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Repairing Diastasis Recti for Your Postpartum Clients


Learning how to properly train prenatal and postnatal clients can be confusing, especially when trying to understand diastasis recti. In this article you will learn how to check for diastasis recti in your postpartum clients, understand how fascia and creating a strong deep core play a vital role in diastasis recti recovery along with recommended exercises you can teach your clients.

Learning Objectives:

  1. Learn how to check for diastasis recti in your postpartum clients.
  2. Understand how creating good fascial and deep core muscle connection is key in repairing diastasis recti.
  3. Discover recommended exercises and techniques for minimizing further separation and repairing diastsis recti.

Diastasis Recti is a separation of the rectus abdominis muscles along the linea alba and typically occurs during pregnancy and in the postpartum phase.

Factors that can affect diastasis recti and the degree of diastasis recti are:

Sometimes there may be no good explanation as to “why” a client ended up having some abdominal separation, but now that she does you can help her in her recovery and repairing her abdominals with the following:

Increase Fascial Connection

In a study by Robert Schleip, PhD (2005) found that fascia itself is able to “contract and relax and thereby influence biomechanical behavior,” and “suggests a new understanding of pathologies with an increased or decreased myofascial tonus.”

This is an amazing finding and something that I have noticed with clients over the years. New research is finally proving that we can manipulate the fascia and fascial connection. This means that when training your clients with diastsis recti, stimulating fascial connection could help decrease her abdominal separation and create better deep core connection without actually increasing her muscle mass, but rather the fascial connection.

Teach Deep Core Connection

When teaching deep core connection it’s important that she understand how to properly activate her pelvic floor muscles along with transverse abdominals simultaneously. This has been verified in a study by R.R. Sapfords, the study found “…that abdominal muscle activity is a normal response to PF [pelvic floor] exercise in subjects with no symptoms of PF muscle dysfunction…” and D. Chritchley also found that same relationship - that pelvic floor muscles and transverse abdominals co-contract together - but also found an increase in transverse abdominal thickness. Could this also result in a decrease in low back pain? It can’t hurt to have stronger deep core muscles to provide the low back more support.

These studies bring about another topic addressing pelvic floor dysfunction. If you have a client that can not properly connect her deep core (possibly due to pelvic floor dysfunction) it may be a good idea to recommend her to a specialist for pelvic floor manipulation. Be sure to give her some time to learn and try to “find” her deep core muscles as it may just take her a while to figure it out.

Possible reasons why she may have pelvic floor dysfunction are:

  1. She may have never truly activated her pelvic floor muscles properly her entire life.
  2. Had an episiotomy during delivery of a child (this is where they cut the perineum). This can create scar tissue and disconnection of the pelvic floor muscles or a bad natural tear during delivery.
  3. She may just need time to “find” those muscles, so be patient with her.

Teaching to always lightly activate her deep core muscles is a must, especially with diastasis. An easy way to explain that is to guide her to “zip up” as she exhales. She should lightly lift up on her pelvic floor muscles while continuing that zipping feeling up through the top of her head, while creating a light intercostal ribcage connection, causing her ribs to draw down and inward slightly.

You should also notice improvement in posture and her lower belly flatten at least slightly indicating that she is indeed activating her deep core muscles properly. Just by “zipping up” her core she is also creating better postural alignment habits – a key to repairing diastasis.

Focus on her activating her deep core, starting with her pelvic floor and then zipping up on the exhale with each exercise, especially if she is having a hard time recruiting. If you notice her holding her breath, this indicates she is “over-activating,” which can be counterproductive. Her deep core connection should always be a “light” and “gentle” connection, rather than a strong contraction as you might think of when doing a crunch.

She can practice her deep core connection any time. A study by P. Neumann (2014) found that the standing position was the best position for optimal pelvic floor and abdominal interaction and activation. I’m going to add one more importance piece to that: be sure to teach her neutral alignment and to avoid tucking her pelvis and locking her knees. The standing position is great for deep core strengthening but all bodies are different. Try teaching her deep core activation in different positions as you may find supine exercises, such as hip rolls (see Third Trimester Pregnancy Guidelines article here) or kneeling exercises, such as cat cows or forward roll pulses (see Guidelines for Training Your Postpartum Clients article here), or squats (see Second Trimester Pregnancy Guidelines article here) work best for some. Each of these exercises is a great option for clients with diastasis recti.

