Diastasis rectus abdominis (diastasis recti, diastasis, DRA, or DR), the partial or complete separation of stomach muscles, has become a buzzy diagnosis aimed at moms during the postpartum period (“Get rid of your mom tummy!”), and it can sound like a scary prognosis.
To find out more about it, we recently interviewed Munira Hudani, PT, a pelvic-health and women’s-health physiotherapist located in Toronto. Hudani has been a physiotherapist for 10 years and holds a master of science in physical rehabilitation degree from the University of Toronto. She's the director of the Pelvic Health Program at Bosnar Centre for Health in Toronto, has taught courses on DR to rehab and fitness professionals, provides clinical mentorship to physiotherapists, is really a cofounder of Made for Women workouts, and it is on the teaching faculty of Pelvic Health Solutions, the key educational body in Canada for pelvic-health education. Hudani talked about all aspects of DR, including the way it has an impact on body image.
“It’s not for anybody to judge or to tell you what you need to be feeling. If you want your stomach back, that’s OK. If you feel like all you want to be able to do is run again, that’s fine too,” she said.
Read on for additional of Hudani’s thoughts about how to heal from diastasis recti.
Experience Life | What is diastasis rectus abdominis (diastasis recti, or DR)?
Munira Hudani | The word “diastasis” means separation. Diastasis rectus abdominis is literally defined as separation of the rectus abdominis muscles (the two sections of muscle in the front from the abdomen that are, before pregnancy, connected by the linea alba). The important thing to note is that with DR, although we're really focusing on the linea alba and the space between the two muscles, the reason it occurs is because there is a sustained quantity of pressure from the inside that pushes out around the linea alba and the whole abdomen. The linea alba and abdomen adapt to accommodate due to the pressure from the inside. We need to take this and set it into context with what else is happening. It’s the whole abdominal wall that is affected and not just the linea alba.
EL | How does someone get DR?
MH | It’s by pointing out pressure. It could be a sustained increased pressure on the long period of time, or it could be repeated amounts of pressure frequently enough that the tissues themselves didn’t have time to accommodate, so they become extended and stay there afterwards.
It doesn’t need to happen in pregnancy only. It may happen in people that are very athletic and doing exercises on a consistent and regular basis where these exercises produce a lot of intra-abdominal pressure. If there isn’t sufficient time between sessions or they overloaded on that day, then the tissues may not be able to keep up with that, so they remain widened. But if they gave themselves amount of time in between, the tissues could have adapted and kept everything together.
It can also happen in people who have an increase in abdominal mass or weight, which may happen over a period of time, that is a very different kind of stretching.
EL | Is it ever past too far to start healing DR?
MH | It’s never too late. The body, muscles, and ligament are responsive and adapt based on what we are doing. If we are beginning the procedure, they will change.
EL | Do corset-like binders help initially to carry the body together?
MH | I recommend abdominal support for that fourth trimester (the first 13 weeks postpartum), not corsets, but binders. Corsets and waist trainers are a whole different category that I don’t recommend for anybody.
Just as we would initially support an ankle that was sprained, we would do the same thing for that abdominal wall. We are attempting to support the body in the immediate period of time because it was stretched out for so long. The body will decipher it, but it helps guide the body.
EL | Is there a timeline on how long it takes to heal DR?
MH | It’s impossible to tell someone how much time it will take. What we can do is take a look at the person in front of us and see what factors may be at play and give them a more customized answer rather than saying everyone with DR will require a certain amount of time to get better, and if they don’t, they’re doomed. There are many factors for healing DR:
- What is the starting point?
- How strong are you to start with in your muscles?
- How much connective-tissue laxity do you have?
- How well are you aware of the muscles?
- How good is your mind–muscle connection to the pelvic floor, transversus abdominis (TA), diaphragm?
Building mind–muscle connection may take a couple of minutes or a couple of months — or longer. Overall healing may take a few months to a couple of years. Even when it’s five years later, that’s fine too.
EL | What is the process someone can take to heal her diastasis?
MH | We need to consider where we’re concentrating on the entire abdominal wall and not simply the linea alba. Closing that gap has run out of our control. We don’t have the ability to voluntarily do something in that moment to shut that gap. If you read the anatomy and muscles and how they contract around it, no muscles pull the rectus abdominis together; they pull within the opposite direction. We need to consider a different idea instead of “close the gap, close the gap.” We want to think of how we can restore the function of the whole abdominal wall, including all of the muscles that are there, that also includes the rectus abdominis, which we’ve been shying away from.
