Diastasis Recti Abdominus

Over the last few days, I was asked some questions about care for diastasis recti abdominis (DRA). How long is this condition supposed to last for post-pregnancy? Should I get surgery to correct this issue? Will the surgery help my low back pain, to is it just a cosmetic procedure? My physiotherapist tells me that I cannot do sit-ups or else I could end up making things worse, but my surgeon says that those exercises are totally okay, what should I do?

As always, I want to give you a good clear definition of that the condition is. DRA is central splitting of the rectus abdominis (RA) muscle and thinning of the linea alba fascia. Lets looks at a picture:

It’s important to note that there is also a few other abdominal muscles running into the linea alba for support: the transversus abdominis (TA – the deepest layer, with fibers running horizontally), and the internal and external oblique muscles (IO and EO – fibers running in a cross pattern diagonally).

So why does DRA happen? What are the risk factors for developing DRA?

Close to the 14th week of gestation, there is a peak of a hormone called relaxin in the system. This hormone, in combination with progesterone (another pregnancy hormone) will soften the body’s connective tissue. Decreased strength of the connective tissue is very important because it will allow the fetus to grow in the uterus and push onto the abdominal wall without being restricted, AND it allows more motion at the sacroiliac joints and pubic symphysis to allow the child to exit though the vaginal canal (natural child birth). The linea alba is connective tissue, and the abdomen obviously increases in size through pregnancy. As the abdomen increases in size, the rectus abdominis may split to allow more room for the child. Gilleard and Brown measured a 115% increase in the length of rectus abdominis – another problem that may lead to decreased stability in the anterior abdomen. Some studies have shown upwards of 67%-100% (Boissonault & Blaschak, Hannaford and Tozer, respectively) of women having DRA during and/or post pregnancy.

Lo, T et. al. went to discover what were the risk factors to development of DRA. Listed are:

• Increased age of mother
• Larger weight gain with pregnancy (other authors state >30lbs is enough)
• Larger infant size (just “googling”, there are claims of massive birth-weights of 20lbs!!! Obviously not the norm, but I can imagine the pressure put on that linea alba!)
• Carrying multiples (more inside = more size)
• Multiple births (A 2nd child, especially with no exercise training or stability training between births may hold that stretched position on the rectus abdominis for longer periods. I could speculate that back to back births (that women with 19 kids and counting, yikes!) does not allow adequate “healing” time).
• Cesarean Section (the surgeon/OB/GYN is cutting right through that linea alba)

How can I tell if I have DRA?

Sometimes it is obvious to you that there is bulging occurring anteriorly (over the stomach) with activities such as getting out of bed, but sometimes it may not be as apparent. To be sure, it is best to book an appointment with your OB/GYN specialist or a physiotherapist that is knowledgeable in post-natal care.

The degree of DRA is based on a measurement, sometimes referred to as the inter-recti distance or IRD. There are a few ways of your clinician to measure this, but some methods have poor inter- and intra-rater reliability (ie: if I the clinician measures it once, my measurement shows a completely different result (intra) and if I the clinician measures the space, and another clinician measures the space, we have again different results).

The least reliable (as shown in a study by Bursh, G. in the Journal of the American Physical Therapy Association) is measurement by finger breadth. If the clinician is only measuring with the hands, your classification for how pronounced the DRA is, may be off.

More reliable results come from measurement through use of calipers (Chiarello C.M. et. al), and better yet through ultrasound (Liaw, L.J. et. al.). I’ve read some studies that measure the distance with CT, but that’s just too much radiation in my mind.

Measurements through care by the clinician are important, especially in the case of physiotherapist, when we can then progress your exercises as the space becomes smaller.

How long does DRA last?

Totally variable. Some DRA’s are resolve within 6 months of the pregnancy, but there is substantial numbers whose DRA does not resolve (Ranney et. al. looked at 1738 post-pregnant women getting hysterectomies several years after their last birth, and found that 39% still had DRA).


Is it the DRA that is causing my back pain?

A study by Parker, M.A. et. al. in the Journal of Women’s Health Physical therapy in 2008 looked into this.

