Diastasis rectus abdominis (diastasis recti, diastasis, DRA, or DR), the partial or complete separation of abdominal muscles, has become a buzzy diagnosis aimed at moms during the postpartum period (“Get rid of your mom tummy!”), and it can sound like a scary prognosis.
To learn more about it, we recently interviewed Munira Hudani, PT, a pelvic-health and women’s-health physiotherapist based in Toronto. Hudani has been a physiotherapist for 10 years and holds a master of science in physical rehabilitation degree from the University of Toronto. She is the director of the Pelvic Health Program at Bosnar Centre for Health in Toronto, has taught courses on DR to rehab and fitness professionals, provides clinical mentorship to physiotherapists, is a cofounder of Made for Women workouts, and is on the teaching faculty of Pelvic Health Solutions, the leading educational body in Canada for pelvic-health education. Hudani talked about all aspects of DR, including how it has an impact on body image.
“It’s not for anybody to judge or to tell you what you should be feeling. If you want your stomach back, that’s OK. If you feel like all you want to be able to do is run again, that’s fine too,” she said.
Read on for more of Hudani’s thoughts about how to heal from diastasis recti.
Experience Life | What is diastasis rectus abdominis (diastasis recti, or DR)?
Munira Hudani | The word “diastasis” means separation. Diastasis rectus abdominis is literally defined as separation of the rectus abdominis muscles (the two sections of muscle in the front of the abdomen that are, before pregnancy, connected by the linea alba). The important thing to note is that with DR, although we are really focusing on the linea alba and the space between the two muscles, the reason it occurs is because there is a sustained amount of pressure from the inside that pushes out on the linea alba and the whole abdomen. The linea alba and abdomen adapt to accommodate due to the pressure from the inside. We need to take this and put it into context with what else is happening. It’s the entire abdominal wall that is affected and not just the linea alba.
EL | How does someone get DR?
MH | It’s all about the pressure. It could be a sustained increased pressure over a long period of time, or it could be repeated amounts of pressure frequently enough that the tissues themselves didn’t have time to accommodate, so they become stretched out and stay there afterwards.
It doesn’t have to happen in pregnancy only. It can happen in people that are very athletic and doing exercises on a consistent and regular basis where these exercises produce a lot of intra-abdominal pressure. If there isn’t enough time between sessions or they overloaded that day, then the tissues may not be able to keep up with that, so they remain widened. But if they gave themselves time in between, the tissues could have adapted and kept everything together.
It can also happen in people who have an increase in abdominal mass or weight, which would happen over a period of time, which is a very different kind of stretching.
EL | Is it ever too late to start healing DR?
MH | It’s never too late. The body, muscles, and connective tissue are responsive and adapt depending on what we are doing. If we are beginning the process, they will change.
EL | Do corset-like binders help initially to hold the body together?
MH | I recommend abdominal support for the fourth trimester (the first 13 weeks postpartum), not corsets, but binders. Corsets and waist trainers are a whole different category that I don’t recommend for anybody.
Just as we would initially support an ankle that was sprained, we would do the same thing for the abdominal wall. We are trying to support the body in the immediate time period because it was stretched out for so long. The body will figure it out, but it helps guide the body.
EL | Is there a timeline on how long it takes to heal DR?
MH | It’s impossible to tell someone how much time it will take. What we can do is take a look at the person in front of us and see what factors may be at play and give them a more customized answer rather than saying everyone with DR will take a certain amount of time to get better, and if they don’t, they’re doomed. There are several factors for healing DR:
- What is your starting point?
- How strong are you to begin with in your muscles?
- How much connective-tissue laxity do you have?
- How well are you aware of the muscles?
- How good is your mind–muscle connection to the pelvic floor, transversus abdominis (TA), diaphragm?
Building mind–muscle connection can take a couple of minutes or a couple of months — or longer. Overall healing can take a few months to a couple of years. Even if it’s five years later, that’s fine too.
EL | What is the process someone can take to heal her diastasis?
MH | We need to consider where we’re focusing on the entire abdominal wall and not just the linea alba. Closing that gap is out of our control. We don’t have the ability to voluntarily do something in that moment to close that gap. If you study the anatomy and muscles and how they contract around it, none of the muscles pull the rectus abdominis together; they pull in the opposite direction. We need to consider a different idea rather than “close the gap, close the gap.” We want to think of how we can restore the function of the whole abdominal wall, including all the muscles that are there, which also includes the rectus abdominis, which we’ve been shying away from.
