Carrie Koziol is a Women’s Health Physical Therapist, Pilates Specialist, DRA Trainer, and Puberty/Perimenopause Coach passionate about educating vagina owners about their body whether they are in puberty or perimenopause. In this episode, Carrie speaks about diastasis rectus abdominis (DRA), which is a separation of the left and right side of the abdominal muscles impacting pregnant women, older women, babies, and men.
In this episode, Carrie covers:
Causes of DRA and other conditions that may come with it
How to prevent and treat DRA including precautions about surgery & the types of kegels you do
How a women's health PT can help (and when it is time for surgery)
What you can do if you can't afford a women's health PT
Georgie Kovacs: What is diastasis rectus abdominis?
Carrie Koziol: Diastasis rectus abdominis, or DRA, refers to an abnormal separation between the left and right rectus abdominis, or six pack muscles. And I say abnormal and emphasize that because some women are under the impression that those muscles are fused together. They'll say, “I really want to close my gap.” You never fully close a gap. There's always a tiny space, about a half centimeter, between the two six pack muscles.
The research is very divided as to when it becomes abnormal, and numbers hovering around one and a half centimeters to two and a half centimeters. Generally, the general consensus is about two centimeters and above is considered an abnormal separation.
But less and less are we talking about the gap. And more and more, we're actually talking about the tension in the connective tissue between those two, six pack muscles. And I know that gets a little hairy when we're thinking about all those different terms. But it's important to know what causes it, which is any excessive, repetitive forward pressure on the connective tissue. Women, kids, and men get this. We're going to talk primarily about women but somebody that has, for example, a chronic cough, and that constant pressure on the connective tissue can create a separation. We see this in kids in third world countries with those poor big bloated bellies where the pressure of their abdomen is pushing out into the connective tissue.
But when we're talking about a population that's really vulnerable, this is where we're talking about pregnant women because they have the hormones progesterone and relaxin that serve to soften the connective tissue all over the body during pregnancy, not just in the pelvis. So they're hormonally at a little bit of a disadvantage, because those tissues are a little bit weak. And then we talk about the excessive repetitive forward pressure of a growing baby and a growing uterus that creates some pressure and strain there. And then I'm going to add on to that body mechanics, because sometimes we do things movement wise that put too much pressure on the connective tissue, or we choose exercises that we think are really healthy for us, but strain an area that is already vulnerable.
So right off the bat, a couple of moves in pregnancy that I really asked women to try to avoid are:
Head lifting exercises
Twisting, especially a weighted twist.
If you have something in your hands and you're doing a weighted twist that can put this area in a really vulnerable state. Being in the all fours position is fantastic because it awaits the baby from the spine, but you don't want to be there for a really long period of time.
Georgie Kovacs: How do you know if you have diastasis rectus abdominis?
Carrie Koziol: Most women don't even know they have it. So here's some things to look for, and this is both in pregnancy and then after you have a baby and well beyond after you have a baby. Some women will notice when they go from lying down to sitting up, they see almost like a doming in their midsection, like something's kind of poking out between those six pack muscles. Or maybe if they do a backbend. So they're standing and they just kind of extend back a little, they'll see that same doming.
Some women say, I have my baby and the baby's just kind of bouncing on my belly, and it feels like they're like bouncing on an organ. And if that connective tissue has thinned to such an extent, it will feel like they're bouncing on an organ.
Or women will say, I'm trying to fix my belly. I don't like the way my belly looks. But when I go to the gym, and I do all the traditional ab exercises, it actually ends up looking worse when I'm done. That's another cue or a clue that perhaps this might be going on.
And then just general weakness. We're going to say just, I feel like Gumby. I feel like I can't sit up straight. I feel like I'm disconnected. I just don't feel like my core is strong, something is wrong. And all of these are indications that this could possibly be going on.
Georgie Kovacs: Women need to be aware that this could be happening sooner rather than later to be able to properly heal. Can it ever be too late to heal it?
