“Separation” Anxiety – Diastasis Rectus Abdominus (DRA)

There is a lot of hype about “Separation” post birth, and rightly so. Cosmetically, it can look unsightly, but more importantly, did you know it may be the cause of your back pain, incontinence and pelvic organ prolapse?! They can go hand in hand: 66% of women who have a DRA, have pelvic floor support problems. (that is: Urinary Incontinence and/or Pelvic Organ Prolapse!

But what if you may be able to prevent it from happening in the first place, or improve it in the early post-natal period and rehabilitate it to help you move better and improve your pelvic floor?

 

WHAT IS IT?

DRA is a problem with a piece of connective tissue called the Linea Alba. This linea alba runs from where your ribs meet just below your sternum, all the way to your pubic bone. There are 4 layers of abdominal wall muscles, 4 on the right and 4 on the left. All 4 muscles on each side converge in to attach to the Linea Alba in the centre. As the baby grows throughout pregnancy, the most vulnerable tissue to stretch is the linea alba, creating abdominal separation and thus ‘a gap’.

WHY SUCH A BIG DEAL?

Muscles only work well if what they connect to is solid. If the Linea Alba is stretched and thinned out, it is no longer a solid anchor for the attachment of the 4 layers of abdominal muscles on either side. If they do not have this, then they do not do their job well, potentially leading to incontinence, prolapse and pain!

HOW DOES THIS HAPPEN?

The body will move through daily activities regardless of whether there is a fabulous anchor point for these muscles, because that’s just what we do right!? Innocently we are carrying babies, lifting prams, pounding the pavement and all the while adopting non-optimal strategies for the transfer of loads because our deep abdominal wall isn’t doing its job properly!

LET’S LOOK AT THE PHYSIOLOGY…

We know that in woman without incontinence, prolapse or pain, there is a nice co-contraction between the pelvic floor and transverse abdominal muscles.

We also know that in women with Urinary Incontinence, prolapse and pain, these muscles don’t work well together. It may be that the timing of when these muscles should turn on is wrong. Or it may be a lack of coordination. Either way, the final result being that during loading tasks, this poorly timed or poorly controlled contraction of the pelvic floor and the transverse abdominal muscle system, fails to control joint motion and leaves us open for the potential loss of urethral and pelvic organ support. — Incontinence and prolapse!

SO WHAT TO DO ABOUT IT?

New research by Diane Lee and Paul Hodges has emerged about DRA, and it makes perfect sense! Results from their study found that regardless of the size of the separation, without recruitment from the deep abdominal muscles the woman is unable to provide a stable base for muscles to attach, and thus joint stability was compromised.

So basically, the gap isn’t the problem; we need a solid base for our muscles to attach, to allow a a lovely contraction of our deep muscles to provide control and joint stability.

Previously, treatment has been all about closing the gap, but we now know that the gap is somewhat irrelevant, so let’s make a stable base by providing a tensile force to the linea alba, and train the deep stabilizers to turn on at the right time, and coordinate movement

How do I avoid a Diastasis? PRE-NATAL

Have an abdominal separation check during pregnancy. Although there is no scientific evidence behind this, we have found that checking woman during their pregnancy and flagging those at high risk of separation and providing education about how to avoid separation, we have been getting great results.

  • Get your core stabilisers assessed by a Women’s Health Physiotherapist and ensure they are working optimally. If not, there are lots of great exercises you can do in your pregnancy.
  • Learn to move with minimal abdominal wall involvement. For example, when on your back roll on to your side, the push yourself up with your arms, rather than sitting up through a normal “sit up” movement pattern.
  • Learn to LET YOUR ABDOMINAL WALL GO. You see your uterus is going to expand anyway, so the last thing you need is an abdominal wall that is tight and high in tone. If the muscles don’t allow space for your uterus to expand, the linea alba will stretch and in some cases tear.
  • DO NOT DO HIGH INTENSE ABDOMINAL EXERCISES in pregnancy. We can not stress this point enough. It makes no sense to try and “work” and therefore shorten a muscle that needs to be lengthened. There is plenty of time to rehabilitate the abdominal wall post baby. Plus, abdominal exercises also create a lot of intra-abdominal pressure and this places undue strain on your pelvic floor and pelvic organs.

POST-NATAL check 0-12 weeks.
Again research is scarce, but we think based on tissue healing theories and what we see clinically, that we have a 12 week window post natally, whereby if we treat the DRA well, we will improve the integrity of the linea alba (i.e.: help fix the diastasis).
We will check the quality of your movement and look at the recruitment and timing of your deep muscle system, to ensure you are not at risk of pelvic dysfunction or pain. You will be prescribed very specific rehabilitation exercises. In addition, you will be shown which movements and exercises to avoid.

ALREADY HAVE A SEPARATION?

If you are reading this beyond 12 weeks post natal, and you have a diastasis, don’t worry we can still help. The sooner you address the issue the easier it is to fix it! We will do a full body assessment and look at reversing compensatory strategies and work on fixing the function of the linea alba through manual therapy and rehabilitation.

So, for those women with “Separation” Anxiety…it’s not about the distance, it’s the attachment that is important.

Suzie Williams
Physiotherapist
Women’s Health Practitioner

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