They initially noted a study by Thornton et. al. that had a case report of a women at 22 weeks gestation having low back pain feel relief during a family ski trip while wearing tight compressive ski pants with overalls. The pain eventually returned post-trip after not wearing the support. Was this because of the added anterior support from the pants? Or maybe it was the compressive forces on the sacroiliac joints (SIJts) that relieved the pain.

Interestingly in the study of Parker et. al., they found that there was no significant difference in VAS (visual analogue scale) pain rating between groups that had DRA and those who did not. This study also showed that those with a IRD of 2.5cm or more had the same pain levels as those with separation of 2cm-2.5cm.

The significant difference was only noted with those who had DRA had a higher level of pain anteriorly in the pelvis and abdominal areas.

What can I do?

A small study (with it’s own limitations) by Chiarello C.M. et. al. found that those who have exercised during pregnancy (basic stabilization and pelvic tilt exercises) had less of a gap than those without the program. The exercise program consisted primarily of activation of the TA muscle with pelvis tilts and extremity involvement.

If you go see a physiotherapist who specializes in women’s health, there is a good chance that their focus will be on TA activation and core stabilization. One renowned physiotherapist, Diane Lee, gives some great therapy based information on her website:http://dianelee.ca/education/article_diastasis.php as well has handout http://dianelee.ca/articles/Diastasis-rectus-abdominis.pdf.

While reviewing the current journal articles, I have yet to see the substantiating evidence on why a post-natal woman can not do situps. I can understand mechanically that during pregnancy the RA is longer and is bowing to the sides and why this could be further damaging to the DRA, but I am not convinced it is not important to re-include these into workouts at a certain point post-natally.

Why is there so much concern around pregnancy and exercise?

An article that was published last year made a slight comment on the reasoning (Borg-Stein, J.P. et. al.). The medical profession did not know the effects of exercise on pregnancy, and were worried about birth outcomes. As a result, the American College of Obstetricians and Gynecologists (ACOG) released conservative guidelines (1985) because of lack of research evidence. Since then, research has begun to show the positive benefits of exercise during pregnancy and postpartum. I suggest reading the article Exercise, Sports Participation, and Musculoskeletal Disorders of Pregnancy and Postpartum (Borg-Stein) for an overview of current literature.

What is the take-home message?

DRA is a very common concern of pregnant and postpartum women, though does not have strong evidence outlining the best treatment/therapy for it. Your therapist/clinician should be able to answer questions concerning your DRA. Exercise has shown some benefits to DRA size, but studies are small and may be skewed by race and class.

Although there have been recent studies showing the benefits of exercise during pregnancy and postpartum, it is still very important to consult your physician, your OB/GYN, and/or your physiotherapist. Complications during pregnancy may exclude you from obtaining benefits of exercise and may actually be harmful to your baby.

Be persistent with your medical professional to be sure all your questions and concerns are answered, and do your own research.

Bibliography:

Borg-Stein, J.P. et. al. (2011). Exercise, Sports Participation, and Musculoskeletal Disorders of Pregnancy and Postpartum. Seminars in Neurology 31(4). pp.413-422.

Chiarello, C.M. et. al. (2005). The Effects of an Exercise Program on Diastasis Recti Abdominus in Pregnant Women. Journal of Women’s Health Physical Therapy 29(1). pp. 11-16.

Parker, M.A. et. al. (2008). Diastasis Rectus Abdominus and Lumbo-Pelvic Pain and Dysfunction – Are They Related?. Journal of Womens’s Health Physical Therapy 32(1). pp.15-22.

Lo T. et. al. (1999). Diastasis of the Recti Abdominus in Pregnancy: Risk Factors and Treatment. Physiotherapy Canada 51(1). pp. 32-37.

Collie, M.E. et. al. (2004). Physical Therapy Treatment for Diastasis Recti: A Case Report.  Journal of the Section on Women’s Health 28(2). pp.11-15.

Bursch, S.G. et. al. (1987). Interrater Reliability of Diastasis Recti Abdominis Measurement. Journal of the American Physical Therapy Association 67(7). pp.1077-1079.

Liaw, L.J. e.t al. (2011). The Relationships Between Inter-recti Distance Measured by Ultrasound Imaging and Abdominal Muscle Function in Postpartum Women: A 6-Month Follow-up Study. Journal of Orthopaedic & Sports Physical Therapy 41(6). pp.435-443.