Carrie Koziol: I don't really think it is ever too late to heal a diastasis. I see women in their 70s and 80s that have this and do fantastic with a rehab program. Where it does become a little bit more urgent is right after you have a baby. Research shows you have this six to eight-week window to maximize your healing. But that doesn't mean if you don't discover this until you know 12 weeks postpartum, or 12 years postpartum, that there's not anything you can do. There's still quite a bit you can do. I just like when women have this on their radar, and can do some things in that first six-week postpartum time to really maximize their ability to heal without having to do a rehab program.
Georgie Kovacs: Tell us about your journey and how you came to realize all the nuances about diastasis rectus abdominis that may not be common knowledge but are critical to prevention and healing.
Carrie Koziol: I developed diastasis rectus abdominis between my second and third pregnancy. And this was so frustrating because this is my business. I'm in the women's health world. So I really have to take a look back at the exercises I've been doing to figure out if there was something I could have done differently to maybe avoid this or at least make it not so severe of a condition.
So I started taking a lot of programs in the United States and I gleaned little bits of wisdom from each one of those programs. However, what I found is that most of the programs were asking me to contract my abdominals to such a great extent that the intra abdominal pressure had nowhere to go but down. And they ended up creating cysts to seal a bladder prolapse where the bladder starts to make its way down out the vaginal opening, which by no means did I want to fix my abs at the expense of creating another problem further down the way.
And you know, I see this a lot with intra abdominal pressure, it takes the path of least resistance. So it's either going to come out in between the opening between those six pack muscles through the connective tissue there, where it's going to come out down in the pelvic floor region. So we really have to be careful as women that we see those two exits for pressure and start to develop exercise programs that make sure that we're maintaining the pressure in our body in a way that's healthy.
So I ended up flying to Canada. I took a great class called Bellies, Inc. that was specifically research based geared towards women's health physical therapists. And in that class, all the pieces finally came together. I realized that there has to be this coordination In between your thoracic and pelvic diaphragm, in order for any of the programs to work. There has to be this focus on movement.
We'll exercise for an hour in the morning, and then we'll slump into our cars and drive home from the class. Or we'll bend over our children or dishes, or we'll get online and be bent over computer workstations, and then slumped into the couch at the end of the night and say, “Oh, this was a good movement day for me because I did that exercise this morning.”
And unfortunately, our bodies don't work that way. They're responding to the forces that we place on them all day long. So while yes, there are key exercises that I think you need to do to strengthen your deep abdominals and your pelvic floor, we need to switch the mindset and move my body in a way that respects the parts.
And so with a condition like diastasis rectus abdominis, we have to manage the pressure. We have to coordinate your respiratory and your pelvic diaphragm. But we really need to put a lot of emphasis on body mechanics, and just moving your body better. And that applies to pregnant women, postpartum women, and women who are far beyond menopause.
This is how we lift laundry.
This is how we lift kids.
This is how we use our bodies in a way that manages the pressure and respects our parts.
There are a small percentage of women who will require surgery for this condition. But surgery is fixing the anatomic problem without taking into account the biomechanical forces that created the problem to begin with. So if you don't re-educate a woman how to sneeze properly, or how to lift properly, or how to get out of bed properly, you put a bandaid on the problem without getting really to the root cause of what is that problem.
Georgie Kovacs: How can women find a diastasis rectus abdominis expert because, as you said, there are important nuances and not everyone may understand them.
Carrie Koziol: I think OB GYNs are more well-versed in what a women's health physical therapist does. A women's health PT, in addition to treating orthopedic things like back pain, neck pain, knee pain, specialize in more intimate diagnoses, such as pain with intercourse, urinary incontinence, fecal incontinence, tailbone pain, and then a whole host of pregnancy and postpartum issues.
We treat these things individually and interactively. And a lot of women are very nervous or apprehensive about us being in such an intimate space, but we really take our time with these women. There's a separate room. It's not like you're out in the gym with everyone doing their bicep curls and bench presses. There's a lot of education that goes into it. We spend a lot of time working on parts.
