2015 Diastasis Research Update + 16 Lesser-Discussed, KEY Pieces of the Puzzle - Burrell Education

2015 Diastasis Research Update + 16 Lesser-Discussed, KEY Pieces of the Puzzle

Are you working with women experiencing Diastasis Recti?  If yes, I think you'll love this blog......

On February 10th I was immensely honoured to be asked to present alongside my friend and colleague Women's Health Physiotherapist, Maria Elliott, at an evening lecture for nearly 200 physiotherapy/fitness/wellness professions hosted by Physio UK and led by Diane Lee, one of the key thought-leaders, researchers and practitioners in this area of women's health.  The title of the evening lecture was: Rectus Diastasis Rehabilitation - Integrating Post Natal Physiotherapy and Functional Fitness Training........Don't Mind The Gap!

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It was a full house for this presentation simply because this area of Women’s Wellness has become one of those topics for which there are continually shifting lines in the sand mostly because the ‘solution’ for each person is as unique as they are and everyone is quite literally, learning on the job.  Glady, the emphasis is truly moving away from catastrophizing this 'problem' as life-defining for women and professionals feeling that they need to FIX their clients and more towards a restoration of function without or without the re-approximating the bellies of the Rectus,  hence the session title and the subsequent research presented.

The overall take-home from this event and the research that Diane Lee and her colleague Paul Hodges and so many others have been working on most recently is that the issue of DRA is a hugely multi-faceted and complexed one that just isn’t about closing the gap between the two bellies of the rectus muscle and indeed one can actually be pain-free and functional with a considerable inter-recti distance as long as the load of movement and everyday tasks can be transferred well, pressure is managed well and the biotensegrity of the global system is in order.

Full references are below but the key summary points of the evening and more recent research are as follows:

  1. The very nature of growing a baby means that you will develop a Diastasis, the abdominal wall must stretch to accommodate the growth and the inter-recti distance (IRD = distance between the edges of the two bellies of the Rectus Ab muscles) will increase.
  2. The issue is simply not confined to what’s going on at the midline of the abdominal wall, the whole anterior abdominal wall needs to be considered at the least.
  3. 66% of women with DRA have been found to also suffer from some other kind of PF/Prolapse/Continence Dysfunction (2)
  4. Diane Lee and Paul Hodges (4) found that: Activating the deep system TvA prior to a curl up increased the IRD but also, critically improved the tension of midline tissues and that with prior TvA activation omitted before the curl up the ‘distortion index’ of the linea alba increased (demonstrating a lack of tension) and IRD was less than when using the TvA pre-activation strategy. (5)
  5. Inter-Recti Distance (IRD) has ALSO been shown to reduce under isometric contraction of the abdominals in Post Partum women.(3) 
  6. The IRD is not a true indication of or the potential for dysfunction or an inability to transfer load throughout the core or global system.  Many women are pain free and functional with a ‘Diastasis’.
  7. This isn’t just an issue for the Post Natal woman, children and men and nulliparous women can also develop Diastases (1).
  8. Some Diastases require surgical intervention to restore force closure and functionality but for many women conservative non-surgical holistic approach (such as posture, breath and muscle activation re-education) to aid restoration and reintegration really does work when guided by a dedicated professional.  Surgery is also not always a permanent solution.
  9. Overall, the tension of the Linea Alba appears to be more important than the Inter Recti Distance (the distance between the edges of the two bellies of the RA).
  10. Don't give up on these ladies!  Sometimes clients have improved their condition and associated symptoms many years after giving birth when they had all but given up hope.
  11. On a scale of 'things that could go wrong in your life'......this 'problem' needs to be right-sized!  For very few women, this issue will be serious, resulting in loss of painfree movement, continence, bowel motility as well as the aesthetic issues but in reality, for many, huge improvements can be made to restore functionality with a dedicated programme where the practitioner and client both commit to their parts to return to health.  In short, there are lots of success stories when conservative/non-surgical protocols are applied.


