Imagine a balloon—a standard latex party balloon. You put a tiny seed in it. A watermelon starts to grow. You pick up the balloon with the watermelon growing inside. You carry it with you all day. You sit with it, stand up with it, run with it, take it wherever you go. What happens? How long will that balloon hold up?

Now imagine the same scenario with a stronger balloon, a Mylar balloon, with reinforced seams.

Eventually, of course, with enough internal stress (the growing watermelon) and enough external stress (activities of daily life, cardio exercise, strength training), both balloons will pop. However, the stronger balloon will obviously hold up longer.

A pregnant woman’s abdomen is pretty similar. With a weak “latex-balloon”
core, she will have trouble keeping her “watermelon” stable. The overstretched outer layer of her abdominals—the rectus abdominis—will begin to separate into its left and right halves. This condition, known as diastasis recti abdominis (DRA), is likely to affect all women during the last month of pregnancy and immediately after delivery, whether or not they notice it or complain about it (Mota, Pascoal & Ba 2015b; Bursch 1987). However, with specific, targeted exercises, women can develop a stronger core capable of supporting that watermelon baby effectively.

Exercise During Pregnancy

Studies show that exercise during pregnancy can reduce the prevalence of DRA by 35% (Benjamin, van de Water & Peiris 2014). Additionally, women who do any kind of exercise program tend to have milder diastasis, whereas those who don’t exercise typically display more severe diastasis (Armstrong 2005; Candido, Lo & Janssen 2005; Akram & Matzen 2014).

In other words, if your pregnant client does not want a weak core and a visible, palpable separation of her recti muscles when she contracts them, then she needs to do some form of exercise. If she already has DRA and wants to decrease its severity, then she should exercise. Almost any exercise, including walking, has a protective prenatal effect, but certain exercises are more beneficial than others. One study showed that when pregnant women participated in a weekly 90-minute abdominal class for 6 weeks, just 12% of them exhibited DRA (compared with 90% of nonexercisers in a control group). Furthermore, those 12% who participated in the abdominal strengthening class displayed an average separation of 1.14 centimeters, compared with a 5.95 cm separation in women who did not exercise (Chiarello et al. 2005; Benjamin, van de Water & Peiris 2014).

Exercise After Pregnancy

Now let’s say your client did no prenatal exercise. She comes to you for training a month, a year or even 10 years after delivery because she just can’t shake off that baby weight. She’s got the typical mom stance: rounded shoulders, tipped-down chest, sway back and—what she is really complaining about—a weak, protruding abdomen with or without a visible ridge running vertically where her recti muscles separated.

Your plan: Strengthen the abdominal region, support the core and improve posture without diving into situps, crunches, trunk twists or standard rectus abdominis and oblique workouts. This client needs deep core control and support. The deepest of the abdominals, the transversus abdominis (TA) muscle, will give her that support by pulling the left and right recti muscles back together. To train her safely and effectively, you must start with TA contractions; you’ll move on to more superficial musculature only after your client can demonstrate basic strength and control.

In a research study on women who did TA contractions, resistance training and cardio exercise, both pre- and postnatal groups were equally and significantly able to reduce DRA (Sharma, Lobo & Keller 2014). Translation: It’s not too late. If your client didn’t exercise while she was pregnant, it’s okay. Although the biggest improvements occur in the first 8 weeks postpartum (Mota, Pascoal & Ba 2015b), you can still teach her how to strengthen her core and improve overall strength and function. According to a case report in 2014, one postpartum woman shrank her diastasis from 11.5 cm to 2 cm. She started with the TA isometric/drawing-in maneuver (see the sidebar “Isolating the Transversus Abdominis”) and progressed to more advanced exercises in 18 sessions with a physical therapist over 4 months (Litos 2014).

Another case study described a woman suffering abdominal and lumbar-back pain, weakness, fatigue and reduced lifestyle participation 8 years after delivering her baby. A 6-week program of core strengthening, aerobic exercise and neuromuscular education drastically improved her quality of life (Zappile-Lucis 2009).

The Deep Core

Now, if all a woman needs to do is exercise and strengthen the core, then why is DRA so prevalent? Why are about 4 in 10 women still displaying symptoms 6 months after delivery and even decades later into menopause and older adulthood (Mota, Pascoal & Ba 2015a)? The answer: Because most people don’t strengthen their core musculature appropriately. They perform all sorts of exercises to strengthen the rectus abdominis and the obliques instead of, or in addition to, strengthening the TA.

As is frequently the case with fitness, more is not necessarily better. Rectus abdominis strengthening is not helpful; indeed, it should be avoided because it can excacerbate recti separation (Litos 2014). Your client needs to be able to isolate only the deep transverse fibers to keep everything in place. If she resorts to using her rectus abdominis, obliques or diaphragm instead, the TA will never get a chance to contract properly and won’t improve.