If you think about what happens during pregnancy and childbirth, and just the act of being a sexual person on this planet, there's a lot of trigger points that can develop in the pelvic floor. And sure, you can do some stretching and whatnot, but just like you can't always stretch out a knot in your neck, you really need a specialist who is able to go in there and identify the trigger points or identify a muscle that's too tight.
You mentioned kegels earlier. Sometimes we hand out kegels like candy on Halloween, but if you came into the clinic with a bicep muscle that was stuck in place, I wouldn't say go home and do 300 bicep curls. I'd say, “Wow, I actually don't want you to do anything to work your bicep right now. We need to lengthen this muscle out. Really massage to get it to stretch because a strong muscle knows how to contract and to fully relax.
The same in the pelvic floor where some women shouldn't be doing a ton of work down there. If their muscles are really tight and guarded, they should be learning how to lengthen and relax those muscles before adding on the strengthening. So it really takes a professional person that can evaluate those muscles and can tell if the muscles are strong or weak, if they need more endurance, if they need to be relaxed, if there's trigger points.
Georgie Kovacs: Should all pregnant women see a pelvic floor PT?
Carrie Koziol: Any woman that has a baby deserves to see a women's health PT at least one time, just to get checked out. Women really do need to advocate for that themselves. It's not always a typical standard of care that you go to see your doctor and you get a referral for physical therapy. So before you sign up for anything like surgery, or something more invasive, I would always suggest seeing a women's health PT to look at some of these intimate areas and see if they can be fixed from a fitness or a muscular standpoint before going to a surgical solution.
Georgie Kovacs: What are some other key considerations or information women need to be aware of?
Carrie Koziol: Research shows that 60% of women with a diastasis will have some other support related issue, whether that's:
Lower back pain because their abs are not functioning properly
Pelvic organ prolapse.
A lot of women come to see me or at least know that they have this condition because they see aesthetically it doesn't look the way they want it to look, but it really is a true health concern.
Georgie Kovacs: What are practical tips for women with diastasis rectus abdominis, especially for those who cannot afford a women’s health PT?
Carrie Koziol: The first is coordinating your pelvic and your respiratory diaphragm, and this gets a little tricky, but it's about the way you breathe when you work your muscles and breathing tone really matters.
Think about your pelvic floor as the space between your pubic and tailbone, or the space between your two butt bones. It's like a diamond.
So you're going to inhale and melt, let those muscles go. And on the exhale, you're going to contract your pelvic floor like you're stopping the flow of urine. So tummy is quiet, butt cheeks are quiet. It's just the pelvic floor working. On the inhale, allow those muscles to melt like melted butter into the surface that you're sitting on.
Now, 95% of women doing this right now will do the opposite - inhale and suck up the pelvic floor, and then exhale and let it go. But we've got a pelvic and a respiratory diaphragm now that are not coordinated. And this matters, this completely matters. So we really have to think about exhaling on the exertion is the lift of the pelvic floor.
There's three layers of the pelvic floor. So when we just do that generic contraction, we're really only getting the superficial muscles, but a great visual. To get the muscles a little bit higher up towards the fallopian tubes, where they where they go all the way up, is to picture that we're sitting over a ripe blueberry. (You're never gonna look at a blueberry the same way again.) Inhale. Let your muscles melt over the top of the blueberry. And on the exhale, wrap your muscles around your blueberry lifted up two to three inches into the vaginal opening.
Now it's a blueberry, not a refrigerator. So this is not the hardest lift of your life. It's a tiny controlled lift, but pull it up a few inches.
On the inhale, let that blueberry just drop out and roll away on the floor. And by doing that contraction, now we're pulling it up a little bit higher.
So any woman regardless of what sort of access she has, can work on exercises that time the breathing, and get the diaphragm and the pelvic floor working like a piston system like a merry-go-round, where they're moving up and down together. You're coordinating it well. And you're doing a really good solid contraction that values the contraction just as much as it does the relaxation portion of it.
Georgie Kovacs: What are the watchouts for correct and incorrect kegel exercises?