Rectus abdominis muscles help you bend forward. While you're reading things that suggest they don’t do anything whatsoever, I would simply say, “How did you get out of bed in the morning?” They are essential, and we aren’t training them up after they’ve been stretched. They'll remain weak unless we build them up.
The process, I would say, is a three-step restorative process (see below) that involves the whole abdominal wall but begins with the deeper-core muscle system — the pelvic floor, the TA, the diaphragm, and the multifidus muscle in the back. We have these muscles we should be working on before we target the outside muscles. That’s the stuff most people in general don’t know what to do with. Everyone knows how to do sit-ups and planks. But we don’t are all aware how the inner muscles work and fasten with the deeper core. It’s difficult to strengthen the muscles should you don’t know how they work where they are. Everything got affected in pregnancy — even the outside muscles, even the obliques.
- Awareness and Connection: Connecting and awareness is often the first step. Connecting to your breath as well as your TA, which draws in the whole abdomen, connecting towards the pelvic floor, which is sphincter control, a supportive role. Finding out how to do those basic connection exercises.
- Get Synergized: Once you know these muscles, have worked with them a little, and can control them voluntarily, it requires less mental effort. You say “turn on” plus they do. You’re then in a position to move on to the next step — strengthening the inner muscles. Get them to become coordinated with one another (first step), then strengthen the pelvic floor and also the TA muscle. This is the biggest missing piece in many programs right now: the strengthening of the TA muscle. Pulling in that entire abdominal wall and letting it stay there in the pulled-in position in a number of other exercises and movements. I believe one of the best things is planks if you can draw in the abdomen while standing, let’s load it up. Can you do it when you’re in a modified pushup or plank against the wall? If it’s easy, move to the ground. If it’s way too hard, we need to build up to do it. If you can hold and draw in your whole abdomen and be breathing, and never doming (more on that below), this means you’re really strong. If you're able to pull in lower, middle, upper, and stay engaged within a plank or other hard exercises, that’s how you train up the TA. If the pressure inside is too much, that’s when you’ll see doming or bulging, and you’ll know you’ve gone too far.
- Load and Strengthen: That takes care of the inner core. Then as you’re strengthening the TA, it’s time to start strengthening other stomach muscles. We don’t need to wait for the TA to be fully strong before we do anything else. Now it’s a matter of getting all of the muscles cooperating. It involves rotation, flexion movements, and a variety of exercises that gradually challenge that individual. Every person will be different with what they are able to handle and where they’re at. We are telling people “don’t do this and do that” until your core is strong enough to handle it. But then we aren’t telling them what to do to get there and make it stronger.
EL | We hear a great deal about “doming” or “coning” if you have diastasis recti, which if you see this while performing a workout to immediately stop the movement. What are your thoughts on doming?
MH | There’s a continuum. There’s a little amount of doming, and there’s a serious amount of doming, which would also involve the whole abdomen bulging outwards.
That’s where you want to put your mind — just how much doming is there? As long as we aren’t in the extreme ranges I think we are OK, we aren’t doing anything harmful or damaging. Even if we are in the extreme, it may be OK too, as long as we aren’t spending all of our time there. Because if you’re in the extreme and actively pull in, and you've got a lot less bulging, it teaches you still have control and can pull in after that. So at this point it’s just feedback.
If you’re seeing it happen, and also you can’t pull it in from that point, it’s OK. You’re able to keep building those muscles.
EL | At what point do you move someone from rehab to strengthening?
MH | If people are ready to move on from rehab, it’s time to move on. If it takes two years to find the connection and synergize, then that’s OK, but when you’re ready, move on.
EL | How does the entire core (TA, pelvic floor, obliques, and diaphragm) interact to heal a diastasis injury?
MH | When it comes to healing DR, we are returning to healing the whole abdominal wall, not just the linea alba. The only way to work the linea alba would be to work the muscles that attach to it. So gradually strengthening all of these muscles and getting them to work in a coordinated manner, so they can do their collective role in containing intra-abdominal pressure, is how to heal the whole core.
They all have their individual functions. Obliques rotate, the diaphragm is a respiratory muscle, the pelvic floor supports, and also the TA pulls inwards and contains the organs inside of you. Together they create a sturdy abdominal cannister that intra-abdominal pressure can be contained. The TA can’t do this all by itself. It needs the obliques and rectus abdominis.
EL | What role does relaxing or releasing the TA and pelvic-floor muscles play in optimal functionality and healing?
