Internet and social media are full of informations on regaining perfect body and flat stomach after childbirth although there are not so many scientific reports an this topic. One should be careful on choosing the exercises suitable for DRA?
What is Diastasis Rectus Abdominis (DRA)?
DRS is a state when the muscles rectus abdominis (known as 6 pack) become separated by a distance that is larger than normal. DRA is often described in relation to pregnancy, but occurs both in postmenopausal women and in men – often correlated to being overweight and having low muscle tonus. DRA is more dominant in the supra – umbilical region and studies report connection with mother’s age and body mass index. The inter-recti separation ranges from 2 to 3 cm in width and 2 to 5 cm in length, going the entire length of RA. The criteria to determine the DRA is a separation of more than 2cm at one or more points of the linea alba.
The linea alba is the main structure to be mentioned in association with DRA. It is the central seam connecting the fascia that covers the rectus abdominis muscles. It is the central insertion point of the rectus abdominis and other 3 abdominal muscles on each side: internal obliques, the external obliques, and the transversus abdominis.
The most common way to assess DRA is to perform a small abdominal crunch and palpate with two fingers below and above the belly button to feel for the separation of the abdominal wall. If the separation is smaller than one finger width it is fine and larger separation are considered DRA
When this collagen structure of connective tissue (linea alba) is not able to provide support and appropriate tension DRA occurs. We can notice the DRA when the abdominal muscles are not firing in optimal pattern. We can see this ad coning of the abdomen when exercising or sitting up from lying. In some cases DRA can be noticed at rest, usually called “mommy tummy” and it may last long after giving birth. Hormones relaxin, progesterone and estrogen, mechanical stresses (rectus abdomins stretches and lengthens due to growing fetus) on the abdominal wall and displacement of the abdominal organs causes elastic changes of the connective tissues and cause DRA.
When can this happen?
DRA is very common in the 3rd trimester (66% to 100% women experience DRA during third trimester) and postpartum (53%). Women with DRA (66%) often report pelvic floor dysfunction (pelvic pain or incontinence). DRA has negative effect on women’s health. DRA can cause health problems such as low back pain, pelvic pain, pain in the abdominal area, lower back pelvic pain. Most pregnant women have an anterior pelvic tilt which causes changes in posture and influence postural biomechanics. Changed trunk mechanics, loosened pelvic stability and impaired posture cause that the lumbar spine and pelvis are more vulnerable ti injury. DRA is not a health issue for all postpartum women as it resolves itself.
Can DRA be prevented?
It is common to hear that all kind of crunches and plank are forbidden during pregnancy. Crunches can be safe and effective for strengthening the core if performed correctly and do not need to be avoided during pregnancy or postpartum. It is often said to draw in the belly toward the spine but these action can increase pressure down the midline of the abdominals and adds to the strain on the linea alba thus causing widening of the inter-recti distance (IRD). On the other side the curl up action can close the gap. So crunches and core exercises may be effect-full in preventing DR. Although it is not all black and white, some studies report that that core exercises may distort the linea alba in women with DRA. The effect can be reduced when exercises are performed with engagement of transversus abdominis.
To clear up, crunches are not good or bad per se but must be learned to be performed correctly. It is easier to prevent than to cure so it is important to prevent the atrophy of core muscles that can happen during nine months of pregnancy. The best advice to minimise the DRA or to prevent it is to maintain a strong core and healthy weight gain.
After the first trimester it is advised to avoid exercising on flat surface so it is useful to use a stability ball, bosu, inclined bench…Core exercises such as planks, pelvic tilts, modified push ups and other exercises that engage abdominals are a must and should be accompanied with deep breathing exercises. It is important to avoid deep twisting through the midsection and quick twisting movements (e.g. bicycle crunches).
Correct breathing is crucial to keep the core strong and to avoid excess strain. When the exertion of movement is executed there should be an exhalation so there is less pressure on the abdominals and pelvic floor.
Each exercise starts with proper alignment and correct posture that promotes pelvic and hip stability and corrects muscle imbalances. Due to growing belly it is important to avoid excessive anterior pelvic tilt and thus lessen the strain on the abdominal wall and lower back.
