Keep it together

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So what exactly is abdominal separation?

Quite literally, a split of your abs. Technically known as diastasis recti, it is a separation of the outermost abdominal muscles, whose job is to support your back and your organs.  When it happens, the abs separate away from the connective tissue or sheath running down the centre of your stomach.

A separation can run for part or all of the distance between the pubic bone and the breastbone. Some women separate only above the navel, some only below. Many women only separate around the navel but often that can self-heal.

Although a common complaint during pregnancy, it can also happen to men.

Why do some pregnant women not have the problem?

Because some women have more laxity in their oblique muscles, on the sides, and these relax and open to allow the growth that happens in pregnancy to expand horizontally. This can be down to genetics but it can also be achieved through training. Women who are really thin and sporty will often have a separation during pregnancy unless they are really good at working the obliques so they are able to relax and open those muscles a bit.

Another common cause is for women to unwittingly get in the habit of bearing down or pushing outward with their stomach muscles. This puts extra inter-abdominal pressure on their muscles. Sometimes when they are getting up, they don’t realise that they push out with the action. So, these women may encourage a separation, but be completely unaware of what they are doing.

How does it affect you?

If you have a diastasis recti, you will look bigger than before – your stomach will often stick out or bulge, even after working out and losing excess weight from other parts of your body.

Many women develop incontinence because there is a lot of synergy between your pelvic floor, your transverse and your oblique muscles; the whole abdominal cavity is meant to work as a whole.

The other thing to recognise is that in this state your body is damaged; that injury is a stress on the body. Some of your body’s resources are constantly being redirected at trying to heal the source of the stress. It’s draining. Anyone who has done even a half hour session of physio to repair a diastasis will know how exhausting it is. You are a little bit compromised in all other areas of your body.

Then there are other issues. A lot of women develop things that they don’t even realise are related to having a diastasis, like lower back pain – it can exacerbate a problem that may have been waiting to happen.

Some women start getting hip pain, which can impede activities that used to be enjoyable, like tennis where you are meant to swing with the power of the core. If you then end up swinging more with your arm to compensate for a weak core, you can cause other damage.

There can also be neural damage after a diastasis. Here it is not just that the muscle has detached – because of the tearing, it is accompanied by a neural compromise where nerves are damaged. The brain can’t talk as effectively to the chain of command in the abdominal area, so sometimes women can’t switch on different areas of the abdominals; they may know it’s sticking out but they don’t know how to hold it in.

But it’s not just the physical – there are also psychological and mental implications. Some women work so hard to keep in shape but their stomach still looks three months pregnant. It can be distressing. They can’t figure out what’s going on, why they have back pain or why they can’t do a roll up or roll down and this can negatively affect how a woman feels about herself.

Almost all cases of diastasis can be addressed, but in rare cases it can lead to a prolapse, total incontinence or hernias.

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How do you know if you have one?

Lie on the floor then roll your head, neck and shoulders up, and try and take a peek at your navel. As you’re doing the roll up, you get your fingers and place them just above the navel and when you roll up, you’ll see whether your muscle comes together or whether there’s a hole. It’s pretty easy to tell whether or not you have one, which is why it always surprises me that a lot of women aren’t diagnosed with it. You can either feel your muscles come together and it’s firm or there’s a little cavity. The way they measure your diastasis is how many fingers sink into the hole across. I usually test above, at and below the navel, to get a good idea of the total damage.

What can you do about it?

Do Pilates! Pilates will help to prevent and heal a diastasis.

If you’re really diligent about exercise and you catch it before your muscles are fully reset in their open position, you have a good chance of closing it. So, ideally you want to start to work on integrated exercises during the post-natal stage, 12 weeks after delivery, if not sooner. If you’ve got a four-finger diastasis, you’re probably not going to close it all the way but you can drastically improve it if you are diligent.

There are different things women can do. First of all, it’s a good idea to see a physio or a doctor, though some are much savvier than others. Get evaluated first – benchmark where you are. They can let you know how long and wide the split is and give you specific tailored advice.

Then you will need to decide on your course of rehab. The most important thing is to set expectations accurately. If you go to a Pilates class once a week, you’re not going to cure your diastasis. Unfortunately, because you have to repair nerves, you have to chip away at it daily. So if you really want to heal it, you need to set aside three months and do your five basic exercises three times a day, marking them off your daily check list. A lot is about trying to get the nerves to start to repair and reminding that neural muscular pathway where it once was.

But the more you do it, the faster your recovery becomes and the more successful you will be. Unfortunately I think most women don’t give themselves enough dedicated time to assess whether it’s really working or not.

Supportive bands can also help. If you’re taught how to use it properly by a physio, it’s a good way of reminding you how to pull in those muscles.

Most insurance companies will cover a diastasis repair physiotherapist, which is another reason to go to your doctor – for a referral letter.

And what do you do if the exercises don’t fix it?

At some point if it is not getting better, you may want to assess your situation to see whether or not you should have surgery. I would suggest that you ask yourself these three questions: Are you in pain and no matter what you do, you cannot alleviate it? Is it a lifestyle compromise that means you can’t do what you want to do? Have you done everything you can to try to repair it? You will have to make up your own mind but you may need to go down the surgery route if the split is large or causing you great discomfort.

What does surgery involve?

Some surgeons put a mesh in and others will do just an old fashioned corset stitchery all the way up. This will pull the muscle back together. There is a big scar though – it replicates the C-section line but it is probably 2cm wider. While most insurance companies will cover it, it is not a decision to be taken lightly.

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