MH| To become able to contract the muscle and go through its full range you have to let it go. It can’t be in a contracted state and then strengthen it through its full range. It would be a very short range if you begin contracted because you’d be strengthening it from the point it’s contracted at.
If you let the muscle go, you’ve given it more ability to go through that strengthening excursion. If you’re not letting go, you’re not will make it easy to make your next contraction to become done well. That’s during exercise and technique.
If the general state of your muscles is tight — should you begin contracting an already tight muscle — you’re likely to continue to tighten that muscle further. You want to spend time relaxing the muscle so it can be used appropriately. Tight muscles become nonfunctional muscles.
EL | Exactly what does it mean to have a functional gap or core?
MH | There is lots of misunderstanding under the idea of “functional.” If you look at the anatomy, we are looking at muscles that attach to the linea alba; when they contract the lateral muscles, they tug on the linea alba and take up the slack. You can’t tense the linea alba if you don't tense those muscles. If you're able to tense up the linea alba with a lot of pressure underneath, and you can keep the tension there also it doesn’t push through the linea alba (doming), you are considered functional. I take it one step further by saying if you can keep your tension there.
Some positions and exercises will be OK. You’ll be able to create and sustain tension without doming. In others, not. If you can’t produce tension while lying on your back, that position may not be conducive to generating tension.
EL | We hear a lot about movements women should avoid performing to not hinder healing their diastasis. What is your take on this?
MH | Any exercise that elevates pressure is what we need to keep in mind. Sit-ups have gotten a poor rap lately. It’s not only sit-ups. But they have been unfairly designated because they create pressure. There are lots of exercises that create pressure to that particular level.
It’s interesting to understand this continuum of pressure. We don’t possess a lot of information based on the research which exercises create that much pressure. But we've ideas of what is the lower end from the continuum and the highest end from the continuum — the extremes.
No pressure is the place you’re lying on your back and your is resting. The complete opposite end of the spectrum that has been recorded occurs when you’re coughing, jumping, and bearing down (constipation, sickness, spontaneous laughter). Now, sit-ups aren’t in that list. If sit-ups aren’t in the extreme, then maybe it’s dependent on how many sit-ups you’re doing, how frequently you’re doing them, what technique you’re using, along with other exercises you’re doing which are similar in levels of pressure. We have oversimplified it by focusing on sit-ups. There are a lot more factors to think about when you’re pondering intra-abdominal pressure.
EL | How can you take the fear out of having DR and someone getting comfortable in their body again with movement?
MH | This is exactly what I primarily am seeing every day. So many women come in and they feel broken, discouraged, frustrated, injured, weak, scared, overwhelmed, don’t get sound advice, want to improve but don’t want to harm themselves so are doing nothing at all. This is the consequence of the kind of information — even well-meaning — that we’ve been putting out there.
When people come in and feel like that, the most important thing is to acknowledge that’s how they’re feeling. We have to acknowledge it because this is real. I explain to them what DR is and isn't. We discuss why they might be feeling upset, scared, frustrated, and broken. Then I show them another way to see it. I change the process of how they feel about themselves and also the situation before I go into what we should need to do about it.
I allow them to observe that the body is strong, resilient, responsive, and adaptive, and it will do things and change depending on what we are doing with it. If we are not moving, which our body is designed to do, then it has no reason to change. If we feel weak, we need to begin building strength. When we aren’t doing strengthening exercises, we cannot change that. We need to do the things we aren’t doing or allowing ourselves to complete. When we start doing those activities, then the tissues have what they desire to begin that change, and that’s when you’ll start to notice the change. And if you can feel strength building, tissues thickening, and feeling less hollowness happening, it will motivate you to continue.
Just know the extremes and just what to watch out for. You have your parameters to operate within, then if it doesn’t feel challenging, that’s bad. You can’t go to the gym and do a 2-pound deadlift and expect something to occur. Let’s assume that the body can handle at least the amount and weight of the child. So many people are afraid they can’t lift up their own kids.
EL | How does collagen help to heal or prevent DR?
MH | In relation to connective tissue — we know that it’s comprised of collagen. It’s the primary protein that’s within connective tissue. Connective tissue responds as to the we do with it, like muscles. It’s very adaptable. Ligament is made of up collagen, if you want to build up the collagen content, from a workout perspective we have to load it. It has to undergo a certain level of stress to ensure that us to stimulate and initiate the regenerative process. This really is no different for the abdominal wall — if you wish to target that area, you need to do exercises that challenge that area. Including exercises for the muscles in and around the abdomen which will naturally put tension around the linea-alba tissue, because every time those muscles contract they will tug at that linea alba. So we have to figure out how to put tension with that tissue repeatedly, gradually, so that over a period of time it can begin to thicken and build the integrity of the linea alba.