If your client cannot maintain an isometric TA contraction, then she is missing one of the most important parts of proper exercise technique and will eventually hurt herself—and her abdominals will have less chance to come back together. Diastasis recti can resolve itself naturally, but abdominal muscle function and the distance between the recti muscles will likely not return to normal (Akram & Matzen 2014).

Now the question is, if the greatest recovery from DRA occurs during the first 8 weeks postpartum (Coldron et al. 2008), then why do so many women hold off from any exercise during that time? Unless there were complications during labor or delivery, a woman who is healthy and able to care for her infant should benefit from basic TA. When subjects in a randomized controlled trial performed only 2 sessions of progressive abdominal and pelvic-floor exercises within the first day after delivery, DRA width decreased significantly (Mesquita, Machado & Andrade 1999).

Since most trainers don’t see their clients on the day of delivery, it is even more imperative to teach prenatal core strengthening. Make sure pregnant clients go into delivery knowing the importance of the core and TA and can effectively contract the TA to support their bodies. When a client becomes pregnant, make TA strengthening part of her daily exercise routine, and ensure that she fully understands the basic TA isometric sequence (steps 1–6, in the sidebar “Isolating the Transversus Abdominis”) and will remember how to go back to it after delivery.

Of course, any client should receive her physician’s clearance before training with you during and after pregnancy. If you notice a severe or persistent diastasis recti, encourage the client to revisit her doctor for follow-up assessments.

Putting It All Together

If a client understands how to isolate her transversus abdominis with the sequence shown in the sidebar, then she can work up to holding that TA contraction during all her activities.

Ideally, she should contract her TA to “tighten her core” during any movement that involves force transfer from upper body to lower body; for example, running, jumping, reaching to the floor, swinging a golf club or picking up a child. The same rules apply to any functional movement that has weight added to it, such as transferring a pot of soup from the counter to the fridge. If she can’t maintain the contraction while in her kitchen, then why is she lifting heavier weights in the gym?

Eventually, she may work up to planks, crunches and other rectus abdominis and oblique exercises. To maintain a strong core, she needs to contract her TA throughout the entire plank and before each crunch. If she can’t hold her TA isometric that long or that often, then she has no business doing planks or crunches anyway. The same goes for squats, shoulder presses, biceps curls, lunges, and any repetition of any exercise. Teach her to maintain the TA isometric!

If she can practice TA isometrics for about a month, engaging the technique before she picks up anything or reaches anywhere, or even when she walks through a doorway or brushes her teeth, then the feeling should start to come naturally. This practice should trigger her neuromuscular connections to fire more quickly, and she will notice she doesn’t have to plan or think about the contraction as much.

In other words, the more she practices the basic TA isometric sequence, with advanced exercises when appropriate, the more her TA will just contract on its own, meaning her DRA can heal and she’ll get the added benefit of better posture and a flatter belly. Meanwhile, you’ll get the benefit of being an amazing trainer, coach and friend.

DIASTASIS RECTI ABDOMINIS

Diastasis

ISOLATING THE TRANSVERSUS ABDOMINIS

The following exercises are best performed during the warmup to activate the TA prior to more strenuous activity, but they can also be completed throughout the workout, again during cooldown and periodically throughout your client’s day.

Instruct your client in the following steps to help her isolate her TA:

  1. Belly breathing. Lie supine (i.e., on your back), then take a deep breath in, letting your belly rise toward the ceiling as you inhale. Next, let the belly shrink back down as you exhale all the air out. (Make sure your client has mastered belly breathing before moving on to step 2. If she doesn’t grasp it right away, try again at the end of the session, in the next session and again until she fully understands it.)
  2. Belly breathing with TA isometric “drawing-in” maneuver. Lying supine, take a big breath in, letting the belly rise toward the ceiling again. Keep the air in your lungs, but try to pull your bellybutton back toward your spine. Then let your belly release. Then let the air out of your lungs. Try again. And again.
  3. Belly breath with 3 TA isometrics in a row. Take a big breath in while your belly rises. Then, keeping the air in your lungs, pull your belly in toward your spine. Then, still holding the air in your lungs, let your belly out. Then, still with the air in your lungs, pull your belly back in. Then, still with the air in your lungs, let your belly out again. Then exhale. Whew! Do it again. (Here it is in fewer words: Inhale. Belly in. Belly out. In. Out. In. Out. Exhale.)
  4. Now in a seated position. Do steps 1–3 10x each in the seated position. You can put your hands on your lower abdominal region for a little biofeedback.
  5. Now standing. Do steps 1–3 10x each while standing.
  6. Basic TA isometric. Here’s where it gets harder. Try to pull your bellybutton in toward your spine and hold it there while you breathe normally. Got that? Breathe normally! If your breathing is affected and you are holding your breath at all, then you are recruiting your diaphragm instead of your TA. Breathing is key. Now, try to hold the contraction for 10 seconds. Then try to talk while you are keeping the contraction held. Then try to walk. Then squat. Then pick up a 1-pound dumbbell from the floor, all while maintaining that isometric TA contraction.