Full References:

  1. Beer, G. M., Schuster, A., Seifert, B., Manestar, M., Mihic-Probst, D., & Weber, S. A. (2009). The normal width of the linea alba in nulliparous women. Clinical anatomy (New York, NY), 22(6), 706–711. doi:10.1002/ca.20836
  2. Spitznagle, T. M., Leong, F. C., & van Dillen, L. R. (2007). Prevalence of diastasis recti abdominis in a urogynecological patient population International Urogynecology Journal and Pelvic Floor Dysfunction, 18(3), 321–328. doi:10.1007/s00192-006-0143-5
  3. Pascoal, A. G., Dionisio, S., Cordeiro, F., & Mota, P. (2014). Inter-rectus distance in postpartum women can be reduced by isometric contraction of the abdominal muscles: a preliminary case-control study. Physiotherapy. doi:10.1016/j.physio.2013.11.006
  4. Lee D & Hodges PW, 2015.  Behaviour/Morphology of the Linea Alba 17 Health Men & Nulliparous Women. British Journal of Obstetricians and Gynaecology.
  5. Lee D & Hodges PW, 2014.  Behaviour/Morphology of the Linea Alba 26 Women with DRA. British Journal of Obstetricians and Gynaecology.

So what was my main topic of discussion at the lecture?  Well, alongside my colleague Maria Elliott we were asked to present on the topic of how we help women make the journey from the clinical setting back to the gym, running, sport and basically the more dynamic movement that many women want to get back to post birth.  How do we create in-side out protocols that respect the human healing process that also very much takes into account the challenging life-phase of the modern mom?

How do we really coach this woman back to doing what she loves to do with true consideration of the ‘full circle’ of who she is, her needs and her goals.

I feel so strongly that we have now achieved such high level of clinical/technical understanding about this ‘problem’ that now equal attention needs to be given to the other equally important and KEY factors that influence recovery for those women challenged by DRA.


16 Other Key Diastasis Factors

 (Click Diagram To Enlarge)