Carrie Koziol: Now there's 22 different types of kegels. We're taught one kegel, and most of us are not even doing it the right way. So if you want to know if you're doing it the right way, the next time you're taking a shower, you're gonna put your finger into your vaginal opening like one inch. And when you do this contract, like you're stopping the flow of urine on the exhale, you should feel your muscles wrap around your finger and lift your finger up into the vaginal opening just a little bit, you should not feel your muscles torpedoing your finger out of your vagina. It should be a gentle lift.
Georgie Kovacs: What are other watchouts for diastasis rectus abdominis?
Carrie Koziol: Avoiding some of those exercises until you fix the condition, which I mentioned, such as:
A lot of times on all fours
A lot of planking
A lot of weighted rotation
So I am not anti any exercise. I'm not anti sit-up. I'm not anti CrossFit, I'm pro bringing more of your body to the exercise that you're doing. So really scaling back in the beginning until you rehab your body and then taking your body back to those exercises that bring you happiness and joy with a new appreciation of how you're using your body.
Georgie Kovacs: What are proper movements women should consider to prevent or minimize the risk of diastasis rectus abdominis?
Carrie Koziol: This is not just thinking about exercise, but also about how you're moving. Examples include:
How you lift that baby
How you get out of bed in the morning
How you life the laundry basket
Think about this. If you have a newborn, and are getting out of bed six or seven times in the evening, are you jackknifing out of bed popping up with these tender tissues to look over at the baby to see if they're still breathing or what that noise was or what that gurgle was? Instead, you should slide on to your side and press yourself up in a way that respects your deep abdominals.
The fact that they've just been through some sort of trauma requires you to treat your body with a little more care.
Questions you can ask yourself:
What part of you is participating in that activity?
Can you bring your ribs together?
Can you hug your belly gently towards your spine?
And can you lift your blueberry, all your core working together before you bend over and lift up that laundry basket.
We have to get out of the mindset of thinking, “I'm going to do this hour of exercise in the morning and then not move my body all day.” Instead, think about how you are going to take your body through all the activities of daily living in a way that manages the pressure and respects your parts.
Georgie Kovacs: How can we make this feel less overwhelming for our busy lives?
Carrie Koziol: We're trying to create a muscle memory so that you can tap into that in the postpartum phase, where you start out your pregnancy journey in a way that you start working these deep abdominals in your pelvic floor.
It's going to help your body support your baby throughout that pregnancy.
It's going to help with this diastasis condition because we're strengthening the muscles in a more proper way so that we don't predispose you to this happening.
It's laying the foundation for everything that comes afterwards.
So absolutely, starting in a pregnancy, with a really solid core strengthening program that works your body and treats birth, almost like an event. It’s going to help in the pregnancy, but then in those weeks afterwards, it's really going to help you tap into that muscle memory so that you have a more comprehensive, quicker recovery.
Georgie Kovacs: How does this tie to postpartum recovery and standard of care postpartum?
Carrie Koziol: We have this six week postpartum visit. So much is happening in those first six weeks. And it's almost like we are scared to see women in that six weeks. We know you're trying to figure out breastfeeding, we know things are hanging out down in the vaginal area where we don't even want to mess with you until that six weeks. I think we really do women a disservice by not seeing them to the six-week mark, because you have the six to eight-week window where you can really maximize your recovery.
Georgie Kovacs: What are you postpartum tips to prevent diastasis rectus abdominis?
Carrie Koziol: Number one, I'm a huge fan of belly binding. There's different schools of thought where some will say that if you put the binder on, the muscles just go to sleep. And so you're really atrophying things. I disagree. You've had basically an injury, a trauma to that area. We wouldn't think twice about wrapping an ankle. If you sprained an ankle, you've had an injury to this area. So wrapping the belly not only makes you more proprioceptively aware of how you're moving your body around the world, but it helps bring those two six pack muscles closer together, and helps the connective tissue generate more tension. So I say for the first six weeks as close to 24/7as you can, wearing some sort of even a generic belly binder or something is really helpful.
