 Last week, we went LIVE on Instagram to clear up many of the misconceptions regarding diastasis recti and “the gap”. Diastasis rectus abdominis, or DRA, refers to the thinning and widening of the connective tissue, or linea alba, between the left and right sides of the abdominals. It is a natural adaptation that occurs during pregnancy and will persist in 33% of women one year postpartum.
Traditionally, there has been a lot of fear surrounding diastasis and particularly the phenomenon of “coning” in which the person exercising visually observes a tenting and distortion along the midline during core-focused exercises. Much of the general information online recommends blanket lists of exercises to avoid including planks, sit-ups, crunches, and heavy lifting. In the past, diastasis rehab has been very focused on strengthening the abdominals and particularly targeting the deepest abdominal layer called the transverse abdominis, or TrA, in order to create tension through the midline. But in more recent years, there has been a shift in thinking regarding addressing DRA. There should be no blanket list of exercises to avoid when a person has diastasis. Strengthening should be progressive and include appropriate increase in challenge and load in order to actually start to change the connective tissue and balance of the abdominal muscles. Observing coning during exercise is not inherently “bad”, “harmful”, or “damaging” and avoidance of exercise due to fear of coning likely has far greater devastating effects. Improving the appearance of the abdominals and addressing a diastasis should include much more than core strengthening. A comprehensive rehab program should address any areas of mobility restriction that may also be holding back the abdominal muscles’ ability to work cohesively, and this may include looking at areas such as the spine, ribcage, posture, scar tissue, breathing, diaphragm, pelvic floor, lats, and psoas to name a few. And of course, a complete picture would also need to include impact on mental health and self-confidence, function, and specific goals beyond “closing the gap”. It may need to include addressing constipation, bloating, nutrition, hydration, and sleep as these lifestyle factors can additionally contribute to the appearance and function of the abdominal area. And despite what the plethora of quick fix programs out there would have you believe, the healing rate of connective tissue (the linea alba) is extremely slow and can take 1-2 years and beyond to fully change. Genetics also plays a role in the ability of the connective tissue to return to its prior elasticity and tension. So unfortunately, appearance goals are not something that any program should be guaranteeing, because in reality, each person will be different and we won’t know what will ultimately happen until we try. Help us spread the truth about diastasis! If you enjoyed this content, please feel free to share with a friend or family member who you think would benefit.
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 Did you know that you can use different breathing techniques to help your body relax, decrease stress/anxiety, engage your core better during exercise, relieve pressure on the pelvic floor and back, and help to manage pain during contractions in labor? Your breathing muscle is called your diaphragm and it is located in a cross-section underneath your rib cage and between your chest and abdominal cavities.
The first breathing technique we will practice is called a 360 diaphragmatic breath. This is where we learn how to breathe using your diaphragm and not the muscles in your chest, neck and shoulders!
The second breathing technique is called the destressor breath. This type of breath is great to use if you are feeling stressed or anxious and can also be a way to manage pain during early and active labor contractions.
Our final breathing technique is called the connection breath. This type of breath will help turn on your deepest core muscles for good support when you are exercising.
A final note is that when performing strengthening exercises (even gentle body weight strengthening), do not hold your breath. This is a compensation (cheat!) that puts extra pressure on your back, pelvic floor, or abs and overtime or with increased loads, can result in pain or injury. As a general rule of thumb, it is best to “breathe out during the work phase” of an exercise. The work phase is the harder part of the movement. For example: during a bicep curl, breathe out as you lift the weight up and breathe in as you lower the weight. During a squat, breathe in as you lower down and breathe out as you stand up. If you would like more guidance on how to incorporate these breathing techniques to help manage pain/anxiety, to prepare for labor, or to optimize your workout, reach out by clicking the Book Now button above!  Even if you haven’t heard of the term “diastasis recti” or “DR”, chances are you have probably heard of the “Mommy Tummy”. Diastasis can be one underlying cause resulting in the appearance of a “Mommy Tummy”. So what exactly is diastasis recti and how can you tell if you have one?
