MIND THE GAP: Reducing abdominal separation several years post-childbirth

Women’s health expert Dianne Edmonds looks at the case of a personal trainer who discovered her own abdominal separation nine years after giving birth, and proceeded to reduce it by rebuilding her deeper core.

THE QUICK READ

• Abdominal separation – or diastasis recti – occurs to varying degrees in up to two-thirds of pregnant and post-natal women
• Some women will not realise they have the condition until a considerable time after they have given birth, with some discovering only several years later
• By learning how to modify training, and remove exercises that put excessive tension on the abdominal wall and cause ‘doming’, trainers can help clients reduce their abdominal gap and safely strengthen their pelvic floor
• Many personal trainers will not have the knowledge to screen clients for diastasis recti and to program their training accordingly

Abdominal separation – or diastasis recti – is common in pregnant and post-natal women, with up to two-thirds displaying separation of some degree. The condition is defined by a separation of the connective tissue (linea alba) joining the two strips of muscles (rectus abdominis) down the middle of the abdomen. It occurs when the abdominal wall muscles and their connective tissue attachments stretch due to a combination of abdominal weakness, hormonal changes, weight gain and abdominal wall stretch caused by the growing foetus.

Case study 1: The 9 years post-natal PT

Amber is a personal trainer who had twins 9 years ago. Until she attended a practical professional development course on training post-natal clients, she had no idea that she herself had an abdominal separation remaining as a result of her pregnancy. She discovered that she had a 3-finger-width separation above and at her umbilicus (belly button) level, and the gap felt like quite a dip in between her rectus abdominis muscles.

Amber had noticed ‘doming’ in her abdominal wall while performing certain exercises during CrossFit training, but had not been aware of what the gap was. During the post-natal client training course, she learnt what an abdominal gap was, how to check for its presence in female clients, and what exercises to implement with clients who exhibited the condition to help train their changed abdominal wall.

For her, the big revelation was learning how the pelvic floor is wired together with the lower abdominal muscles, and although she had worked transversus abdominis before, she hadn’t felt the link working with her pelvic floor. This changed the pattern of recruitment she was using and, over time, she felt her gap reduce as she increased the effectiveness of her deep transversus abdominis action with her pelvic floor.

Several months later, the gap was less of a distinct dip, there was more tension formed in the linea alba and it had reduced to a 2-finger width. Amber also learnt how to control the tension during training and ensure that her activation patterns improved with specific core exercises. She focused on first recruiting her pelvic floor with transversus, before adding load, so that doming no longer occurred along the length of the linea alba.

Identifying the knowledge gap

With this new knowledge front of mind, Amber reflected on her training career and recalled seeing doming in some of her female clients. She remembered that while training to become a PT, she had observed a client with some abdominal wall changes who also had back pain – but that there had been no strategy in place to screen and check for abdominal separation as part of the client assessment process. She also recalled her PT training having very limited information about pregnancy-related abdominal muscle changes and hardly anything about the role of the pelvic floor and its importance in training, particularly for women who have given birth.

Amber now screens her clients for an abdominal muscle separation and works with them to prescribe abdominal training at an appropriate level for the client, to protect from any doming or strain on an existing abdominal separation. She also now includes pelvic floor training and protection principles in her programming.

‘Clients often don’t know what they should be feeling, so I spend time explaining this to them and giving them feedback’ says Amber; ‘There are some questions I ask the clients now that I didn’t before doing the course. I explain why certain movements are included in my program, and start the clients at an appropriate level so that they are less likely to need to regress their program due to an ab gap bulging or doming with an exercise that is too challenging for their core.

‘Sometimes, if they are used to working hard, they find this frustrating at first, and are challenged or annoyed that their body can’t go straight back into doing what it used to do, but with education and progression and monitoring their progress, they notice the improvement, and can make an informed decision on how hard they work in their training.

‘Whether clients present a few months post-natal or several years after the birth, they need their abdominal wall to be screened. The other thing I now do is to recommend clients go to see a physiotherapist working in women’s and pelvic floor health so that they can get their pelvic floor technique checked. This is not something I as a trainer can do, so it really helps the client’s awareness of the action of these muscles.

‘PT’s need to know the importance of the pelvic floor in the recruitment patterns of the lower abdominal wall. Some of our overweight clients could have a pelvic floor issue or an abdominal muscle separation, so checking and screening for this is important before starting to program for them.

‘Some women want to push regardless of what is going on in their body, however I’ve heard of some of the problems that can occur in addition to an abdominal muscle separation, such as pelvic organ prolapse.’

Case study 2: The 2-months post-natal client

Amber’s realisation of her abdominal separation came fairly belatedly, but many women will identify something being ‘not quite right’ far sooner after giving birth.

Post-natal mum, Sally, was ready to return to the gym following the birth of her first baby by caesarean section. She had learned how to do ‘post-natal abdominal bracing’, activating through transversus abdominus, and had been doing the baseline exercises in sitting, standing, and side lying. She had no pain in her caesarean site and so went to the gym at seven weeks post-natal to commence light weights and treadmill walking. She planned to introduce stationary cycling and then, over the next few weeks, the rower.

