- Learn how to test for DRA or Diastasis Recti,
- Understand which movements and exercises to avoid when a client is experiencing this condition,
- Decide which exercise choices make the most sense for your client, and
- Increase the probability that her abdominal wall will return to normal condition as efficiently as possible.
One of the most common occurrences during pregnancy is a condition that has not been evaluated or researched much over the years (Boissonnault et al., 1998; Chiarello et al., 2005; Keeler, et al., 2012). This condition is known as Diastasis Rectus Abdominis (DRA), or abdominal separation, and occurs when the rectus abdominis muscles can no longer stretch enough to accommodate the growing fetus, and they separate, or pull further away from the linea alba. This can potentially decrease core integrity, and could be associated with other conditions such as low back and pelvic pain (Chiarello et al., 2005; Keeler et al., 2012; Parker et al., 2009).
Diastasis Rectus Abdominis occurs in a large percentage of pregnant women and is attributed to the growing fetus, as well as to the softening of ligaments and fascia because of hormones including relaxin and estrogen. However, if this is such a normal consequence of pregnancy, should we be concerned? There are some factors, that when combined with pregnancy, may call for some concern. In addition, checking for Diastasis Recti may be appropriate for even your non-pregnant, or even male clients if they experience certain conditions affecting the core region. Consider the following:
- The current obesity epidemic increases the probability of working with clients who store more visceral body fat around the internal organs.
- Many people demonstrate poor breathing techniques, and holding one’s breath during exertion increases intra abdominal pressure.
- Bloated or constipated bellies push out against the abdominal wall, even without the ever-growing fetus!
Consequently, the pressure against the recti muscles is considerably more than the pregnancy requires. Now, how about those crunches?
The question is: Which exercises should we select for core training when working with a pregnant client?
The ultimate goal? Let’s not add to the stress against the abdominal wall that a normal pregnancy requires by making poor choices for core exercises!
The American Congress of Obstetricians and Gynecologists (ACOG) is the governing body that provides guidelines for exercise during pregnancy and the postpartum period. In the latest bulletin from 2002 (reaffirmed in 2009), there is no discussion about core exercises.
It is up to us as personal trainers to determine the best and safest progressions for our clients.
Checking for Separation (DRA Test)
I encourage trainers to check the width of the pregnant client’s linea alba during the first session with her, no matter if she is 6 weeks, or 24 weeks pregnant. “Normal” width of someone’s linea alba can vary from 7mm ± 5 at xiphoid, 13mm ± 7 above umbilicus, and 8mm ± 6 below umbilicus (Beer et al., 2009).
An easy way to feel for abdominal separation is to measure the distance between the recti muscles as she contracts them as in a crunch or a head lift:
- Instruct your client to lie supine, with knees bent and feet on the floor.
- Instruct her to put one or both hands behind her head, and lift up her head while breathing normally.
- Using your two fingers, palpate the abdominal wall starting at the xiphoid process and going down to below the umbilicus.
In Video 1, I check for abdominal separation. You can see the protrusion as she lifts her head up.
Video 1: Checking for separation and observing the protrusion
It is important to assess the normal width of the linea alba and then use that width as a benchmark from which to measure change as the pregnancy progresses. If the separation gets wider at one point, or along the entire linea alba, you should avoid making it worse with exercise.
If you see a protrusion, or doming from within the separation as she exerts herself, you should avoid any movements/exercises where you see this. Consider:
- Lever length (chest press instead of fly)
- Weight or resistance
- Range of motion (don’t reach as far forward when doing toe touch exercises)
- Number of repetitions
- Overall fatigue
You might observe the straining and protrusion while she does chest flys, bicycle crunches, lat pulldown, planks, or simply sitting down into a chair! She should also avoid sitting straight up from a supine position and get used to rolling to the side to get up. Our challenge is to have her use her core integrity without making the separation worse with exercise. (See Video 2)
Video 2. Sitting down
So, what are the best core exercises? Pregnancy is the perfect time to teach a client what the true purpose of her core is: to stabilize the spine, and transfer load to the extremities. It is imperative to teach her to “keep her core on,” deliberately bracing upon exertion. The following exercise demonstrates how to do this:
The Basics: Elevator Exercise for pelvic floor and core integrity (Noble, 1995):
- Inhale through your nose, and as you exhale through your mouth, contract the pelvic floor (Kegel exercise), as if pulling something up inside of you, for a count of 7. You should feel your core muscles engaging as you do this.