This condition is a midline separation between the left and right halves of one of the abdominal muscle layers called the rectus abdominis. This layer of muscles is what we traditionally refer to as our “6-pack abs” (yes, they’re in there!) and they naturally separate during pregnancy along the connective tissue called the linea alba to accommodate for the baby as she/he grows inside your abdomen. This is completely normal during pregnancy, and in fact, 100% of women will have this type of abdominal separation by the end of their pregnancy and immediately postpartum. For many women, the diastasis will heal slowly postpartum as the two halves of the abdominal wall return closer together. But without specific exercise, 45% of women will still have a midline abdominal separation at 6 months postpartum and one third of women will still have a diastasis at 1 year postpartum! ¹ The separation itself isn’t necessarily cause for concern, but can result in feeling of weakness with activities such as picking up your kids, reaching out to lift something, getting on and off the floor, or sitting up from bed. It can also result in a feeling of abdominal organs wanting to “fall out” when exercising on hands and knees or belly-down positions. You may notice a pronounced “coning” or “doming” shape to your abdomen when sitting up or leaning back. Because the abdominal muscles work together with the pelvic floor, diaphragm (breathing muscle), and deep back muscles as part of our core, a weakness in the abdominals can create more strain on the back or pelvic floor resulting in issues such as chronic low back pain, sciatica, urinary leakage and even painful intercourse. So what’s a woman to do? Well, the good news is that through specific exercises targeted at the deep abdominal layers and breathing/pelvic floor connection, you can close the gap, create better tension along the linea alba and create better support through the core. A pelvic floor physical therapist can assess the extent of your diastasis and how you are able to transfer load through the core. She can also assess the muscles of the low back and pelvic floor to see how they are working with the abdominals and breathing muscle as part of your core team. A pelvic floor PT can instruct you in specific exercises to help rebalance the core system, relieve pain, and tone through the abdominals. She can instruct you in exercises to avoid as you are healing and provide hands-on treatment to help release any “stuck” areas of tension. Sometimes, therapeutic taping techniques can be used to provide additional support for the short-term as you learn how to turn on the deep abdominal muscles again postpartum. What about sit-ups, crunches, push-ups and planks? There are a lot of blogs out there with lists of exercises to avoid or never perform again if you have a diastasis. In reality, there are no hard and fast rules that can be applied to everyone with abdominal separation. Even exercises like sit-ups and crunches can potentially be performed with a diastasis if you have learned the specific techniques to manage the pressure going forward into the abdominals. Every exercise needs to be evaluated on an individual basis, and your pelvic floor PT can help you create a list of “safe to perform” vs “avoid for now” and help you modify an exercise to adapt it to your current strength level as you progress. In summary, no matter how long it’s been since you’ve been pregnant, working with a pelvic floor physical therapist can help you to create positive changes in your body including strengthening, toning, and pain relief! If you would like to get started on healing today, click on the book now button above to request an appointment. 1. Sperstad JB, et al. Br J Sports Med 2016;50:1092–1096. doi:10.1136/bjsports-2016-096065. https://bjsm.bmj.com/content/bjsports/50/17/1092.full.pdf Image: https://brbyoga.com/new-mom-worried-diastasis-recti/  The short answer: yes! If you are like me and like to know the research behind the answer, keep reading below.
If you or a close woman in your life is struggling with a feeling of pelvic heaviness, pressure, or a bulge/lump in the vagina, we would love to help you feel more like yourself! As you read above, there is a very good chance that your symptoms will improve with skilled instruction and training with a pelvic floor physical therapist. Click on the Book Now button above to fill out an appointment request, and we will be in touch shortly!  I'm about to say something controversial: You don't necessarily need to give up running if you have a prolapse or symptoms of pelvic heaviness. Depending on the extent of the prolapse and your ability to manage intra abdominal pressure and the forces on the pelvic organs, many women are able to continue high impact activities such as running without worsening pelvic heaviness. Here are some of the basics that I often assess first with my clients who have a symptomatic prolapse who wish to continue running:
 Did you know that 86% of women have pain with first vaginal sex after childbirth and nearly 1 in 4 still report pain at 18 months postpartum¹? Although it's quite common, sex shouldn’t have to hurt after childbirth! Here are some reasons why it might and what to do about it:
Whatever you do, don’t suffer in silence! As you can see, there are many reasons why sex may not feel the same as pre-baby so it is definitely worth reaching out to a trained professional like a pelvic floor PT. We perform a thorough evaluation to determine which reason(s) are wreaking havoc in the sheets and will provide you with a customized action plan to take back the bedroom. ¹McDonald EA, Gartland D, Small R, Brown SJ. Dyspareunia and childbirth: a prospective cohort study. BJOG 2015: http://dx.doi.org/10.1111/1471-0528.13263  There are many simple lifestyle changes you can make that will help protect your pelvic floor and keep your bladder happy and bowel running smoothly. The recommendations below were made by the Continence Foundation of Australia and the original article can be found at the reference listed below.
Drink Plenty of Fluids
Eat a Healthy Diet
Maintain a Healthy Weight
Quit Smoking
Practice Good Toileting Habits
Stay Active
If you develop urinary leakage when you cough, sneeze, or exercise, know that incontinence does NOT have to become your “new normal” or “just part of being a woman”. Connect up with a pelvic floor PT to learn exercises to help the pelvic floor- especially if these muscles been weakened by obesity, pregnancy, childbirth, heavy lifting or a chronic cough. Seek out a pelvic floor physical therapist to discover how pelvic floor PT can help get rid of leaks for good. Want to work with us? Fill out an appointment request form here. References:
 What is the best exercise for the core? As a pelvic floor physical therapist, this is a question that I get asked quite frequently by my clients; especially with the rise of the buzzword “core” in the health and fitness community over the past decade. But before we can dive into the exercises for the core, we must first have a more complete understanding of what exactly makes up the core.
