Mind the GAP
AMY GREENBURG gets real about abdominal separation.
Having been petite my whole life, and very in- shape pre- baby, I thought my body would bounce back pretty well after having my son. I was shocked when, four months postpartum, my lower tummy bulge wasn’t getting any smaller. Going into full freak-out mode (the hormones didn’t help), I googled and googled until I stumbled on the reason: I had diastasis recti (DR), also known as abdominal separation. ( Diastasis is from the Greek word for “separation”; the Latin recti refers to the rectus abdominus, one of the abdominal muscles located down the front wall of the tummy).
DR, which can develop before, during or after pregnancy, is where the muscle walls along the midline of the abs separate, creating a gap (one to two centimetres is said to be within the normal separation range; anything wider than that may require intervention to close up). This means that when the abs are under pressure, the walls can’t hold together and organs such as the intestine, bladder or uterus may be felt or seen bulging through the thinned and separated abdominal muscles – thus, the protruding belly “pooch” (and, for me, infuriating enquiries on whether or not I was pregnant). Having multiple pregnancies, twins or triplets, or babies with a high birth weight, may be causes for DR separation but, more commonly, DR separation occurs in single baby pregnancies and can happen to anyone. In my case, my small frame just couldn’t deal with the massive baby bump I was carrying around.
Why does DR occur?
In order to accommodate an expanding uterus, the connective tissue, called the linea alba, thins out in response to a mother’s hormonal changes. In many cases, the tissues get so stretched during pregnancy that they lose their elasticity – and therefore the ability to retract back into position (like an overstretched rubber band) post-pregnancy. As a result, a woman’s belly sticks out because the space between the left and right tummy muscles has widened.
For some people, DR can cause lower back pain and incontinence. And, in some instances, such as mine, an umbilical hernia occurs; the intestine or other tissues bulge through the weak spot around the belly button, making the belly button stick out permanently. (Lovely, I know.)
Detection and diagnosis
After finding information about DR online (there’s not as much as you’d think, unfortunately), I frantically booked an appointment to see a physio for help. DANIELLE BARRATT, Women’s Health Physiotherapist at Physio Asia, was able to get a good look at the weak muscles and changes in the connective tissue using Real Time Ultrasound (RTUS), a non-invasive way of viewing the bladder, pelvic floor muscles, core abdominal muscles and connective tissue separations (DR) both at rest and during functional movements. RTUS uses sound waves that bounce off water, tissue and bone to show a real-time picture of the organs and muscles.
“Clients no longer have to rely solely on having a vaginal internal assessment to determine how well their muscles are
functioning,” says Danielle. “With RTUS, pre- and posttreatment measurements and images can be stored, analysed and used as an objective evaluation tool or benchmark for further treatment plans.”
Danielle was confident that I had a three-finger DR separation, a relatively wide gap in DR terms (not only wide but deep, too, from the top of my tummy down to below my belly-button) and, looking at the images, she suspected there may be an actual tear involved, as well – something that could require surgery down the line. However, as only a doctor or sonographer can diagnose a tear, Danielle recommended I seek further investigation in order to get an actual confirmation – the next step in helping me to come up with a suitable plan of action and manage my expectations appropriately.
Personal training
Another next step for me was working on rebuilding core strength and bringing my muscles back together as much as humanly possible. So, I sought out the services of SAM BLAKEY of Ooberfit, who specialises in working with clients with DR. Sam herself has experienced the condition, and regularly works with many of Danielle’s DR patients.
“I was 14 years post-natal when I discovered I had a DR and that was only because I was checking myself while training as a personal trainer! After five pregnancies, it should have come as no surprise – but I had never heard of the condition before my training, so I hadn’t known to check for it. Fortunately, the gap was relatively small at two fingers wide and, with careful exercise, I was able to almost completely close it; so, it really is never too late!” says Sam. “Lots of new mums don’t even know they have a DR and that’s when it can be a real problem. If you don’t know you have it, you can’t protect it, you’ll be resigned to your bulging tummy and risk long-term back issues and other problems.”
As soon as I met with Sam, my mind was put at ease. Acknowledging that my very deep gap may not close completely through exercise (it really depends on the width and depth of the gap, and the health of the connective tissue), she assured me that the exercises would at least help strengthen the muscles and bring them back together as much as possible – and she was right. Though I was completely bummed out to learn that running was out of the question, as my core wasn’t strong enough, I accepted the facts and worked with Sam every week repairing the muscles to keep the gap from getting worse.
The exercises to repair DR are quite specific (and not exactly sweat-inducing), as there are tons of no-no’s involved – regular crunches, planks and push-ups, for instance, put pressure on the abs and can widen the gap further. So, our sessions started with simple core-stabilising movements (sitting on the ball and bringing one leg up at a time, for instance) in addition to arms and thighs, and eventually progressed to modified head-lifts, where Sam felt my stomach the whole time to make sure there wasn’t any tummy bulging. Eventually, we also worked in some very light cardio on the elliptical. By the time I hit six months postpartum, I could see a noticeable difference and it became easier to hide the bulge in my pre-baby clothes. Sure, the gap was still there and bikinis were definitely still out of the question, but I did feel more like myself again.
Now, at around 20 months postpartum, I continue to feel more at ease with my post-baby body. Surgery is definitely in my future, but not until I’m done having kids, as my muscles are likely to separate again during my next pregnancy.
Hypopressives
About a year or so into our sessions, Sam became certified in a special technique called Hypopressives, a series of breathing exercises done in different positions. Developed in the late 70s by Dr Marcel Caufriez, the technique is meant to strengthen the pelvic floor and help tone the abs. Here’s the gist: after fully exhaling all of the air from your body while expanding your ribcage, you hold your breath for four seconds; this breath-holding (called an “apnea” breath) creates a vacuum, which in turn, contracts the abdominal wall and pelvic floor. I’ll admit, I didn’t quite get it right away and I was a bit sceptical. But Sam has a handful of DR clients who have seen immediate results from the method, so I was willing to give it a go, and we added this new technique into the mix each week. It may be a bunch of breathing, but man it’s exhausting! Still, it helps warm up my abs, allowing me to perform better throughout the rest of our sessions.
When surgery is the best option
Before considering surgery, Danielle suggests working with a women’s health physiotherapist as the first treatment approach. However, when women can’t get their abdominal muscles back together, or in the case of a tear, surgical repair may an appropriate option – in fact, it’s widely done with general and plastic surgeons here in Singapore. The surgery is not just for cosmetic purposes (though, admittedly getting rid of the four-month-pregnant look or the umbilical hernia are reason enough for me); since the back and abdominal muscles work together to protect the spine and allow for pain-free and functional movements, a break in this synergistic system can cause lower back pain, as well as pelvic floor muscle dysfunctions such as incontinence, constipation, vaginal pain or pain during intercourse in some instances. Danielle has also noticed, in some cases, that digestive and bowel changes can occur when clients have a wide DR gap or a weak abdominal wall. This has not been clinically proven with research but seems to be a common symptom that clients mention in their initial consults.
“If you decide on surgery, you should always aim to strengthen your abdominal, pelvic floor and other core muscles beforehand, as doing so will help support the sutures and surgery,” says Danielle. “A pre-surgery exercise programme will allow for a regain in overall core muscle strength and function a lot quicker.”