Sally resumed training with her PT and at around 10 weeks post-natal she started performing curl ups with her upper back supported on the fitball. She soon started feeling ‘unusual’ in her upper abdominal wall and, noticing an occasional bulge, she went to see her physiotherapist. Assessment revealed a 3-finger-width gap in her upper abdominal wall which bulged slightly but closed down to a 2-finger-width gap when she lifted her head. At the belly button level, and below it, was a smaller gap of 1-finger width.

She had started also to do some modified planks holding for up to 40 seconds and, on testing, tension was felt through her upper abdominal wall that increased the longer she held the position.

In light of discovering the gap, Sally eliminated both the modified plank and curl up over the ball, and instead focused on hands and knees single arm reach/alternate arm/leg reach, with some work in side-lying and supine to build her deeper core control and endurance levels. She had no problems with her pelvic floor.

A month later, when she was 4 months post-natal, testing revealed Sally’s abdominal gap to have reduced to 1 ½-finger-width, with minimal bulging. She continued to work on these post-natal progressions for several more months, attending the gym and working with her trainer to build her strength and aerobic fitness.

Case study 3: The pregnant PT

Of course, diastasis recti is not only identified in post-natal clients – it can also be detected fairly early into a pregnancy. At 12 weeks of pregnancy, Bobbie, a personal trainer, came in for an abdominal muscle wall check. It was a surprise to find that she had a 3-finger-width gap between her rectus abdominis muscles when measured above and at the level of the umbilicus.

As a PT, she had worked with some pregnant and post-natal women during her career, but she now had to apply her knowledge in a new way, to herself.

Having previously demonstrated some post-natal core progression exercises for some educational materials a year before her own pregnancy, Bobbie knew she had a weakness in her lower abdominal wall compared to her stronger upper abdominal wall and external obliques. Due to her years of training predominantly upper rectus and external obliques, a strong activation pattern dominated in these muscles and inhibited some of her transversus abdominis activation, making them relatively weak in comparison. Also, when she did her pelvic floor activation, the effect of the intra-abdominal pressure created through her upper and lateral abdominal wall resulted in activation and then descent initially of her pelvic floor, when observed on real time ultrasound.

Focusing on some ‘detraining’ and retraining, Bobbie learnt to specifically activate the lower transversus abdominis muscles, using the pelvic floor muscles to initiate the action. She included breathing awareness and took the time to learn the patterns of recruitment needed to change her focus towards learning ‘pregnancy abdominal bracing’ in preparation for the lengthening of her abdominal wall with the uterus expanding. This ‘softer’ approach was learnt during a training session, to replace the ‘train hard’ patterns that she was used to.

At 16 weeks of pregnancy, her abdominal separation had reduced to a 2-finger-width gap above and at the level of the umbilicus. Her patterns of activation of her deep abdominal wall had improved, and she was able to activate around her now-expanding uterus with less excessive activation of the upper section of her rectus abdominus and external obliques. Her pelvic floor technique was now one of ascent (lifting): there was no descent and her endurance had improved.

Bobbie volunteered for some filming of her pregnancy abdominal bracing activation patterns, enabling regular input to refine this pattern, which is often needed with clients as the abdominal wall continues to lengthen. By observing her patterns and feeling the abdominal wall activation in different positions as her pregnancy progressed, these regular checks and ‘tune ups’ helped her to refine her technique.

We were able to film Bobbie activating her abdominal wall using a pregnancy abdominal bracing action at 40 weeks, with a good technique. Her level of gap was maintained at less than 3-fingers-width during her pregnancy.

So, the question to be asked is, how big would her gap have been if she hadn’t had it checked and modified her training at 12 weeks of pregnancy?

It’s never too late – or too early

As the three case studies above show, starting conversations about the changes that pregnancy and birth can bring about in the body is important. Interestingly, some men can also have abdominal separation, which could impact upon their core conditioning training, their back and their pelvic floor.

As Amber’s story illustrates, it’s never too late to look at changing a gap if one is identified in a client. Abdominal separation is something that can be screened for by PTs, so it is advisable to undertake specific training that will teach you to identify the way the abdominal wall is working with the pelvic floor, and how intra-abdominal pressure control is occurring. The occurrence of any bulging or doming during an exercise indicates that there is strain on the linea alba, and the exercise should cease.

If an identified gap measures more than 2 fingers width, the client should be referred to a physiotherapist workingin pelvic health physiotherapy for an assessment and management.

Dianne Edmonds

A physiotherapist based in an obstetric GP clinic, Dianne is a course creator, Women’s Health Ambassador for Australian Fitness Network and the Director of The Pregnancy Centre. She has worked in women’s health and fitness for 25 years and was integral in the development of the Pelvic Floor First resources.

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