When we hear the word “core”, most of us picture the washboard abs called our rectus abdominis and probably think of sit ups, crunches or maybe planks. But in reality, the core lies a little deeper than the muscles that make up your six-pack. We all have four layers of abdominal muscles, and the deepest layer is called the transverse abdominis (TrA). Your transverse abdominis wraps around your abdomen and acts like a built-in back brace to stabilize your trunk prior to leg and arm movements and to create tension in order to transfer load or force. But the core is actually made up of three more muscle groups in addition to the TrA! Let’s think of the core as a 3D cylinder instead of a 2D rectangle. We have discussed the muscle on the front of the cylinder but what about the back, top and bottom of the cylinder? The muscles that help to stabilize the back of the cylinder are called your multifidi. These are short muscles at each segment deep in your low back on either side of the vertebrae. The base of the cylinder is made up of your pelvic floor muscles that fill in the bottom of your pelvic bowl. These muscles act as a sling to support all of your pelvic and abdominal organs. The top of the cylinder is made up of your diaphragm, which is why you may notice that you find yourself holding your breath during strenuous lifting or a challenging abdominal workout if the rest of the core players are not optimally doing their job to help provide stability. Breath-holding isn’t good for your core because it increases your intra-abdominal pressure which can place extra strain on your back, abs, and pelvic floor and put those structures at risk of injury. In order to optimally improve your core, you need to be sure that you are addressing the deepest layer of muscles on all 4 aspects of the cylinder that we discussed above. The order and timing that the muscles fire is also extremely important for optimal stabilizing function. Typically, these muscles are “on” at a low-level to some extent all the time and we aren’t even consciously aware of their timing and firing. However, studies have demonstrated that in people with low back pain and during pregnancy and postpartum, the timing and firing of these muscles becomes disrupted and sometimes reversed or non-existent! A great core exercise is one that takes into consideration how the breath (diaphragm), pelvic floor, abdominal muscles and back muscles all work together with the correct coordination and timing. There are many different ways to accomplish this, from breathing while supported on your back to incorporating into household tasks or Olympic lifting. In pelvic floor PT, we assess how your core is functioning in its parts and as a unit, and we teach you how to engage your core with the correct coordination and timing during tasks that may be difficult or painful. So the answer to “what is the best exercise for my core” is really that there is no one-size-fits-all exercise that will be perfect for everyone but we want to start thinking beyond just isolating the abs.  Throughout my experience as a pelvic floor physical therapist I have heard many misconceptions from clients regarding pelvic PT. In this blog, I would like to provide more information to help clear up some of the most common myths out there about pelvic floor PT.
Myth #1: Pelvic floor PT is the same as “doing your Kegels”. This is a myth that is quite widespread and I hear it from both providers and clients alike! Although knowledge of pelvic floor PT as an option for addressing women’s pelvic floor issues is severely lacking in the general public, most women I work with have heard of Kegels. Many of my clients regretfully inform me that they wish they had listened to their medical provider and “done their Kegels” after childbirth to help their pelvic floor recover. Even more women tell me at their first visit that they have started “doing their Kegels” but a) aren’t sure if they’re doing them correctly, and b) do them halfheartedly when they think of it because they weren’t informed of how many to do or how often to do them. A quality pelvic floor physical therapist will address SO MUCH MORE than Kegels. We perform a completely different type of internal exam than you may be used to at the gynecologist. We are spending time thoroughly evaluating the tone, strength, endurance, speed and coordination of multiple layers of pelvic floor muscles and empower you with information about your body. We perform a holistic assessment including the relationship between your pelvic floor muscles and the bigger picture of your movement strategies/patterns, your posture, your alignment, and how it is all influenced by the context of your life as a person. And yes, we will also let you know if you’re doing a Kegel correctly and if you should be doing them at all. And if they happen to be part of your exercise program, you bet we’ll prescribe reps, sets, frequency and hold times. Myth #2: You have to have delivered a baby to require pelvic floor PT. (Sub-myth: delivery via C-section doesn’t require pelvic floor PT). Many women assume that if they haven’t delivered via the vaginal canal that they are probably exempt from pelvic floor issues. Or women who have never undergone childbirth may feel alone, isolated, and unheard if they are experiencing issues such as dyspareunia (pain during intercourse), urinary leakage (incontinence), or urinary frequency/urgency. The truth is that pelvic floor conditions can impact you regardless of your childbearing history! Past experiences, hormone imbalances, life stressors, or pelvic trauma (even old abdominal or pelvic surgeries) can influence the state of the pelvic floor. And women that have delivered a baby via Cesarean section still had to carry that baby throughout about 9 