Important: You will be tempted to move your client through these exercises quickly, but don’t. Work with her to ensure she completely understands each step. Learning a basic move may take one entire session, or it may take several sessions, and you may need to instruct her with several teaching styles.

Many people rush through, thinking they are fine when they are not. Then they end up with back pain and wonder why they can’t lift as much or run as fast as they could beforehand. It may mean you replace 15 minutes of strenuous workout time each session with more basic TA contractions, but the long-term results will be worth it.

Abdominal Illustration

Abdominal

ADVANCED EXERCISES

Once your client masters the basic TA isometric, she is ready to move on to more advanced exercises. She should maintain the TA isometric before each repetition of the following exercises:

Supine Marching

  1. In supine position on a mat, with hips and knees flexed and feet on the floor, draw the bellybutton in toward the spine for a TA isometric.
  2. While holding the isometric, lift the right knee up slightly to march up and down once.
  3. While still holding the isometric, march once with the left knee.
  4. Release the TA isometric to relax the core.

That’s a single repetition. Once the client can maintain the TA contraction through 1 repetition for about a week, she can progress to holding the contraction for 2 reps, then 3 reps, and so on.

More advanced exercises to perform while holding the TA isometric:

Supine Series
marching
straight-leg raise
bridges with straight-leg raise

Quadruped Series
shoulder flexion
hip extension
opposite shoulder and hip raise

Planks
modified on knees
on hands and feet
with opposite shoulder and hip raise

Squats
isometric wall sit
on wall with stability ball behind back
with body weight

Lunges
stationary
alternating
walking


References

Akram, J., & Matzen, S.H. 2014. Rectus abdominis diastasis. Journal of Plastic Surgery and Hand Surgery, 48 (3), 163–69.

Armstrong, P. 2005. Raising pelvic floor awareness among teenage girls. Journal of the Association of Chartered Physiotherapists in Women’s Health, 97, 55–59.

Benjamin, D.R., van de Water, A.T., & Peiris, C.L. 2014. Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: A systematic review. Physiotherapy, 100, 1–8.

Bursch, S.G. 1987. Interrater reliability of diastasis recti abdominis measurement. Physical Therapy, 67 (7), 1077–79.

Candido, G., Lo, T., & Janssen, P.A. 2005. Risk factors for diastasis of the recti abdominis. Journal of the Association of Chartered Physiotherapists in Women’s Health, 97, 49–54.

Coldron, Y., et al. 2008. Postpartum characteristics of rectus abdominis on ultrasound imaging. Manual Therapy, 13 (2), 112–21.

Chiarello, C.M., et al. 2005. The effects of an exercise program on diastasis recti abdominis in pregnant women. The Journal of Women’s Health Physical Therapy, 29 (1), 11–16.

Litos, K. 2014. Progressive therapeutic exercise program for successful treatment of a postpartum woman with a severe diastasis recti abdominis. Journal of Women’s Health Physical Therapy, 38 (2), 58–73.

Mesquita, L.A, Machado, A.V., & Andrade, A.V. 1999. Physiotherapy for reduction of diastasis of the recti abdominis muscles in the postpartum period. Revista Brasileira de Ginecologia e.

Obstetr├¡cia, 21, 267–72.

Mota, P., Pascoal, A.G., & Ba, K. 2015a. Diastasis recti abdominis in pregnancy and postpartum period: Risk factors, functional implications and resolution. Current Women’s Health Reviews, 11, 59–67.

Mota, P., Pascoal, A.G., & Ba, K. 2015b. Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Manual Therapy, 20, (1) 200–5.

Sharma, G., Lobo, T., & Keller, L. 2014. Postnatal exercise can reverse diastasis recti. Obstetrics & Gynecology, 123 (Suppl. 1), 171S.

Zappile-Lucis, M. 2009. Quality of life measurements and physical therapy management of a female diagnosed with diastasis recti abdominis. Journal of Women’s Health Physical Therapy, 33 (1), 22.

Melody Kentrus, PT, DPT

2 Comments

  1. Janet on January 12, 2020 at 10:56 pm

    I really enjoyed this article in print with the side bar relating to isolating the transverse abdominis.

  2. Vicky on February 7, 2020 at 9:20 pm

    I agree! I have a print copy of this article and was disappointed to see this on-line version missing the side bar which included a lot of useful information

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