The Tupler Technique can serve your low-back pain patients afflicted with diastis recti.
Among the many causes of back pain, poor posture and obesity are two of the most commonly cited culprits.1 Rarely, however, will diastasis recti, also known as abdominal separation, make the short list—even though it may well be the reason for a person’s poor posture and often coincides with an enlarged stomach area. Given that approximately 30 million Americans experience lower back pain, and considering that back pain is one of the most prevalent reasons people seek help from a doctor, properly diagnosing the source of the pain from this widespread problem is crucial to ensure proper recovery.
Back pain and diastasis recti go hand in hand. The outermost muscles (rectus abdominis) serve as a support system for the back and organs. When these thick muscles separate, a thin connective tissue has to do all the work, and the side effects from this ineffective support system can cause back pain, umbilical hernia, poor posture, and gastrointestinal and pelvic floor problems.
This condition also puts a pregnant woman at risk for a caesarean section. Unfortunately, the medical community has failed to connect the dots between diastasis recti and these issues. Thus, most people with these side effects are not checked for a diastasis, and treatment for this condition has been largely ignored.
Understanding the condition
Everyone is born with their abdominal muscles separated. At around 3 years of age, after the nervous system has developed, the muscles usually come together. Occasionally, they don’t or, in other cases, continual pressure on the connective tissue from the activities of daily living, exercising, sports, abdominal surgery, or weight gain in the stomach will cause the muscles to separate again. The weak spot in the linea alba at the umbilicus makes the connective tissue more vulnerable to separating.
All patients with back pain should be checked for diastasis recti, a process that includes evaluating both the distance of the separated muscles and the condition of the connective tissue. If a patient has weak connective tissue, it will take longer for the separation to close. To check the distance of the diastasis correctly, it needs to be assessed when the diastasis is at its largest.
The recti muscles come together as patients bring their shoulders off the floor, making the diastasis appear smaller. Check patients when the recti muscles first start to move. If, upon shoulder lift, the patient has a bulge in the shape of a half-football or a protruding belly button, the diastasis may be severe and you will want to use two hands when checking the distance of the separated muscles.
Feeling with your fingertips across the stomach midline, determine the strength of the connective tissue based on the depth of the crevice. (The deeper you’re able to feel, the weaker the tissue). Another sign of weakness is the presence of a pulsing sensation. If you confirm the presence of diastasis recti after performing this evaluation, it’s time to implement an effective treatment plan.
The Tupler Technique
For more than 20 years, the Tupler Technique program has been treating clients with diastasis recti.2. It is the only research- and evidence-based program for this condition.3 Tupler Technique statistics featuring data from 1,200 clients show that within six weeks after starting the program, patients can make a diastasis 55- percent smaller.
The goal of the four-step Tupler
Technique program is to heal the weakened connective tissue between the two recti muscles called the linea alba. The technique aims to strengthen both the abdominal muscles and connective tissue for improved health. The program promotes healing by:
1.Continually approximating the connective tissue and recti muscles. This takes the stretch off the weakened tissue, allowing it to heal. It also puts the recti muscles in the correct position so they move backward, rather than sideways, when a patient performs exercises. A backward movement of the muscles strengthens the area, while a sideways movement not only fails to strengthen it but also stretches the weakened connective tissue.
2.Protecting the connective tissue from movements, exercises, and activities that stretch it, including:
- Exercises in the hands-and-knees position. In this position, the weight of the organs stretches the connective tissue (swimming, planks, push-ups).
- Exercises while the back is arched and the ribs are flared (backbends, yoga upward facing dog).
- Exercises doing a forward crossover movement (tennis, golf, oblique crunches, swimming, Pilates).
- Exercises while lying back-down with the shoulders off the floor (crunches, Pilates, rollbacks).
3.Strengthening the transverse muscle.
Transverse strength and awareness is important in activities of daily living and when incorporating it in into a diastasis-safe exercise routine. The isometric strengthening exercises bring blood flow to the connective tissue.
During the first six weeks of the program, emphasize developing transverse strength while performing activities of daily living to allow the connective tissue to heal. Doing other exercise programs simultaneously is discouraged.
Patients can still do aerobic exercise such as walking on a treadmill or riding on an upright stationary bike during this time. Then, in week six of the program, patients are taught how to use their now-strengthened transverse muscle during the exercise routine and how to modify it so it remains diastasis-safe.
The exercises progress over 18 weeks. Photos of the patient’s belly area should be taken from the front and side before starting the program. They are taken again in weeks three, six, and 18, as they motivate patients to stay committed to the program.
The time it takes to close a diastasis depends on the severity of the condition and the patient’s commitment to the program. A severe diastasis usually takes no less than one year and as long as three years to close. Patients will see the healing process begin within the program’s first couple of weeks. If the connective tissue fails to heal properly, the patient can reopen the diastasis.
The four overarching steps of the program are:
- Three exercises (seated elevator, contracting, and back-lying head lifts)
- Approximating the muscles and connective tissue with a splint and holding a splint in week four of the program.
- Developing transverse awareness with activities of daily living and while exercising to prevent force on the connective tissue, which stretches it.
- Getting up and down correctly from:
- Seated to standing
- Standing to seated
- Back lying to seated
- Seated to back lying
The above movements use the patient’s whole body weight. This is a tremendous amount of force on the connective tissue.
Patients having abdominal surgery should strengthen their transverse muscle before surgery so they will have the strength and awareness to use it in the recovery process and maintain the integrity of the sutures. Strengthening the connective tissue before surgery also makes the opening easier to sew.
Your pregnant patients should keep their diastasis as small as possible to not only prevent back pain during pregnancy but to keep the uterus in the proper position, ensuring the cervix is aligned with the vaginal canal. With a large diastasis, the top heavy uterus tilts forward, making the cervix point sideways instead of downward. A sideways facing uterus puts a pregnant woman at risk for a c-section.
To address the full range of back- pain instigators, chiropractors need to start checking their patients for diastasis and incorporating the treatment of this condition as part of their protocol.
Julie Tupler, RN, is a certified childbirth educator and personal trainer. She developed the Maternal Fitness Program in 1990 and for more than 20 years has been teaching and developing the Tupler Technique Program for treatment of diastasis recti for women, men, and children. She is a frequent speaker at medical and fitness conferences including the 1st World Conference on Abdominal Wall Hernia Surgery.
1 American Chiropractic Association. “Back Pain Facts & Statistics.” http://www.acatoday.org/level2_css.cfm?T1ID=1 3&T2ID=68. Accessed November 2015.
2 American Physical Therapy Association. “Section on Women’s Health.” 2012;36(3).
3 Journal of Women’s Health Physical Therapy. 2005;29(1):11-16.