We have to load it and challenge it. And it’s not only about exercise. Connective tissue and collagen — we need building blocks in our body to produce that collagen. All the exercise on the planet will only get someone so far if they don’t have the foundations inside of them to help build that tissue when it’s being loaded.
EL | What role do nutrition and sleep play in healing a DR injury?
MH | I am not an expert in nutrition, but vitamin C is a precursor to building collagen so it’s a very important vitamin for collagen production, out of the box vitamin A. In addition to nutrition, part of that is also hydration, specially in the postpartum period. Two-thirds of the volume of our ligament is made up of water.
Also, even if we've the building blocks and we are loading the tissue by exercising, if a person is going through a large amount of stress and not sleeping well, or maybe they are sick or have other autoimmune conditions — these hamper the body’s ability to use what it has to build the tissues up. Sleep is important. We get most of our regeneration when we sleep. If you’re not getting sleep, that could also affect general healing of the body in the postpartum period. If you’re very stressed, overwhelmed, anxious, frustrated, and angry, that’s OK so long as you learn ways of rest and relax every day. These reduce inflammation and cortisol in the body. If there’s a lot of that floating around, it hampers your body’s capability to heal.
EL | At what point is DR surgery an optimistic recommendation for someone?
MH | Surgery is no negative recommendation unless it’s the only option you’re giving them. Conservative treatment first, surgery as the last option. If you’ve been doing rehab for two years, let’s get you building strength for 2 years and see where you’re at then. If you really don’t want to do the surgery, give yourself time to strengthen and the collagen to turn over.
We tend to look down on the surgery, however it does have a really important place for this continuum of care. It’s something people need to know is a legitimate option when each one of these things have failed.
EL | For exhausted and overwhelmed moms who're on a tight budget of money and time, what exactly are your top three things to prioritize in their healing?
MH | For me, No. 1 would be to see a pelvic-floor physiotherapist. I know there might be a time and investment factor here, but even if you saw them once and also got your baseline and know where you stand, know what your pelvic floor does, and how well you tolerated her pregnancy and delivery, and if a prolapse is going on, it’s really good to know right away. It’s integral for core health. The pelvic floor is part of the core and is involved with all of the movement we do to strengthen the core. Learning how to contract the pelvic floor well and properly will help with the process.
No. 2 would be to learn how to strengthen your TA muscle. If you look at the anatomy, the way the TA was created is to pull everything in and relax and let go. It’s a key muscle.
No. 3 is always to go back to other factors that can be playing a role, and just work on one of them:sleep, nutrition, stress, hydration, or general exercise. That way you know you’re doing something for the betterment of your body, mental health, and tissue.
EL | What exactly are three things you want other practitioners to know in treating DR?
MH |
- Doming is not always a bad thing. It doesn’t necessarily mean you’re seeing something that will harm the tissue. That’s what we should are associating with it at this time. I want people to learn how to scale that. Where are you currently in the scale?
- Intra-abdominal pressure isn’t bad. It’s a simple mechanism that our bodies use to provide us with stability. We need pressure. It gives us support. Learning to become friends with pressure and never the enemy. When you start strengthening your core, you’re challenging your core, and it will naturally create more pressure. Know what pressure is and what to do with it.
- Learn how to strengthen the TA. Go back and learn what the muscle does and just how it works and then we will have very clear ways to go back and strengthen it. The plank progression is a superb way to do this.
EL | On Instagram you point out that having weak connective tissue doesn’t mean you are weak. Why is that?
MH | Connective tissue is exactly what binds everything together, holds everything in, and surrounds the muscles. The strength of your core comes down to how strong your muscles are. There are women who have very lax ligament in their abdominal wall but could still do very high-level movement like CrossFit, toes to close, sit-ups. Connective tissue plays a role in what your extremes might be, but it’s not the only thing that determines how strong your core is.
EL | Is there anything else that you want people to know about DR?
MH | It’s OK to strengthen your core. It’s OK to move beyond rehab and do more challenging exercises — in fact it is what you need to do.
Download Hudani’s free diastasis resource guide for patients and professionals for more tips on healing diastasis.