Number two, your body mechanics. So again, the way you pop up to help the baby the way you change diapers bent over a pack-and-play, the way you bathe the baby can be such a backbreaker over the tub. You should create a nursing throne or if you're not nursing a feeding throne. You're sitting to feed the baby eight, nine times a day. We need to start thinking of our bodies like a bank. And we need to start putting some deposits of healthy movement into those body banks. We can't keep withdrawing all the time.
We really need to start treating our bodies a little better listening to the whispers of our body. Our body's telling us if we're doing something it doesn't like. We're just trained as women to shove it under the rug and keep plodding ahead, keep doing what you need to do to care for others. And if we really took a moment to listen to those cues, we could modify how we're moving our bodies so that we're respecting our parts just a little bit more.
Georgie Kovacs: What can women proactively do at the six-week postpartum visit?
Carrie Koziol: At that six week visit, make sure your doctor tests you or ask them to test whether you have a diastasis rectus abdominis. It should be a standard of care that they're tested at every visit and only a handful of women are tested. And for those that do get tested for this, only a handful are given a referral to physical therapy or some sort of core strengthening program. Most are told there's nothing you can do but surgery.
And I will say at that six week checkup, they're going to give you permission to do a few things. Number one sex, which that's a whole other podcast episode in itself because we are not guiding women through how they're to return to being a sexual being on this planet. We're not giving them lubrication recommendations, position recommendations, talking to them about when it should be uncomfortable, when it's a red flag, if it's uncomfortable. We should be returning to vibrant, juicy, lovely sex lives.
But they talk about exercise here too. And this is where they'll say go ahead and resume. You know, if you're feeling good, resume an exercise program. I disagree. You should not have a six week postpartum woman running for her first mode of exercise. You need to treat your pregnant body like a house.
It's like a fixer upper project after you had a baby. You know, if you watch any of those fixer upper shows, there's this demo day where they go in and wrap up the show. I don't want to be dramatic, but birth is a little bit of a demolition project and the second phase of those rehab projects is fixing what's broken, it's fixing the roof. It's fixing the leak in the foundation. If you skip which we want to do as postpartum women, we want the quick calorie burn. We want the results we want the big reveal the fixer upper end of, you know, end of show where it's a brand new house. But if you skip that rebuild phase, it's essentially like seeing a crack in the foundation, smoothing an area rug over it. And you're gonna get by like that for a little while, but that crack is getting bigger underneath the rug, eventually you're peeling the rug off and doing the work you should have done right from the beginning.
So the very first thing you do after your six week postpartum visit is not returning to running is not getting back into CrossFit is not doing all of the stuff you used to do. It's really starting from ground zero. and building up that pelvic diaphragm coordination, finding your pelvic floor, making sure your deep abdominals know how to work, and then you can layer on more.
Georgie Kovacs: Should a woman be more proactive than waiting for a six week postpartum visit?
Carrie Koziol: I think starting some of these exercises on your own, like finding the pelvic floor and the respiratory diaphragm coordination. I think all of this is very fine to do in those first six weeks. As a women's health PT, I like seeing someone after they've been cleared by their gynecologist at the six week mark to make sure that nothing else is going on. Sometimes there's excess bleeding, there needs to be a DNC to remove some piece of placenta. So in the body, it takes about four to six weeks for soft tissues to heal.
I've had women come to me three days postpartum saying they're leaking urine. I remind them we're not going to worry so much right now things are swelling, your body's still trying to figure itself out. So let's wait. And if you're still having this issue at four to six weeks, then we can talk about doing something. So I think there's a lot you can push, you're overwhelmed, and you're trapped under a newborn. So expecting you to go out and make a bunch of PT visits on top of your normal health visits and baby checks, I think is a little unrealistic.
So if you don't have a major issue, I think working on your body mechanics, thinking about how you're moving your body around the world starting to work those deep inner core muscles, nothing exercise-wise, wearing a binder. All of those are things you can do on your own.
Georgie Kovacs: Tell us about the programs you offer.