- Pelvic tilt on floor or stability ball/bosu
Assume a comfortable position and be aware of the pelvis, pelvic floor, hip alignment. The body should be balanced and the feet under the knees. Neck is stabilised. Exhale while lifting up the shoulders and upper chest hips press up away from the ball/floor and squeeze lower abdominals, pelvic floor and glutes. Return shoulders and hips in starting position with the exhalation. The core is engaged all the time.
- Modified push up
Staring position with knees on the floor, back and neck are straight. The core is strong. Hands are in line with the chest and little wider than the shoulders. Inhale and with the exhalation bend the elbows and lower towards the floor. Pay attention on hip height and position of the lower back that should not be sagged. Press back to the starting position.
- Hip circles on ball
Sit on stability ball with a good posture, shoulders relaxed, neck long, back in double S shape. Move hips in small circles. To move use the core and not the legs. Breath easily and execute exercise mindfully.
- Cat- Cow pose
Start on all fours, knees under hips, hands under shoulders. Back is in neutral position. With inhalation move the chest and neck up, curve the lumbar spine down and lower back up. These movement is very small since there is already a bigger lordosis due to growing belly. With the exhalation suck the bellybutton in and make a rounded back, neck can round forward.
- Superman all 4
Start on all fours, knees under hips, hands under shoulders. Inhale and stretch the opposite arm and leg forward and back. Do not move the spine but try to reach forward and backward. With exhalation move the leg towards the elbow and elbow towards the knee. Move slowly and feel the core, glutes, back and pelvic floor engaged. Activate the transversus abdominis.
Postpartum but still DRA?
After giving birth easing back into training should be slow with a focus on rehabilitating the pelvic floor and core and restoring the natural alignment. The goal is ti optimise back the core function and alleviate the pain.
After birth programme to heal DRA must incorporate strengthening of the core control muscles of the lower abdominal region to form a muscular “corset” . Pelvic floor, TrA, deep multifidus and diaphragm o(deep core stabilizing muscles) form a muscular cylinder that has the role to support the spine and the pelvis. Having a strong corset supports the spine and the back, decreases abdominal separation, blends toning and alleviates muscle tension deriving from repetitive physical movement.
Postpartum DRA exercise regimen should consist of abdominal bracing, diaphragmatic breathing, pelvic floor contraction, planks, isometric abdominal contraction as well as the traditional abdominal exercise program. As suggested by the literature transversus abdominis muscle strengthening is probably the most beneficial therapeutic target. Since DRA and pelvic floor muscle weakness are connected there should be emphasis on bringing back pelvic floor awareness.
- Pelvic floor contractions
Contractions should be held for 5 seconds, 20 repetitions and 3 sets. Relaxation is 10 seconds long.
- Breathing exercises
With breathing exercises you relearn how to effectively use and how to descend the diaphragm as during pregnancy was pushed upwards. Diaphragm is the top of the core muscles so it is important to learn how to use it in full motion.
Lie on your back with knees bent, one hand is just above the pubic symphysis and feel the slight up and down motion while breathing in and out. The other hand is on top of the chest, try not to move it when breathing.
Lateral costal breathing:
Place your hands on the lateral sides of the rib cage. Breathe into your hands and feel for the lateral expansion of the rib cage as you inhale and toward the midline during exhalation.
- Postural Awareness
Be aware of the pelvic tilt, usually is exaggerated after pregnancy. Keep your spine in a neutral position. Keep the pelvic floor and diaphragm aligned. Do not push the pelvis forward. Try to be soft in the upper lumbar spine and thoracic area.
- Corrective exercises
Bent knee fall outs
Lie on your back, knees bent, feet flat. Keep your spine neutral. Activate lower abdominal muscles. Lower right bent leg to the right side of your body. Keep left knee bent and pointing upwards towards the ceiling. Keep your pelvis stable throughout this exercise – try to avoid trunk rotation. Return your right leg to starting position. Relax your deep abdominal muscles. Repeat on other side.
Lie on your back, knees bent, feet flat. Keep your spine neutral. Activate your deep abdominal muscles and extend your right leg. When you feel your lower back begin to arch return your leg back to your starting position. Repeat on the other side.
Starting position with feet shoulder width apart, firmly on the ground. Lean against the wall. Engage your core. Go lower as long as you feel the wall behind.
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Till next time,