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Separation of the abdominal wall is a normal anatomical change that occurs gradually throughout pregnancy in-line with the baby’s growth. During pregnancy, women will often notice the ‘doming’ of their abdominal muscles when they go to sit-up, which to some extent occurs in all pregnant women. It is only when this separation becomes excessive that complications and pain can arise.
The doming of the abdominal muscles takes place because the two sheets of the abdominal muscle have started to separate at the linea alba, which is a flat sheet of tendon which vertically connects the ribs to the pubic bone. If this separation didn’t occur, there wouldn’t be much room for the growing baby. It’s important to stress once again, that within a certain tolerance, separation is normal!
Abdominal Separation During Pregnancy And Low Back Pain
How Do The Abdominals Separate?
Excessive abdominal separation is more formally known amongst Physiotherapists and the Obstetric community as diastasis recti, and this is thought by some to increase the risk of an abdominal hernia. However, there is no clinical evidence to support this position and the precise risk of developing a hernia remains unclear. The concerns around the risk of hernias are thought to increase because the abdominal muscles are stretched and consequently become thinner. However, the separation is actually caused by the stretching of the linea alba and not the muscles, so this hypothesis doesn’t really stack up!
Abdominal Separation And Pain
But what does the evidence say about diastasis recti and lumbo-pelvic pain? For several reasons, there are limited scientific links between abdominal separation and pain in the low back and pelvis. Firstly, as is the case with a lot of research in pre and postnatal populations, the sample sizes are very small. Secondly, there is potential for assumed correlation (a relationship, is not the same as cause and effect) because lots of pregnant and postnatal women suffer from lower back pain and divarication of their abdominals. Thirdly, the measurement parameters vary widely depending on the research protocol used and the clinical opinions of the researcher. This third point makes it almost impossible to combine or compare the findings from different research studies. It does, however, highlight the sheer complexity of the human body.
How To Treat Abdominal Separation?
In order to answer the treatment question, it is first necessary to identify the reason(s) why the separation occurs in the first place. We know that separation is a normal anatomical change that occurs during pregnancy to create more space for the growing baby, but why does this become excessive to the point where the abdominals do not return to their normal position post-birth? As is often the case with injury and pain, the core is at the centre of this debate!
The core comprises of all the layers of muscle and connective tissues which attach to the spine, pelvis and ribcage in order to provide stability. This stability is essential to allow give the limbs a platform to move freely without unnecessary movement. If a woman is starting her pregnancy with a weak core then her risk of developing a diastasis recti will be greatly increased. Leading pre and postnatal physiotherapist, Dianne Lee, says “it is clear that abdominal separation is just the tip of the iceberg when it comes to core weakness and back pain”. Lee’s research identified that those with abdominal separation display an inability to engage the deep core stabilisers, particularly the corset-like muscle called the ‘transverse abdominus’. This is the leading cause of most core weaknesses, back pain and incontinence in pre and postnatal women. Additionally, Lee also found that without the co-contraction of the pelvic floor muscles, there is little to no improvement in the deep abdominal muscles.
This research is really important because it casts a significant shadow over the appropriateness and effectiveness of abdominal supports. The use of kinesio tape, Tubigrips and abdominal supports are commonly used with pre and postnatal women who have abdominal separation. However, the research suggests that these supports are likely only to be supporting weaker muscles to become weaker, limiting the function of the core as an integrated unit of muscles.
The most effective course of action will be to adopt as early as possible in pregnancy a core stabilisation programme, which focuses on the deep and enduring muscles in the core. It is worth noting here that exercises like sit-ups and leg raises are not core stabilisation exercises and in fact are contraindicated. These exercises are highly dangerous in pre and postnatal women, especially those with a diastasis recti! Pilates and yoga-based exercises ‘may’ be appropriate for some women, but in reality, if the classes are intended for non-pregnant participants then most of the exercises are likely to be inappropriate.
The best thing that any woman who is pregnant or who has recently given birth could do is to hire the services of a professional fitness instructor or personal trainer who has completed a specialist pre and postnatal course or qualification. If they are still under the care of a midwife then it is likely that they will be able to ask for a referral or recommendation. Those women who have a significant and complicated diastasis recti will likely be referred to a suitably qualified physiotherapist, who will provide specialist care and guidance on remedial exercises.
About The Author
Naomi Schon is a Registered Midwife (RM) with over 10 years’ midwifery experience. She is also a fully qualified Personal Trainer, yoga and Pilates teacher. Naomi is currently the lead clinical consultant for all things related to pregnancy and postpartum exercise at Health and Fitness Education (HFE), focusing primarily on their personal training courses.