- Continue breathing as you maintain this contraction for several seconds, then release.
- This can be done lying down, sitting or standing.
We can use this exercise in several ways:
- We can cue the client to hold this contraction and count aloud for up to 30 seconds, to ensure she is not holding her breath (Tupler), and do 3 sets of 10 repetitions as part of the training session.
- During the workout, we can incorporate this engagement as part of another overall exercise. For example, as the client does a squat and row, we can cue “inhale on the way down, then exhale, and do kegel/core as you stand up,” deliberately engaging the pelvic floor and natural core brace.
- We can instruct her to take breaks at work, doing multiple sets during the workday.
Another effective maneuver is to deliberately use her hands to “guide” the recti muscles together as she does the elevator exercise. (See Video 3)
Video 3. Bracing exercise
Exercises can be modified to decrease the stress against the abdominal wall.
Let’s look at an example of a leg lowering exercise, which is too difficult for the client in the video. The straining against the abdominal wall is clear! See Video 4.
Video 4. Leg lowering
Compare Video 4 (leg lowering) with Video 5, in which the client is standing and performing a “stir the pot” exercise. The core integrity is not compromised in this position!
Video 5. Stir the pot
Exercises done in the kneeling, or half-kneeling position are also great choices during pregnancy. (See image below)
Image 1. Half-kneeling position
The Postpartum Client
The same guidelines discussed above apply to the postpartum client:
- Encourage proper breathing techniques.
- Start with low-level stabilization exercises, and progress the exercise only if these are completed without compensations (Sahrmann, 2002; Lee, 2007).
- Avoid exercises that increase the strain against the abdominal wall.
- Perform the bracing exercise with the hands.
- Consider having her wear a bind while exercising the first few weeks postpartum (Tupler, 2005).
Pregnancy adds stress to the abdominal wall and we as trainers can help our clients improve their strength and keep their strength without further compromising integrity. Review the first video demonstration in this article to learn how to test for one of the most common occurences affecting the core during pregnancy: Diastasis Recti. The remaining videos demonstrate recommended movements and core exercises for the pregnant client. Keep in mind that checking for Diastasis Recti can also be appropriate for non-pregnant women, and men, since body fat, constipation, and poor breathing techniques are major contributors.
- ACOG Committee Opinion No. 267. (2002). Exercise during pregnancy and the postpartum period. Obstetrics & Gynecology, 99.
- Beer et al. (2009). The normal width of the linea alba in nulliparous women. Clinical Anatomy, 22(6), 706-711.
- Boissonnault, J., Blaschak, M. (1988). Incidence of diastasis recti abdominis during the childbearing year. Physical Therapy, 68(7), 1082-1086.
- Chiarello, et al. (2005). The effects of an exercise program on diastasis recti abdominis in pregnant women. Journal of Women’s Health Physical Therapy. 29(1), 11-16.
- Keeler et al. (2012). Diastasis recti abdominis: A survey of women’s health specialists for current physical therapy clinical practice for postpartum women.
- Journal of Women’s Health Physical Therapy, 36(3), 131-142.
- Lee, D. (2007). Diastasis rectus abdominis & postpartum health consideration for exercise training. Journal of Bodywork and Movement Therapies, 12, 333-348.
- Noble, E. (1995). Essential exercises for the childbearing year. Harwich, MA: New Life Images.
- Parker et al. (2009). Diastasis rectus abdominis and lumbo-pelvic pain and dysfunction-Are they related? Journal of Women’s Health Physical Therapy. 33(2), 15-22.
- Sahrmann, S. (2002). Diagnosis and treatment of movement impairment syndromes. St. Louis, MO: Mosby.
- Tupler, J. (2005). Maternal fitness. Simon & Schuster.