Diastasis Recti

What is it?

Diastasis recti (DR) is a common musculoskeletal condition found during and after pregnancy. This condition is a widening of distance between the rectus abdomis muscles along the linea alba.  The recti abdominis are the two muscles that make up your six pack.  The linea alba is a band of connective tissue that connect the two 3-packs along midline.  Women at menopausal age and men may also develop this condition.  If it is left untreated, it may result in a hernia.

DiastasisRectusAbd-LG
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DR commonly occurs during the third trimester of pregnancy, but typically resolves the largest distance within 1-8 days following delivery.  DR has been reported to be experienced by 66-100% of women during their third trimester and up to 53% postpartum.1,2 In 1987, Boissonnault and Blaschak2 published the first research articles published on DR.  They found that DR may compromise the function of the abdominal wall including:

  1. postural stability
  2. respiration
  3. delivery of a fetus
  4. trunk range of motion (flexion, rotation and side bending).2

Several research articles agree that these deficits may result in low back pain, lumbo-pelvic instability, non-optimal loading strategies and cosmetics defects.1,2,4,9 In a study completed in 2007 by Spitznagle8 on the uro-gynecological population, 66% of women with DRA also had at least one support-related pelvic floor dysfunction; such as stress urinary incontinence, fecal incontinence and/or pelvic organ prolapse.  Although DR is commonly found during pregnancy, it is clinically significant if it is painful or persistent following the birth.

Why did this happen?

Researchers agree that the increased distance between the rectus abdominis muscles is thought to be due to stretching and thinning of the linea alba.7,9   Boissonnault and Blaschak1 report that it may be due to the hormonal softening of connective tissue that is experienced during pregnancy and post-partum, the increase in inter-abdominal pressure and/or the displacement of organs from the growing fetus.  Prenatal risk factors have been identified by Spitznagle et al8 as including:

  • a woman’s age
  • pregnancy body mass index (BMI)
  • weight gain during pregnancy
  • BMI at six months postpartum
  • hypermobility score
  • baby weight at birth
  • abdominal circumference in late pregnancy
  • and level of exercise training.

Although, a study by Fernandes da Mota et al4 in 2015 found these risk factors to not be significant in predicting DR.

Do I have it?

It has been accepted that a widening greater than 22-23mm (2 finger widths) as identified by ultrasound measurements to be clinical significant.4  The “finger width” palpation method has been shown to be a good screening tool for clinicians as determined by a systematic review completed by Van de Water, et al.9 Here are some steps in measuring DA:

  1. Lie on your back with her knees bent and feet flat on the floor
  2. Engage your abs by lifting your head off the floor.
  3. Use your fingers to palpate the space inbetween your abdominal muscles.
  4. Determine the width of the distance by estimating how many finger widths it is

Depending on the width of your fingers, more than 2 fingers would be clinically significant.  Don’t freak out unless its been longer than 6 months post-partum.  It should resolve on its own, assuming you have good posture & proper biomechanics.

What can I do about it?

There is no consensus on the best way to treat DRA, but current treatment options include:

  • surgical interventions
  • abdominal exercises
  • postural and back care education
  • external support
  • aerobic exercises

It is important to treat DR.  This has been illustrated by research completed by Lee, et al5 in which they found that injury to the myofascial of the lumbo-pelvic region, may play a significant role in decrease function, incontinence and abnormal respiration, by creating non-optimal loading strategies in the core region. Non-optimal loading strategies develop during pregnancy and perpetuate DR.  Lee et al5 states that restoring optimal loading strategies of this area, may help to decrease the impairments cause by a compromised fascial system of the core following pregnancy.  Good posture and biomechanics is an area that many physical therapist specialize in.  Finding the right practitioner for you is key in treating your DR.

It is important to treat DR even if it is non-symptomatic.

The goal of treatment will be to restore normal movement patterns of the body and prevent future injury.  This will allow your body to restore it’s function and shape.  DR is not a permanent condition, but is a sign of an underlying imbalance in your body.  Even if it is not causing pain, it will be beneficial to treat it if it doesn’t go away on its own.

If you have signs and symptoms of DR, please contact your local physical therapist.  They will be able to provide you with the tools necessary to treat the imbalances found in your body that may be perpetuating the DR condition.  Individualized treatment will include: postural education, manual therapy, neuromuscular re-education, refinement of your motor control, and a home exercise program.  Physical therapist have the knowledge and skills necessary to treat your DR with conservative management, avoiding surgery and preventing future injuries.  A PT should be able to recognize the postural & biomechanical imbalances on the first visit, and be able to make a significant change within a few visits.

Bibliography
  1. Benjamin DR, van de Water ATM, Peiris CL. Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy. 2014;100(1):1-8. doi:10.1016/j.physio.2013.08.005.
  2. Boissonnault JS, Blaschak MJ. Incidence of diastasis recti abdominis during the childbearing year. Phys Ther. 1988;68:1082-1086.
  3. Coldron Y, Stokes MJ, Newham DJ, Cook K. Postpartum characteristics of rectus abdominis on ultrasound imaging. Man Ther. 2008;13(2):112-121. doi:10.1016/j.math.2006.10.001.
  4. Fernandes da Mota PG, Pascoal AGBA, Carita AIAD, Bo K. Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Man Ther. 2015;20(1):200-205. doi:10.1016/j.math.2014.09.002.
  5. Lee DG, Lee LJ, McLaughlin L. Stability, continence and breathing: The role of fascia following pregnancy and delivery. J Bodyw Mov Ther. 2008;12(4):333-348. doi:10.1016/j.jbmt.2008.05.003.
  6. Moseley GL, Hodges PW. Reduced variability of postural strategy prevents normalization of motor changes induced by back pain: a risk factor for chronic trouble? Behav Neurosci. 2006;120(2):474-476. doi:10.1037/0735-7044.120.2.474.
  7. Rath AM, Attali P, Dumas JL, Goldlust D, Zhang J, Chevrel JP. The abdominal linea alba: an anatomo-radiologic and biomechanical study. Surg Radiol Anat. 1996;18(4):281-288.
  8. Spitznagle TM, Leong FC, Van Dillen LR. Prevalence of diastasis recti abdominis in a urogynecological patient population. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18(3):321-328. doi:10.1007/s00192-006-0143-5.
  9. Van de Water ATM, Benjamin DR. Measurement methods to assess diastasis of the rectus abdominis muscle (DRAM): A systematic review of their measurement properties and meta-analytic reliability generalization. Man Ther. 2016;21:41-53. doi:10.1016/j.math.2015.09.013.
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