Rectus abdominis muscles help you bend forward. When you read things that suggest they don’t do anything, I would simply say, “How did you get out of bed in the morning?” They are so important, and we aren’t training them up after they’ve been stretched. They will remain weak unless we build them up.
The process, I would say, is a three-step restorative process (see below) that involves the whole abdominal wall but starts with the deeper-core muscle system — the pelvic floor, the TA, the diaphragm, and the multifidus muscle in the back. We have these muscles we should be working on before we target the outside muscles. That’s the stuff most people in general don’t know what to do with. We all know how to do sit-ups and planks. But we don’t all know how the inner muscles work and connect with the deeper core. It’s hard to strengthen the muscles if you don’t know how they work and where they are. Everything got affected in pregnancy — even the outside muscles, even the obliques.
- Awareness and Connection: Connecting and awareness is usually the first step. Connecting to your breath and your TA, which draws in the whole abdomen, connecting to the pelvic floor, which is sphincter control, a supportive role. Learning how to do those basic connection exercises.
- Get Synergized: Once you know these muscles, have worked with them a bit, and can control them voluntarily, it takes less mental effort. You say “turn on” and they do. You’re then able to move on to the next step — strengthening the inner muscles. Get them to become coordinated with each other (first step), then strengthen the pelvic floor and the TA muscle. This is the biggest missing piece in most programs right now: the strengthening of the TA muscle. Pulling in that entire abdominal wall and allowing it to stay there in the pulled-in position in a variety of other exercises and movements. I think one of the best things is planks because if you can draw in the abdomen while standing, let’s load it up. Can you do it when you’re in a modified pushup or plank against the wall? If it’s easy, move to the ground. If it’s too hard, we need to build up to do it. If you can hold and draw in your whole abdomen and be breathing, and not doming (more on that below), it means you’re really strong. If you can pull in lower, middle, upper, and stay engaged within a plank or other hard exercises, that’s how you train up the TA. If the pressure inside is too much, that’s when you’ll see doming or bulging, and you’ll know you’ve gone too far.
- Load and Strengthen: That takes care of the inner core. Then as you’re strengthening the TA, it’s time to start strengthening other abdominal muscles. We don’t need to wait for the TA to be fully strong before we do anything else. Now it’s a matter of getting all of the muscles working together. It involves rotation, flexion movements, and a variety of exercises that gradually challenge that person. Every person will be different with what they can handle and where they’re at. We are telling people “don’t do this and do that” until your core is strong enough to handle it. But then we aren’t telling them what to do to get there and make it stronger.
EL | We hear a lot about “doming” or “coning” if you have diastasis recti, and that if you see this while performing an exercise to immediately stop the movement. What are your thoughts on doming?
MH | There’s a continuum. There’s a little amount of doming, and there’s an extreme amount of doming, which would also involve the whole abdomen bulging outwards.
That’s where you want to put your mind — how much doming is there? As long as we aren’t in the extreme ranges I think we are OK, we aren’t doing anything harmful or damaging. Even if we are in the extreme, it might be OK too, as long as we aren’t spending all of our time there. Because if you’re in the extreme and actively pull in, and you have a lot less bulging, it shows you still have control and can pull in from there. So at this point it’s just feedback.
If you’re seeing it happen, and you can’t pull it back in from that point, it’s OK. You’re able to keep building those muscles.
EL | At what point do you move someone from rehab to strengthening?
MH | If people are ready to move on from rehab, it’s time to move on. If it takes two years to find the connection and synergize, then that’s OK, but if you’re ready, move on.
EL | How does the entire core (TA, pelvic floor, obliques, and diaphragm) work together to heal a diastasis injury?
MH | When it comes to healing DR, we are going back to healing the whole abdominal wall, not just the linea alba. The only way to work the linea alba is to work the muscles that attach to it. So gradually strengthening all of these muscles and getting them to work in a coordinated manner, so they can do their collective role in containing intra-abdominal pressure, is how to heal the whole core.
They all have their individual functions. Obliques rotate, the diaphragm is a respiratory muscle, the pelvic floor supports, and the TA pulls inwards and contains the organs inside of you. Together they create a sturdy abdominal cannister from which intra-abdominal pressure can be contained. The TA can’t do this all by itself. It needs the obliques and rectus abdominis.
EL | What role does relaxing or releasing the TA and pelvic-floor muscles play in optimal functionality and healing?