  1. Stress and Chronically Elevated Cortisol – Most new moms have elevated cortisol, it’s part of the process but…….how long this state remains and whether things improve is mostly down to sleep and management of the stress of being a new mom.  Elevated cortisol has been shown in numerous studies (5) to retard wound healing.  Stress management and the coaching the client towards removing stressful items from her ‘plate’ could be a very valuable ‘soft skill’ that you bring to your offering.
  2. The Endocrine Status & Emotional State Of The Client – If we are speaking of the Post Natal woman, we can’t really ignore the fact that throughout Pregnancy and then in order to birth, this woman has gone through an Endocrine Tsunami – levels of both Oestrogen and Progesterone both plummet in order to facilitate birth with breastfeeding post birth keeping Oestrogen low and Progesterone.  The resolution of these imbalances aren’t entire for many women and for instance, comparatively low Progesterone could lead to poor sleep patterns, anxiety, increase weight gain and low libido.  Many studies have also shown the prevalence of depression in women suffering with incontinence issues (8).
  3. Inflammatory Lifestyle/Habits – Systemic inflammation is a pre-cursor to so many chronic / /metabolic diseases, the plight of the modern human is not helped by the ubiquitous presence of Trans-fats, Xeno-Oestrogens, Smoking, Caffeine, Alcohol, Sugar and food carcinogens.  Many sleep deprived moms end up hooked on caffeine, starchy carbs and sugar just to get through their day.  It won’t be an easy job but having a plan to help your client move towards foods that will assist rather than retard her healing is an essential part of the job.
  4. The Co-Factors of Other Pelvic Health/Continence Issues – A study by Spitznagle et al in 2007 found that 66% of women experiencing RDA also reported other Pelvic Health dysfunctions. (9) (in Pelvic Health Reference List)
  5. Medications – NSAIDs, Corticosteriods and Anti-Biotics – Both NSAIDs and Corticosteroids negatively impact the necessary early inflammation phase with the ‘4 phases of wound healing’. Anti-biotics, which are routinely administered as part of the C-Section procedure will affect the gut microbiome of the new mom potentially affecting at the very least gut microflora and motility….at the worse…..mental wellbeing (12)
  6. Gut + Bowel Health – defecation is one of the key detoxification pathways, a poor pooping habit at best will increase pressure within the pelvis and against the abdominal wall and at worse re-toxify the system….checking that our clients poop well and often is a biggie that’s often missed.  I love the book ‘Why Isn’t My Brain Working?’ (9) by Dr. Datis Kharrazian.
  7. Hydration – Collagen, the building block of all connective tissue including fascia is more than 70% water.  Optimal levels of hydration are required for reconstruction.  Are we giving clear and direct advice on how much is enough?
  8. Sufficient Macro + Micro Nutrients – at the very least, in order to heal tissue trauma, an adequate supply of essential and non-essential amino acids (the building blocks of collagen) need to be available, Vitamin C is also an essential vitamin and Zinc a hugely important mineral.  But quite literally, the FULL spectrum of vitamins, minerals, fatty acids and macro nutrients needs to be consumed along with adequate water to create an optimal foundation for the 4 phases of wound healing.  The Post Natal period is no time to be restricting calories and entering severe detox programmes.  Drinking some bone broth is an excellent start but it’s just that….a start….most women will need deep education made simple for them and coached though change of habits that they may have had for decades in order to solve their Diastasis puzzle.  If this subject is of interest of you, you might want to take a look at this Optimal Nutrition for Post Natal Recovery and Healing ON-LINE Education.
  9. Post Natal Soft Tissue Imbalances, trauma, adhesions and scar tissue – The entire Pregnancy to Post Natal musculoskeletal system of the Post Natal woman has been thrown out by growing and birthing a baby.  On the global level, soft tissue changes at the feet, ankles, pelvis, thorax and neck.  At the very least we’re considering Upper and Lower Crossed Syndrome…..when we start to dig deeper we’ll most likely see dysfunction throughout all the entire Kinetic Chain and all of the Myofascial Meridians (according to Thomas Myers) and the potential for scar tissue/adhesions at the sight of the C-Section scar or vaginal/Pelvic Floor trauma to cause restrictions to full function not only in the early Post Natal period but sometimes many decades later.  Link to Blog
  10. Poor ‘Force/Form Closure’  –  In order to birth a baby the entire pelvis (including Sacrum, SIJs, Symphysis pubis all need to ‘allow’ the passage of the baby through the Pelvic Floor and vagina. For many the end stages of pregnancy bring about changes to the Diaphragm, the position of the ribs, the lumbar and thoracic musculature, other soft tissue and spine. These changes have the potential to negatively affect form or force closure which when optimised, enhances the stability and load bearing ability of a joint complex.  Reduced form or force closure reduces stability and ‘de-stabilises’ the load bearing ability, allowing for increased movement potential which can lead to pain/discomfort/ and the instability that leads to dysfunction (10 &11). Diane Lee has written/researched extensively about this and there are some great reference links below.
  11. Breathing Strategy & It’s Relation to ‘The Core’, back pain and continence (6) –  On a more intrinsic level, I think we’ve all nailed this one too now….there is a synergistic and intrinsic connection between respiration, the abdominal wall, the deep system, the lumbar and thoracic muscles and fascia and the Pelvic Floor…..all team members need to be in top form for the system to function as a whole….if you only have a 4 man team and even 1 man goes down, you’ve got a problem and for many women, correction of the breathing strategy can be transformational.
  12. Non- Optimal Postural Alignment – I think we’ve all got this one now…..but in summary, the postural and alignment changes of the Pre/Post Natal period WILL affect respiration, Pelvic Floor function, the potential for developing prolapse, how comfortable a woman ‘feels’ in her virtually new body…..you can’t shoot a cannon from the canoe.  A return to strength is an inside out job that starts with the re-education of breathing patterns and re-instatement of Intrinsic Core Synergy alongside a deep protocol to reinstate optimal biotensegrity/optimal and pain-free movement throughout the whole system.
  13. Rest – Poor sleep hygiene will scupper recovery as sleeplessness and a disruption of one’s circadian rhythm will potentially result in chronically elevated Cortisol over time.  Helping your clients to find space to rest is a valuable coaching skill when working with the new mom…..who can help to make space for her to find child-free time to rest?  Women sometimes need to be supported in asking for and receiving help as many view this as selfishness or unnecessary. (1)
  14. Home Help + Support – Momming is a tough job.  End of!  And mom’s need help.  There is no way that a woman can stay sane and tend to the 24 hour needs/demands of a new baby without structured support and time-out. In a mom’s workday,  there are a zillion repetitive tasks that can be either out-sourced and dealt with in bulk.  Disclaimer:  I have just adopted a one year old little boy and delightful as he is, there is no way that I feel I have anything to prove by ‘managing’ his needs all by myself when there are others who can help. Momming = Job 1, Household Management = Job 2, running my businesses = Job 3, looking after my personal, spiritual and physical welfare and not becoming a wife from hell = Job 4…….starting to get my drift?  Moms need help and through developing a coaching relationship with your client and having this conversation this as part of her ‘new mom programme’ you are in the perfect position to influence this woman positively into not simply surviving but thriving in her daily role.
  15. Clear Direction/Communication Between Practitioner and Client– We need to create a clear plan forward for the client with her agreement on our role as the practitioner……we need to remember to check what is her definition of success and whether our skillset is in alignment with what’s being asked for.  This needs to be ascertained through deep pre-screening way before we set sail on our healing endeavours.  This clear direction also needs to include non-ambiguous, time-efficient homework away from sessions to which the client is held accountable.
  16. Practitioner Coaching Skills – This part of the equation requires the purveyor of the solution to COACH….coaching is a completely different skill-set from teaching or instructing….when you coach the client, your standpoint is that the client partners with your guidance/prescription to achieve her stated goals.  It is made clear that she most definitely has a direct role to play in her own success and that your job isn’t to FIX her and especially in the case of improving wellness and function when it comes to human…..expectations need to managed well and a reality check truly needs to be in place as to what is achieveable with your help.

