recovery please comment and let me know, I would be happy to prepare follow up blogs.

I want to finish with a short video created by a local life coach, Linda Johnston (http://www.lindajohnston.co.uk/) who wished to increase awareness of different issues which can impact upon our overall health and wellbeing by creating short information videos like the one below. Linda attended my clinic and spoke with me and Roísín, who discovered she had diastasis following the birth of her first baby. I love the unscripted nature of the video and think that Linda really captured the raw nature of both the physical and mental implications that conditions such as diastasis recti can have. This reinforces the importance of a holistic approach to client care.

(NB this video was edited by Linda and represented my final review with Roísín, progressing her back to normal exercise.  The exercises displayed are not the basic exercises I commenced with. There is a lot of controversy over plank exercises and diastasis however I individually assessed and evaluated Roísín to be safely and appropriately carrying it out. It is an exercise she enjoyed doing pre-natally and therefore a rehab goal we agreed to progress to).

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References

1.  Lee, Diane 2017; Diastasis Rectus Abdominis: A Clinical Guide for those Split Down the Middle (text book)
2. Theresa M. Spitznagle & Fah Che Leong & Linda R. Van Dillen; Prevalence of diastasis recti abdominis in a urogynecological patient population; International Urogynecology Journal 18(3):321-8 · April 2007
3. BØ, K, Hilde G, Tennifjord M K, Sperstad JB, Engh ME (2016) Pelvic Floor muscle function, pelvic floor dysfunction and diastasis recti abdominis: Prospective cohort study. Neurourology and Urodynamics, March 2016
4. Moto, Pascoal, Carita & Bo: Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Man Ther. 2015;20(1):200-205. doi:10.1016/j.math.2014.09.002.
5. Jennifer E. Cheesborough, M.D. Gregory A. Dumanian, M.D., Simultaneous Prosthetic Mesh Abdominal  Wall Reconstruction with Abdominoplasty  for Ventral Hernia and Severe Rectus  Diastasis Repairs, Plastic & Reconstructive Surgery, January 2015
6. Sperstad JB, Tennfjord MK, Hilde G, et al; Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain; Br J Sports Med 2016;50:1092-1096.
7. Bordoni & Zanier; Anatomic Connections of the diaphragm: influence of respiration on the body system, Journal of Multidisciplinary Healthcare, 2013:6 281 – 291
8. Drummond, J: Animal Gelatin, Rebuilding Postpartum Collagen, Diastasis Recti… + Vegetarians, guest blog for MuTu, https://mutusystem.com/mutu-system-blog/animal-gelatin-rebuilding-postpartum-collagen-diastasis-recti-vegetarians