MH| In order to be able to contract the muscle and take it through its full range you have to let it go. It can’t be in a contracted state and be able to strengthen it through its full range. It would be a very short range if you begin contracted because you’d be strengthening it from the point it’s contracted at.
If you let the muscle go, you’ve given it more ability to go through that strengthening excursion. If you’re not letting go, you’re not going to make it easy to make your next contraction to be done well. That’s during exercise and technique.
If the general state of your muscles is tight — if you begin contracting an already tight muscle — you’re going to continue to tighten that muscle further. You want to spend time relaxing the muscle so it can be used appropriately. Tight muscles become nonfunctional muscles.
EL | What does it mean to have a functional gap or core?
MH | There is a lot of misunderstanding under the concept of “functional.” If you look at the anatomy, we are looking at muscles that attach to the linea alba; when they contract the lateral muscles, they tug on the linea alba and take up the slack. You can’t tense the linea alba unless you tense those muscles. If you can tense up the linea alba with a lot of pressure underneath, and you can keep the tension there and it doesn’t push through the linea alba (doming), you are considered functional. I take it one step further by saying if you can keep the tension there.
Some positions and exercises will be OK. You’ll be able to create and sustain tension without doming. In others, not. If you can’t produce tension while lying on your back, that position may not be conducive to generating tension.
EL | We hear a lot about movements women should avoid performing to not hinder healing their diastasis. What is your take on this?
MH | Any exercise that elevates pressure is what we need to keep in mind. Sit-ups have gotten a bad rap lately. It’s not just sit-ups. But they have been unfairly singled out because they create pressure. There are many exercises that create pressure to that level.
It’s interesting to be aware of this continuum of pressure. We don’t have a lot of information based on the research on which exercises create that much pressure. But we have ideas of what is the lower end of the continuum and the highest end of the continuum — the extremes.
No pressure occurs when you’re lying on your back and your body is resting. The complete opposite end of the spectrum that has been recorded happens when you’re coughing, jumping, and bearing down (constipation, throwing up, spontaneous laughter). Now, sit-ups aren’t in that list. If sit-ups aren’t at the extreme, then maybe it’s a matter of how many sit-ups you’re doing, how often you’re doing them, what technique you’re using, in addition to other exercises you’re doing that are similar in levels of pressure. We have oversimplified it by focusing on sit-ups. There are a lot more factors to think about when you’re pondering intra-abdominal pressure.
EL | How do you take the fear out of having DR and someone getting comfortable in their body again with movement?
MH | This is what I primarily am seeing every day. So many women come in and they feel broken, discouraged, frustrated, injured, weak, scared, overwhelmed, don’t know what to do, want to improve but don’t want to harm themselves so are doing nothing at all. This is the consequence of the kind of information — even well-meaning — that we’ve been putting out there.
When people come in and feel like that, the most important thing is to acknowledge that’s how they’re feeling. We have to acknowledge it because this is real. I explain to them what DR is and is not. We discuss why they might be feeling upset, scared, frustrated, and broken. Then I show them another way to see it. I change the process of how they feel about themselves and the situation before I go into what we need to do about it.
I allow them to see that the body is strong, resilient, responsive, and adaptive, and it will do things and change depending on what we are doing with it. If we are not moving, which our body is designed to do, then it has no reason to change. If we feel weak, we need to begin building strength. If we aren’t doing strengthening exercises, we cannot change that. We need to do the things we aren’t doing or allowing ourselves to do. When we start doing those things, then the tissues have what they need to begin that change, and that’s when you’ll start to notice the change. And if you can feel strength building, tissues thickening, and feeling less hollowness happening, it will motivate you to continue.
Just know the extremes and what to watch out for. You have your parameters to work within, then if it doesn’t feel challenging, that’s not good. You can’t go to the gym and do a 2-pound deadlift and expect something to happen. Let’s assume that the body can handle at least the amount and weight of your child. So many people are afraid that they can’t lift up their own kids.
EL | How does collagen help to heal or prevent DR?
MH | With regards to connective tissue — we know that it’s made up of collagen. It’s the primary protein that’s inside of connective tissue. Connective tissue responds to what we do with it, like muscles. It’s very adaptable. Connective tissue is made of up collagen, so if you want to build up the collagen content, from an exercise perspective we have to load it. It has to undergo a certain level of stress in order for us to stimulate and initiate the regenerative process. This is no different for the abdominal wall — if you want to target that area, you need to do exercises that challenge that area. Including exercises for the muscles in and around the abdomen that will naturally put tension on the linea-alba tissue, because every time those muscles contract they will tug at that linea alba. So we need to figure out how to put tension on that tissue repeatedly, gradually, so that over a period of time it can begin to thicken and build the integrity of the linea alba.