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Burrell Education is committed to GOING DEEPER, providing you with evidence-based education that makes sense of all the high science and transports you from deeper initial understanding to creating solution based offerings for your clients that makes them into your raving fans!  Our education includes the MOST uptodate reasoning and client-facing strategies for Diastasis Healing, C-Section Recovery, Functional Training For Motherhood, Integrated Movement-Based Pelvic Floor Exercise, Restorative Modalities, Massage and Remedial Therapy plus education for those of you serving Peri to Post Menopausal Women and sooooo much more.  Come and learn with us – check out all the LIVE in LONDON and GLOBAL ON-LINE OFFERINGS above.

Wow, so that was a big blog, my server went down for a few days so I was actually able to sit and do justice to this topic with a massive brain dump.  I hope it was helpful to you and would LOVE to hear your feedback below and hear how you’ve been working to complete the circle of care for your Post Natal clients.

 References/Further Information

  1. Sleep and cortisol: http://occmed.oxfordjournals.org/content/53/2/143.short
  2. Water & Collagen: http://www.sciencedirect.com/science/article/pii/S0969212601002246
  3. Post Natal Depression and Omega Fatty Acids: http://www.sciencedirect.com/science/article/pii/S0969212601002246
  4. Gut/Brain Connection: http://www.ncbi.nlm.nih.gov/pubmed/25448230
  5. Stress and the Wound Healing Mechanism: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052954/
  6. Breathing, Back Pain, Obesity and Continence study: http://www.sciencedirect.com/science/article/pii/S0004951406700575
  7. 7.       Felde G, Bjelland I, Hunskaar S. Anxiety and depression associated with incontinence in middle-aged women: a large Norwegian cross-sectional study.  Int Urogynecol J 2012; 23 (3): 299-306. http://www.canadiancontinence.ca/EN/research-studies/anxiety-depression-both-associated-with-urinary-incontinence-in-norwegian-women.php
  8. Spitznagle, T. M., Leong, F. C., & van Dillen, L. R. (2007). Prevalence of diastasis recti abdominis in a urogynecological patient population International Urogynecology Journal and Pelvic Floor Dysfunction, 18(3), 321–328. doi:10.1007/s00192-006-0143-5
  9. Why Isn’t My Brain Working  by  Dr. Datis Kharrazian
  10. Diane Lee Articles – Pelvic Stability and Your Core
  11. Lee D 2001 (An integrated model of joint function and its clinical application. 2001 in: Proceedings form the 4th interdisciplinary world congress on low back and pelvic pain. Nov 8-10 Montreal Canada 137-152)
  12. Anti-Biotics and the Gut Microflora – Chris Kessler Blog


You might also be interested in this interview I did with Diane late last year where we covered Pelvic Pain and Diastasis......


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