Diastasis Recti Abdominis

Original Editor - Marianne Ryan

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Definition/Description

Diastasis recti abdominis is a separation of the rectus abdominal muscles at the linea alba. Diastasis recti abdominis can occur as a result of prolonged transverse stress on the linea alba in men, postmenopausal women, and in women during pregnancy. It can also occur in newborns and is defined as an inter-rectus distance that is greater than 3cm in this population.

Diastasis Recti Abdominis and Pregnancy

During pregnancy the linea alba softens due to hormones and the mechanical stretch resulting from the accommodation of the growing fetus. Because of this, there will be a progressive increase in the width of the linea alba (the inter-rectus distance or IRD) throughout the trimesters, with the highest incidence occurring in the third trimester.

A recent study by da Mota and colleagues included 84 first-time pregnant women and found that 100% of them had DRA by gestational week 35 when using a diagnostic criterion of 1.6cm at 2cm below the umbilicus. The prevalence decreased to 52.4% at 4-6 weeks postpartum and continued to decrease to 39% at 6 months. While this agrees with other studies that have also found a decreased prevalence at 4 weeks and 8 weeks postpartum, a study by Coldron and colleagues found that healing reached a plateau at 8 weeks postpartum and that IRD and rectus abdominis thickness and width did not return to the control values one year later.

Clinically Relevant Anatomy

The two rectus abdominis muscle heads run parallel to each other and are separated by a connective tissue along the midline of the body called the linea alba. The distance between the rectus abdominis muscles is referred to as the inter-rectus distance.

Clinical Presentation

An adult is considered to have a diastasis recti abdominis when they present with an 'abnormal' inter-rectus distance. On palpation, if a therapist can place two or more finger breaths (≈2cm) in the sulcus between the medial borders of the rectus abdominus muscles the patient may present with diastasis recti abdominis. Palpation, in clinical practice, appears to be sufficient for detecting the presence or absence of diastasis recti, however ultrasound imaging can produce a more precise measurement.

Currently, the literature is not in agreement with what the diagnostic cut-off is for diastasis recti abdominis. Our best approach is to inform our clinical practices with the work done by Beer and colleagues who suggest that, in nulliparous women (women who have not given birth), the normal width of the linea alba should be less than 1.5 cm at the xiphoid level, less than 2.2 cm at 3 cm above the umbilicus, and less than 1.6 cm at 2 cm below the umbilicus.

Role for PT Management

However, evidence doesn’t fully support this as da Mota and colleagues and Sperstad and colleagues found no link between DRA and lumbopelvic pain. Bø and colleagues also found no link between DRA and weakness of pelvic floor musculature or prevalence of urinary incontinence and pelvic organ prolapse.

While the condition is very common, there is a lack of high-quality evidence to guide management in clinical practice. This creates debate when it comes to carrying out a conservative care approach. However, Dufour and colleagues interviewed credentialed women’s health physiotherapists to create 28 Canadian expert-based recommendations, which were further categorized into primary and secondary importance.

Beginning exercises prenatally may help to maintain the tone and control over abdominal musculature to decrease some stress of the linea alba. Early literature suggests that functional capacity of abdominal musculature may be compromised due to a change in the muscle’s line of action. Since then, Chiarello and colleagues found that the occurrence and size of DRA is greater in pregnant women who do not exercise and that, since the abdominals play an important functional role in exercise, women must be screened for the presence of DRA. More recent evidence supports deep core stability-strengthening 3 times a week for 8 weeks, in addition to bracing, to improve inter-recti separation and quality of life as measured by the Physical Functioning Scale (PF10). The exercises included diaphragmatic breathing, pelvic floor contraction, plank, isometric abdominal contractions, and traditional abdominal exercises. Lee and Hodges proposed that narrowing the IRD may not be optimal and that pre-activation of TrA can increase the tension and decrease the distortion of the linea alba, which will allow for force to be transmitted across the midline.

However, Gluppe and colleagues found that a supervised exercise class once a week for 16 weeks, in addition to daily home training, did not reduce the prevalence of DRA at 6 months postpartum. The exercises focused on strengthening the pelvic floor, but also relaxation and stretching, as well as strengthening of the abdominals, back, arms, and thighs.

Patient Education

It is important to educate our patients on diastasis recti abdominis during and after pregnancy. The video below by a Canadian physiotherapist uses a great analogy to explain the concept of diastasis recti abdominis.

Common Postpartum Exercises

Kegel Exercises

Pelvic floor exercises can help strengthen deep abdominal muscles. These exercises can be performed throughout pregnancy and may be started in the early postpartum period.

Breathing Exercises

Breathing exercises help to retrain the diaphragm to relearn how to descend after childbirth. During pregnancy, the diaphragm is pushed upwards by the growing uterus and loses its ability to descend during inhalation. Since the diaphragm forms the top of the core muscles, it is important to retrain it to function with a full excursion again. Here are 2 good exercises

1. Inverted Breathing - Lie supine with the buttock on a pillow wedge, raised above chest level. Teach the patient to take short, shallow breaths “through the pelvic diaphragm.” Have the patient place one hand just above the pubic symphysis and teach them to feel for a slight up and down motion while they breathe in and out. Place the patient's other hand on top of their chest and tell them to try not to have their chest rise when breathing.
2. Lateral Costal Breathing - In the seated position have the patient place their hands on the lateral sides of the rib cage. Teach them to “breathe into their hands” and to feel for the lateral expansion of the rib cage as they inhale and the movement of the ribcage toward the midline during exhalation.

Progressive Core Exercises

There are several exercises that can be used to help restore core strength after pregnancy. For more information refer to Diane Lee’s work on the Diastasis Recti.

Body Mechanics

It is important to teach the patient how to perform ADL’s without increasing abdominal pressure, such as rolling out of bed, instead of doing a “sit-up” to get up. Avoid “jack-knifing” behaviour that increases intra-abdominal pressure. Teaching patients to roll to their left side and use their top arm to help push themselves up is a commonly prescribed technique. Other activities to watch out for is getting out of a bath, lifting and carrying older children and heavy objects during pregnancy and the early postpartum period. Teach them to “exhale as you lift.”

Postural Awareness

After pregnancy, some women tend to stand with and an exaggerated anterior pelvic tilt and with their pelvis pushed forward. In order to stand up against gravity, their bodies typically develop areas of rigidity in the upper lumbar and the lower thoracic area along with the buttock muscles. Diane Lee refers to this as “back clenching and buttock griping behaviour.” Manual therapy and relaxation exercises may be indicated before initiating strengthening exercises. (http://dianelee.ca/articles/UnderstandYourBack&PGPopt.pdf)

Abdominal Supports

Abdominal Binders: Binders may be helpful for some women in the postpartum period, but the wrong or overuse of them can cause more problems. It is best not to use an abdominal binder unless necessary, for example during pregnancy in the third trimester and 6 weeks after delivery if there is a separation of 2 fingers or more.

Belly Band: Wearing a belly band during pregnancy (one made specifically for pregnant women) may help increase proprioception and muscle awareness. A belly band or tight tube top can be used after childbirth for the same reasons.

References