months of pregnancy! And you bet the pelvic floor had to adapt to accommodate those changes. Not to mention the impact that changes in posture, ligament laxity, and breathing mechanics during pregnancy have on the pelvic floor as well. Check out our blog “What Does a Pelvic PT Actually Do?” for signs that indicate you would benefit from seeing a pelvic floor PT. Myth #3: It’s too late for me to get help, I’ve let things go on for too long. This is my favorite myth to bust! Women quite frequently express this tender fear to me at their first appointment, that perhaps they are a lost cause. This couldn’t be further from the truth! No matter what your age or how long you’ve been sucking it up and struggling silently with your symptoms, there is hope. You can always gain power in knowledge about your body, build novel body awareness, commit to some lifestyle changes or form a new habit, start up a new exercise routine, build muscle strength, learn stress reduction and breathing techniques or finally be connected to the right provider to help manage your condition. No matter how bad you think things are or how alone you feel, know that there are actually many other women out there dealing with a very similar issue! You are not alone, it’s never too late-- please reach out!  If you are reading this and weren’t even aware that physical therapy exists for the pelvic floor you are not alone! As a pelvic floor physical therapist, my job is to help bridge the gap between being told to do nothing for the first six weeks after your delivery and then suddenly being cleared for return to all activities but having no clue where to start and feeling lost in your postpartum body.
In a perfect world, it is my (clearly biased) opinion that every woman should have access to an evaluation by a pelvic floor physical therapist sometime around 6-8 weeks postpartum at least to check the state of the pelvic floor after both C-section and vaginal deliveries as well as provide tips regarding nursing positioning, proper lifting and carrying mechanics, and a stepwise exercise progression for return to activity safely. There are however some signs that you should definitely see a pelvic floor physical therapist for more individualized help. 1. You are having accidental urinary or fecal incontinence (leakage) that continues to occur beyond six weeks after delivery. This could be happening during a cough, laugh, or sneeze or during activities such as walking, stairs, bending over, running, or jumping. It could also occur due to a strong overwhelming urge that is difficult to control or without you realizing that leakage is happening. Even if the amount of leakage is just a couple drops, it is still beneficial to address it sooner rather than later, as it is a sign of a larger weakness in the core muscle system. Leakage doesn’t have to be something to laugh off or that is “just part of being a mom”; it is something that can typically be completely resolved. 2. You have a feeling of increased pelvic heaviness/pressure or the sensation of pelvic organs falling down. This is a sensation related to pelvic organ prolapse, which occurs when the bladder, urethra, vaginal wall, uterus, small bowel or rectum is collapsing downward. You can have a greater risk of developing a prolapse after childbirth just due to the amount of pushing and pressure down on your pelvic floor during delivery, as well as some of the hormonal changes that contribute to increased ligament laxity during pregnancy to allow for birth. The good news is that you can learn strategies to help protect your pelvic floor as it is healing in order to avoid continued excess pressure on the pelvic organs. A pelvic floor physical therapist can also teach you how to strengthen the muscles in the pelvic floor and in the core in order to help better support the pelvic organs as well. 3. You are having pain or discomfort when returning to sexual intercourse with your partner. Sometimes this discomfort can be due to scar tissue from perineal tearing or an episiotomy or even C-section incision. Sometimes the discomfort can be due to extra tension in the muscles of the pelvic floor- remember these muscles had to work extra hard all throughout your pregnancy to help hold the baby up- so sometimes they need to be retrained how to relax again. Whatever the cause of the pain, your pelvic floor PT can help figure out the reason behind why the pain is occurring and develop a plan to be able to be intimate with your partner without pain. Of course, there are other issues postpartum such as diastasis recti (abdominal muscle separation or “mommy tummy”), symphysis pubis dysfunction (SPD), and coccyx (tailbone) pain including other joint pains that can develop due to the repetitive activities you are now performing on an hourly basis as a new mom (think feeding, lifting, carrying) as your body is still healing. A pelvic floor physical therapist can help you address any and all of these potential issues that arise throughout the fourth trimester and the postpartum period. Luckily, even if your medical provider doesn’t refer you to a pelvic floor PT, you can seek out a pelvic floor PT on your own in New York State without a referral. To get started with a free consultation or to book an initial evaluation, contact jberube@livewellcnypt.com. Dr. Julie Berube is a pelvic floor physical therapist who is on a mission to revolutionize the standard of healthcare for women in Central New York. She is the owner and founder at LiveWell CNY Physical Therapy, LLC in Syracuse, NY. |
AuthorDr. Julie Berube is a pelvic floor physical therapist who is on a mission to revolutionize the standard of healthcare for women in Central New York and the Syracuse area. Archives
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