When and Why to Avoid Crunches

After addressing fascia I think you’ll better understand why to avoid crunches, not forever, but for a long while when repairing diastasis recti. Crunches put a lot of stress on the rectus abdominals; something that should be avoided in those with diastasis.

Your client must be able to do full planks, properly connect her deep core and have repaired her diastsis before adding “crunches” to her workouts. I’m going to add, in my professional opinion, that I recommend doing neutral-aligned crunch-type exercises over traditional flexed-position crunches. This movement helps to activate the deep core muscles along with the rectus abdominals, rather than just the rectus abdominals alone.

To Plank or Not to Plank

Based on my professional experience, I love incorporating planks to teach clients how to properly activate their deep core muscles. That said, you must properly progress her to planks. Be sure to follow the exercise progression guidelines below very strictly with your clients and you’ll find that “plank slides” are a very effective exercise for strengthening her deep core muscles once her body is ready.

When Diastasis Recti Is Truly Healed

There are many variables when it comes to true healing of diastasis recti. For some, separation will completely close (note that one finger-width separation is normal), but others with larger separation may always have more separation of the linea alba. But, do they have “good” fascial connection? This is why focusing on creating fascial connection can help in repairing diastasis even if she is never able to completely close that gap.

As you progress your client’s program, I recommend taking her through the recommended exercises below. Every so often, incorporate those simple, yet very effective exercises to confirm that she can do the most basic of core exercises and has continued to create deep core muscle and fascial connection.

How to Assess for Diastasis Recti

Before assessing abdominal separation, be sure of these three things:

  1. She is at least 6-10 weeks postpartum
  2. You have already started to teach her how to activate her deep core
  3. She is comfortable with you touching her belly to check for separation

Interesting thing is that just by teaching your client how to activate her deep core muscles properly, she may be able to close the gap a bit with that instruction alone.

Instead of focusing on “core” exercises right away, focus on getting her to stimulate deep core connection while doing full body exercises, such as squats and the other recommended exercises in the Guidelines for Training Your Postpartum Clients article (whether she is recently postpartum or not).

Always instruct her to position herself to her side, then to her back and the reverse to get up, to avoid that “crunch” position until her diastasis recti is healed.

Assessing Her Separation

Note: this is the only time she is allowed to do a “crunch” because it’s required in order to properly assess separation. Guide her to:

  1. Begin in a supine and neutral position with knees bent and feet hip-width apart.
  2. Exhale and contract as much of her core muscles as possible (this includes pelvic floor engagement).
  3. Flex upward, staying in a neutral lumbar spine, and encourage her to keep her abdominals as contracted as possible (lax abdominal muscles can display larger diastasis than she may actually have).
  4. Gently palpate down her linea alba from just below her sternum, about 2 inches above her pubic bone, measuring at 4 points where and how much separation she may have:
    Point 1: just below the sternum
    Point 2: just above the belly button (typically this is where you find the most severe separation)
    Point 3: just below the belly button
    Point 4: lower abdominal area, 2 inches above her pubic bone
  5. Then, take note of how much fascial connection you may or may not feel. This also gives you an indication on how severe the diastasis recti may be:
    • If you can press down into her abdominal cavity, it’s an indication of more severe diastasis and very little to no fascial tension.
    • If you feel a slight taughtness between her rectus abdominis, this indicates she does has some fascial connection even though she may have separation.

Recommended Exercise Progressions for Clients with Diastasis Recti

Note: every client is different and may progress at very different rates.

