Restoring Your Core from Diastasis Rectus Abdominis

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:

  • Excessive crunches

  • 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

  • Urinary incontinence

  • Sexual dysfunction

  • 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: