Lately I haven’t had much to say about diastasis recti, mostly because almost 9 years after discovering mine, I find myself thinking less and less about my belly. Also, advice hasn’t changed as much as you’d think it would. Despite all the well-meaning guidance circulating the web and inside clinical practices, we still don’t have actual evidence that exercise helps close diastasis recti. In fact, we have evidence to suggest it does a whole lot of nothing rather than the other way around.
And yet…this doesn’t mean women should stop exercising or stop trying to remedy their blown apart bellies. I wrote about my experience here and most of that post has held pretty steady over the last 4 years. Exercise seemed to help me, but I still don’t know exactly how or why. I’ve decided not knowing doesn’t matter that much because exercise is good, so we should disconnect our motivation to move from the hope we will improve one body part.
Letting Go of Sacred Cows
Although the more recent studies on diastasis recti haven’t unlocked the code for closure, they have put to rest some strongly held beliefs held by many in the postpartum world: Let’s all admit that exercises fixated on the transverse abdominis and pelvic floor will NOT close an abdominal gap, at least not according to any actual evidence.
For example, last year Gluppe, Hilde, Tennfjord, and Bo published a study called “Effect of a Postpartum Training Program on Prevalence of Diastasis Recti Abdominis in Postpartum Primiparous Women: A Randomized Controlled Trial.” That’s a mouth full, but to the point. Why did they do this study? The authors stated “to date, there is scant evidence for the effect of any exercise programs in prevention and treatment of DRA.” Therefore, they tested an exercise protocol that was designed to strengthen the pelvic floor muscles but that also included strength exercises for the abs, back, arms, and thigh muscles, as well as stretching and relaxation, which seems to cover the exercise bases.
Their results were…
At 6 weeks postpartum, more than 50 % of the women in each group were categorized as having DRA. We found no significant differences between groups in DRA prevalence at baseline, immediately after the intervention period at 6 months postpartum or at follow-up 12 months postpartum.
Other researchers have come up with similar nil results, even showing that drawing in the transverse abdominis widens, instead of narrows, the gap. In the face of this evidence, people like Lee and Hodges have not abandoned their advice to activate the TrA but have rather changed its tenor by coming up with a new hypothesis — put simply, if the TrA doesn’t narrow DR, then DR doesn’t need to be narrowed.
Gluppe et.al. ever so subtly called BS when addressing the Lee and Hodges hypothesis. They wrote:
They [Lee and Hodges] postulated a new hypothesis that contraction of the PFM with co-activation of the TrA may tighten the linea alba and hence be important for the function of the abdominal wall. For the time being this hypothesis needs further investigation, and to date there are no RCTs to support this suggested training protocol in clinical practice. We would argue that for women with DRA, the main goal is to close the diastasis and that this has been, and is, the expected outcome of exercise training interventions for this prevalent condition.
In case you don’t read block quotes, I’ll summarize. Gluppe and her colleagues said that Lee and Hodges don’t have any evidence to support their hypothesis that TrA drawing-in is still important. They also point out that most women just want a narrower DR, which means women expect the gap to get smaller after all their exercise efforts.
In my opinion, it’s probably true that the gap doesn’t need to get smaller in some cases, but it also smells a little like Lee and Hodges didn’t get the results they expected and instead of giving up a maneuver they’ve been teaching for years and years have simply come up with another rationale for doing the same old thing. That said, I still like to contract the TrA because I’m nothing if not confusing.
The Gluppe study highlights the main problem with DR research. Long term general exercise interventions are a bit like throwing spaghetti at the wall and seeing what sticks. And for now, not much has been sticking. To further muddy the waters, DR size is not constant over time. For many, if not most, women DR rates will naturally decrease over time without doing anything at all. For other women, nothing will work. And, for some women, exercise will probably work, but trying to find the cohort of women that will benefit from a specific exercise is very hard to do.
In this study, within group variation was large, suggesting that something other than exercise was influencing the rate of gap closures. Individual anatomical variation is huge, so trying to find the one exercise or group of exercises or breathing patterns is likely a pointless goal from the get-go. Any doable sample size is unlikely to be large enough and granular enough to show much of anything.
All About Me
Thinking back to my own experience, which is all I’ve got, I’ve noticed how much the (lack of) evidence resonates. Pelvic floor muscle training and TrA activation did nothing for narrowing my DR. Nothing. But… they absolutely helped my pelvic floor, so I still recommend it.
Once I felt strong enough to do more aggressive exercise, I saw more improvement, which suggests that focusing on the inner core wasn’t a complete waste of time. You can’t lift heavier weights or put more stress on your abdomen until you feel like you won’t pee yourself. As far as I’m concerned, not peeing yourself is an important exercise prerequisite, no matter what Crossfit says.
At this point, I’ve accepted the size of my gap (only about 2 finger-widths), and I’m on the fence about doing anything to get rid of the extra skin. I feel like exercise and time has gotten me as far as I can go, which has been surprisingly far. I have no idea which specific exercises did it, so I stick with what I like.
The diastasis recti puzzle isn’t even close to being solved. We have huge gaps (pun intended) in our knowledge, and I’m not sure what kind of study would fill the gaps. I appreciate the authors who have tested the most sacrosanct theories because sometimes abandoning pre-held notions is the most we can ask.
9 years out my advice for anyone struggling with DR is still not revolutionary.
- See a female centric physical therapist if you experience pain or pelvic floor issues.
- Make sure you aren’t overdoing exercise in terms of ballooning your belly, but also stress your muscles enough so that you see improvement. You don’t need to exercise an hour a day. Stay away from all or nothing thoughts and feel proud even if 10 minutes is all you can fit in.
- Beware of overconfident advice. Exercise is good for the body. That is established, but it’s a crapshoot when trying to figure out if anything in particular will affect a DR.
- Don’t feel like surgery is a failure. You don’t have to prove anything to anybody in terms of your body, whether that means going under the knife or not. Similarly, don’t feel like maintaining a gap between your abdominal muscles is the great tragedy of your life. Working for improvement is good, but fixating obsessively and looking for the one cureall is foolhardy.