Abdominal Separation and Weakness: Pelvic Physical Therapy Can Help

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By Dr. Lisa Ricker, DPT

This intimidating name refers to a condition where the large abdominal muscles down the front of the belly separate. Diastasis Rectus Abdominis or DRA is often see after childbirth, and is frequently described as a dome-like bulge in the middle of the belly.   It can be a frustrating condition since no matter how many crunches or abdominal exercises are done, DRA and the bulge can remain.  It can also contribute to other conditions of the pelvis, back and hips.

To understand what happens with DRA, it helps to understand a little bit of anatomy.  We have four layers of abdominal muscles:  Transverse Abdominis, Internal Obliques, External Obliques and Rectus Abdominis.  Rectus Abdominis are the two large abdominal muscles that are closest to the surface and meet in the center of the abdomen: the “6 pack” muscles.  The two sides of the muscle meet at the midline of the belly at the linea alba, which makes a line from the bottom of the breast bone all the way down the abdomen. This line is actually a piece of connective tissue that stretches and separates from the Rectus Abdominis in DRA.  DRA is common after childbirth but it can also occur from any situation that results in excessive stretch to abdominal muscles, such as obesity or hernias, and is not limited to women. Yes men it can happen to you!  Nevertheless, studies have shown that 100% of women who are 35 weeks pregnant have some DRA, with over 39% having some separation remaining after 6 month postpartum, so it is extremely common in this group.  The separation can be at any point along the linea alba, but it is most likely either at or above the belly button.

Most often DRA is first noticed as a belly bulge after childbirth.  Women often state, “I still look pregnant” even though it may be months, or even years, since their baby was born.   In other cases a DRA bulge may only be noticed when the abdominal muscles are tense like when coughing, when going from lying down to sitting up, or when doing exercises, especially abdominal exercise.   When lying down, DRA can look like a valley along the middle of the belly.  In extreme cases, which are not common, the separation is large enough to allow a hernia to occur, where the internal organs push against the skin.   

DRA can have more than an aesthetic impact, however.  The abdominal muscles are important for stability and movement.  They work together with the pelvis and lower back to help movement and to transfer weight through the pelvic area, they form a wall that holds intestines and other organs in place, and they lend support to the pelvic floor.  With DRA, there can be an interruption of this support, or interference with movement. Many women with DRA indicate that they don’t feel as if they have any core strength, or have back instability, especially when they pick things up.  Separated abs can cause changes in posture, decreased stability, and pelvic floor problems, which can lead to urine leakage, constipation, pain with sex and low back pain.    

Many of these symptoms are also common right after childbirth, so it can be difficult to identify DRA initially.   Furthermore, within the first eight weeks postpartum significant decreases in any separation are often noted, with closure in some cases.  Therefore most women do not investigate treatment for DRA until a few months after birth, if at all.  Many aren’t aware that a pelvic health physical therapist can address DRA.

 

Research has shown that physical therapy is the chosen conservative therapy for treatment of DRA.  In rare conditions, notably hernia, surgery is recommended.  With DRA there are a number of items that a therapist can address.  The physical therapist will assess not only the DRA, but movement patterns, strength, range of motion, joints, and any other pertinent conditions.  The therapist will design a program to address any issues.  With respect to the DRA, in order for the connective tissue in the abdomen to become stronger, to heal, it requires specific tension and activity.  A physical therapist will design activities ensuring that the loading is appropriate.  In some cases the separation will not close, however the distortion and doming will be eliminated.  If DRA, prevents tension being maintained through the abdomen, there can also be use or overuse of other muscles in order to provide the necessary stability.  Back, pelvic, hip, other abdominal muscles can be overworked and fatigue or cause pain.  

 

A physical therapist can identify the muscles being used and modify the order in which the muscles are used, change the muscles being used, or strengthen the weak muscles so they are used more effectively. There is a focus on developing and using the deep, core muscles in many DRA therapies.   Additionally the therapist can address other impacts of pregnancy, where appropriate.  With the increase of weight and changes in body shape during pregnancy, many women change their posture to accommodate their growing baby.  This change in posture requires muscles to work differently in order to stay balanced:  some muscles have to work harder and can become shortened and very tight, and the opposite muscles may work less and become weakened and loose.  With the increase in hormones during pregnancy ligaments can become lax, especially in the pelvis.  This is important in order to allow childbirth, but it can also lead to a decrease in stability, and sometimes increase in pain.  A pelvic health physical therapist specializes in treatments for these conditions as well.

No matter how long it has been since you’ve noticed possible DRA, it’s never too late to be evaluated. Call our office today at 732-508-9926 and allow us to help you!

 

Tamra Wroblesky