We need to load it and challenge it. And it’s not only about exercise. Connective tissue and collagen — we need building blocks in our body to create that collagen. All the exercise in the world will only get someone so far if they don’t have the building blocks inside of them to help build that tissue when it’s being loaded.
EL | What role do nutrition and sleep play in healing a DR injury?
MH | I am not an expert in nutrition, but vitamin C is a precursor to building collagen so it’s a very important vitamin for collagen production, as is vitamin A. In addition to nutrition, part of that is also hydration, especially in the postpartum period. Two-thirds of the volume of our connective tissue is made up of water.
Also, even if we have the building blocks and we are loading the tissue through exercise, if a person is going through a lot of stress and not sleeping well, or if they are sick or have other autoimmune conditions — these hamper the body’s ability to use what it has to build the tissues up. Sleep is important. We get most of our regeneration when we sleep. If you’re not getting sleep, that could also affect general healing of your body in the postpartum period. If you’re very stressed, overwhelmed, anxious, frustrated, and angry, that’s OK so long as you learn strategies to rest and relax every day. These reduce inflammation and cortisol in the body. If there’s a lot of that floating around, it hampers your body’s ability to heal.
EL | At what point is DR surgery a positive recommendation for someone?
MH | Surgery is never a negative recommendation unless it’s the only option you’re giving them. Conservative treatment first, surgery as the last option. If you’ve been doing rehab for two years, let’s get you building strength for two years and see where you’re at then. If you really don’t want to do the surgery, give yourself time to strengthen and the collagen to turn over.
We tend to look down on the surgery, but it does have a really important place for this continuum of care. It’s something people need to know is a legitimate option when all these things have failed.
EL | For exhausted and overwhelmed moms who are on a tight budget of money and time, what are your top three things to prioritize in their healing?
MH | For me, No. 1 would be to see a pelvic-floor physiotherapist. I know there might be a time and investment factor here, but even if you saw them once and got your baseline and know where you stand, know what your pelvic floor is doing, and how well you tolerated the pregnancy and delivery, and if a prolapse is happening, it’s really good to know right away. It’s integral for core health. The pelvic floor is part of the core and is involved in all of the movement we do to strengthen the core. Learning how to contract the pelvic floor well and properly will help with the process.
No. 2 would be to learn how to strengthen your TA muscle. If you look at the anatomy, the way the TA is designed is to pull everything back in and relax and let go. It’s a key muscle.
No. 3 would be to go back to other factors that can be playing a role, and just work on one of them:sleep, nutrition, stress, hydration, or general exercise. That way you know you’re doing something for the betterment of your body, mental health, and tissue.
EL | What are three things you want other practitioners to know in treating DR?
- Doming is not always a bad thing. It doesn’t necessarily mean you’re seeing something that will harm the tissue. That’s what we are associating with it right now. I want people to learn how to scale that. Where are you in the scale?
- Intra-abdominal pressure isn’t bad. It’s a fundamental mechanism that our bodies use to provide us with stability. We need pressure. It gives us support. Learning to become friends with pressure and not the enemy. When you start strengthening your core, you’re challenging your core, and it will naturally create more pressure. Know what pressure is and what to do with it.
- Learn how to strengthen the TA. Go back and learn what the muscle does and how it works and then we will have very clear ways to go back and strengthen it. The plank progression is a great way to do this.
EL | On Instagram you mention that having weak connective tissue doesn’t mean you are weak. Why is that?
MH | Connective tissue is what binds everything together, holds everything in, and surrounds the muscles. The strength of your core comes down to how strong your muscles are. There are women who have very lax connective tissue in their abdominal wall but can still do very high-level movement like CrossFit, toes to bar, sit-ups. Connective tissue plays a role in what your extremes may be, but it’s not the only thing that determines how strong your core is.
EL | Is there anything else that you want people to know about DR?
MH | It’s OK to strengthen your core. It’s OK to move beyond rehab and do more challenging exercises — in fact it is what you need to do.
Download Hudani’s free diastasis resource guide for patients and professionals for more tips on healing diastasis.