Oh NPR!

This week one of my favorite news sources put out a story that had my Facebook feed on fire. I have to say that my husband regularly notices that I get different posts than he does. Posts like images of uterine alignment, vulvar-vaginal tissues, and diastasis recti. What can I say? I have friends with connections in “low” places!

NPR did a story on diastasis recti (DR) which refers to abdominal separation that sent my colleagues and me into tizzy. The title “Flattening the ‘Mummy Tummy’ with 1 Exercise, 10 Minutes a Day” with an instructor promising that “you can easily expect to see 2 inches off your waist in three weeks of time,” triggered those of us that are working hard to improve women’s pelvic and abdominal health. Read the whole article for yourself here.

I personally and professionally have so. many. problems. here. With the grabby title, with the promise of an easy fix, and most of all with the content and evidence that was used to validate what was perceived as a positive outcome. Please understand that I am very happy that women’s health challenges are being reported on national media. I also appreciate that the author did present some good information from health professionals and a variety of resources in the article. But the main premise, as the title promises, is a quick fix to a very complex symptom and the research uses a measure that has very little to do with health or function as evidence-based “success.”

Root medicine is about finding the cause of a symptom, not simply solving or relieving a symptom. In fact, symptoms such as pain or dysfunction are regarded as important signals to learn from rather than fix or medicate. DR has several root causes: intra-abdominal pressure, reflexive movement patterns, and muscular integrity through a range of motion. Although DR is generally considered a postpartum issue, women that have never had a baby and many men have experienced abdominal separation. Therefore, clearly, pregnancy is not a root cause; however, all women will have some degree of stress on abdominal musculature when pregnant. DR becomes a concern when abdominal thinning or separation do not heal or when dysfunctional co-morbidities are present.

Many of my colleagues are pushing for postpartum physical therapy (PT) in the US. I mean, we get routine PT for joint surgeries. While that is important, these surgeries are generally less disruptive to overall function than the process of pregnancy and birth. Often accompanied by tissue damage and surgical interventions, birth has very limited follow up care in the US. Additionally, this tender, torn, and tired mama must feed and care for a completely dependent newborn. And then return to work promptly. Stress much? PT, tribal support, meals, maternal/paternal leave, flowers, and much more is needed for our young mothers. What isn’t needed? A promise of an easy fix and a quick  return to a trim waistline.

Because, trust me, if the fix were easy, the problem wouldn’t be so pervasive. There aren’t easy answers and the root causes are not being addressed in our health care system. Our bodies are complex. Although we are able to heal, healing happens most thoroughly when all of our systems are working together in their beautiful complexity.

So, let’s look back at those root causes and how the method of bringing the “belly to the spine” technique supports healing. First off, intra-abdominal pressure (IAP): pulling your stomach in increases IAP–which is one of the causes of DR. So how can the cause be the fix? It can’t. It only displaces IAP. Breathing is dependent on the management of IAP, which is why the women in the class had to take tiny breaths–they couldn’t take a deep breath with so much pressure. If a belly is pressed to the spine, and a deep breath is required, IAP forces are transferred toward the area that can “give.” Forceful abdominal contraction with increased IAP is created reflexively to push something out by coughing, sneezing, or vomiting–creating “give” through the throat and clearing out blockages or poisons. Intentional over-contraction makes a necessary movement like coughing less  effective. Since breathing may ultimately depend on coughing something out, the reflex-driven force increases and may lead to stress incontinence, especially when pelvic floor muscles have been compromised from pregnancy and birth and may have more “give” than the throat. Symptoms are simply transferred rather than fixed when root causes are not considered.

Which brings us to the second root cause of DR: a confused reflexive core. Our societal drive for a sculpted 6-pack is driven by media, not health professionals. Having a “strong core” does not guarantee less back pain, better posture, breathing, or a reduction in the incidence of DR. Overriding our reflexes by constantly engaging the core also tenses the pelvic floor which works in tandem with deep abdominals. Constant tension reduces our ability to relax or even feel tension. This may seem like a way to decrease “give” and reduce leakage, however, since the core is over-engaging, most likely so is the pelvic floor. It is common to have at too-tight pelvic floor as the root cause of many problems such as urge incontinence, nerve impingement, digestive issues, uterine displacement, and difficulty in sexual intercourse or with orgasm. That is why working with a pelvic PT is so important. Besides back pain relief, no other typical co-morbidities are discussed in this article. We know nothing about how the 63 women in this study are functioning the other 23 hours and 50 minutes of their day.

The third root cause is about contraction of abdominal muscles themselves: this is about connective tissue adaptability and recovery from stress. Strong muscles have tone throughout their range of motion–not just in their shortened and contracted state. In the abdomen, range of motion needs to be adaptive enough to allow for expansion of organs–and in pregnancy, to accommodate a full term baby. If a growing baby increases IAP and muscles cannot stretch with integrity and tone, some portion of the connective tissue becomes stressed, undernourished, and weakened. Eventually there may be tearing and separation from attachments. So in a sense, weak muscles are a cause of DR, but the weakening is due to a lack of adaptability and maintaining tone in a stretched state. Limiting the range of motion by constant tensioning is the reason for this lack of adaptability. Re-establishing tone in a shortened state only will not fix the inability of a muscle to stretch and maintain integrity. The next pregnancy will cause DR again.

Finally, the proper way to measure recovery from connective tissue stress and DR is by muscular responsiveness through a complete range of motion. In the research quoted in the article, success was measured by how many inches lost from the waistline and the width of the DR in a contracted abdomen. Waist circumference is not a valid measure for muscle tone since waists include fat, organs, and digesting food. Although measuring the DR split in a contraction is somewhat indicative of tone, it has reliability problems and should only be used as a comparative guideline rather than a validity measure. A much better way to measure tone is through ultrasound and having the client move through a range of motion to test if a muscle is responding.

With a small sample and no control group, poor validation, and mostly, with an extremely superficial understanding of what diastasis recti involves, this pilot study is just plain sad.  As the article indicates, even ACOG recommendations are vague so I will forgive NPR this one time. I’m hopeful that more help, research, evidence-based practices, and reports are on the way. Let’s fill up everyone’s social media with lots of really good information on women’s health. That would make me happy.

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