Hip Rolls

This is a simple, yet very effective exercise to teach clients how to activate her pelvic floor muscles along with transverse abdominals and intercostals. This may not be a super strong connective exercise, but that’s why it’s a great exercise to do at any stage postpartum or beyond to activate her deep core muscles. It’s important to teach this exercise with the correct breath as that relates to proper deep core activation. Perform in sets of 5 to 10 repetitions.

hip rolls 1 hip rolls 2
  1. Lay supine with spine in a neutral position, knees bent and feet hip-width apart. Place a small ball or pillow between her knees. (Neutral spine is when the pelvis is balanced between the exaggerated posterior and anterior positions, the PSIS and ASIS points.)
  2. Exhale to gently lift up on the pelvic floor muscles, squeezing the ball or pillow, while simultaneously articulating spine up into a bridge position. Avoid the ribs “popping.”
  3. Inhale to hold position.
  4. Exhale to slowly articulate rolling the spine back down one vertebrae at a time, initiating the movement by gently drawing the ribcage down.
  5. Finish in a neutral spine position.

Modified Side Planks

This exercise is not a session one exercise for most, but it’s imperative that she be able to connect her deep core muscles. Once she has found that “light connection,” even with diastasis modified side planks are a great option. Be sure she is lifting or “zipping up” through her center and finding her intercostal connection. Alignment is key for this exercise, as is breath. I recommend starting with small pulses moving with the breath for 10 to 20 repetitions then switching sides.

modified side planks
  1. Place elbow under shoulder and bend the bottom knee to line up under the hip. Be sure to activate that glute.
  2. Exhale to pulse up while focusing on lengthening and lifting through the body, while maintaining the ribcage connection.
  3. Inhale to lower down slightly. 

Plank Slides

This is a more advanced exercise when it comes to repairing diastasis, but a very important exercise once her body is ready. In order for her to progress to planks her abdominal separation must be close to normal (one finger-width) or have good fascial connection across her abdominals - even if she still has some separation. Watch for any bulging of her abdominals. While in a plank position, note the difference in extra loose skin hanging vs. a good flat fascial connection across her lower belly. The loose skin is inevitable and will decrease with time. The focus with planking is to better increase her deep core muscles, fascial strength and connection.

plank slides 1 plank slides 1
  1. Begin in a full plank position on forearms and toes. Press legs together to help engage the pelvic floor, transverse abdominals and intercostals while also pulling up with the quadriceps.
  2. Exhale while moving the body forward and maintaining a plank position.
  3. Inhale while moving the body back. (Focus on stretching the calves in the backward movement.)
  4. Modify: Hold a modified plank on forearms and knees, or continue with modified side planks until ready.

Conclusion

Now that you understand how to check your postpartum clients for diastasis recti, the importance of teaching her to strengthen deep core muscles along with fascial connection, and key exercises for your clients with diastasis recti you can feel more confident in creating safe and effective workouts for her.

References

Critchley, D. (2002). Instructing pelvic floor contraction facilitates transverse abdominis thickness increase during low-abdominal hallowing. Physiother Res Int., 7(2), 65-75.

Neumann, P., & Gill, V. (2014). Pelvic floor and abdominal muscle interaction: EMG activity and intra-abdominal pressure. International Urogynecology Journal.

Pereira L. C., Botelho S., Marques J., et al. (2013). Are transversus abdominis/oblique internal and pelvic floor muscles coactivated during pregnancy and postpartum? Neurourology and Urodynamics, 32(5), 416–419. doi: 10.1002/nau.22315

Salvesen, K., & Morkved, S. (2004). Randomized controlled trial of pelvic floor muscle training during pregnancy. BMJ, 329(7462), 378-380.

Sapsford, R.R., Hodges, P.W., Richardson, C.A., Cooper, D.H., Markwell, S.J., & Jull, G.A. (2001). Co-activation of the abdominal and pelvic floor muscles during voluntary exercises. Neurourol Urodyn., 20(1), 31-42.

Schleip, R., & Klinger, W. (2005). Active fascial contractility: Fascia is able to contract and relax in a smooth muscle-like manner and thereby influence biomechanical behavior. 1st International Congress of Osteopathic Medicine.

Smith, M.D., Coppierters, M.W., & Hodges, P.W. (2007). Postural response of the pelvic floor and abdominal muscles in women with and without incontinence. Neurourol Urodyn., 26(3), 377-85.