Carrie Koziol: Women can take self-paced programs that they just sign up for and do at their own pace: Prenatal Pilates, Postnatal Pilates and DRA Core Restore. Sometimes women like the group scenario, so I do virtual group classes you can join from anywhere in the world and at least you're with other women that are going through similar things, and I deliver the information that way.
And other women prefer to do private sessions, especially if you have some other things going on because then I can tailor the program to completely meet your individual needs.
Of course I'm really well known in my home community and people do come into my home studio to see me in person. But with the nature of the world as it is, I really wanted these programs to be accessible to everyone. So they are all online at CarrieKoziol.com.
Georgie Kovacs: What is your greatest hope for women’s health?
Carrie Koziol: I have two.
The first one is that we, as women, really need to identify the difference between common and normal. We're told by social media and by commercials that, after you have a baby, you're going to be peeing your pants, so just slap on a big pad and dance your way around the world.
I really want to challenge women to demand better.
Our bodies were not designed to fail us having a child doesn't mean that we have to live with a lifetime of urinary incontinence or other female related issues. A lot of these things are fitness issues that deserve a fitness solution. I really want to challenge women to demand better from their providers and their bodies and listen to their bodies.
The second thing is shifting the focus from exercise to movement. I love exercise. I exercise almost every morning on my own. It's a stress reliever for me, and it's my business.
It's like going to a dentist with yellow teeth. No one wants to come to a fitness teacher who hasn't been doing the work herself. Some women are trapped under a new baby, or working three jobs, or they just don't have the willpower right now. I want to say, start simply, but simply start with thinking about movement and just moving your body better.
How do you stand at the kitchen sink to wash your dishes, do you lean into the counter and outsource the work of your body to the counter? Or do you take one step back and actually wash the dishes? By holding yourself upright?
When you brush your teeth, do you lean into the counter? Or can you step back?
When you drive your car, do you slump down into the seat and have to pull the rearview mirror down to your little granny self? Or do you think about, “Wow, let me change the way I'm sitting so that I'm using better posture.”
When we think about moving our bodies better, instead of putting pressure on this daily exercise, think about it as a cumulative effect of what we're doing all day long. Moving better from morning till night, instead of just doing that one hour of exercise and then not mindfully thinking about how you move. Those are my two big hopes.
Georgie Kovacs: I appreciate that you put a practical spin on both of those because I think that's needed.
Carrie Koziol: Thank you for the opportunity. I loved being here.
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About Carrie Koziol
Carrie’s passion is empowering and educating women about their bodies. She specializes in tackling “taboo” topics with a blend of humor, expertise, and practical tips that women are able to use right away to start moving their bodies better. A Women’s Health Physical Therapist and experienced speaker, she has spoken in front of large audiences like MommyCon Chicago and more intimate settings in living rooms across the state, delivering messages to remind women that their bodies are temples and should be celebrated for all they are capable of doing!!!
She is a mother of three who understands what it is like to juggle motherhood, run a household, and manage a career while striving to remain fit and well. She is excited to share simple ways to infuse more nutritional movement into your daily lives without adding extra stress.
About Fempower Health and the Founder
Georgie Kovacs, is the founder of Fempower Health, the go-to resource for all things women health serving women, their providers, and companies looking to build/improve on products for women. She also hosts the Fempower Health Podcast, where she interviews experts to help women better understand how to navigate their health both day-to-day and in partnership with their providers. Her mission is to minimize the years many take to seek proper diagnosis and treatment.
Georgie founded Fempower Health after her first-hand experience with infertility and endometriosis. Leveraging this experience along with her 20+ year tenure in the biopharmaceutical industry and consulting, she leads this movement to empower women. With limited research dollars and women’s “training” to grin and bear it, both women and doctors are in the impossible position to diagnose and treat conditions with little information. Women deserve more and better information, insight and innovative health solutions.
**The information shared by Fempower Health is not medical advice but for information purposes to enable you to have more effective conversations with your doctor. Always talk to your doctor before making health-related decisions.
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