Mind the Gap: Diastasis Recti Abdominis and What We Don’t Know: Part I

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Joanna Hess, PT, DPT, PRC, WCS

Summer holidays are approaching. You’re lounging at the beach and feeling quite proud of the ruffled swimsuit that guards the battle marks of the mom bod—the wrinkly and poochy belly. On the horizon, a woman in string bikini framing her flat tummy joins the four children sitting next to you. She must be their nanny, or maybe the children were adopted, or she probably had a surrogate. But after a short conversation, she reveals that in fact is the biological mother of these children and that she carried to full term. And when you awkwardly compliment her on the restoration of her college-era body, she nonchalantly shrugs and says, “Genetics? Maybe the coconut oil that we brought back from Bali?”

As the power of airbrushed social media images expand, the Cinderella stories of mummy tummy to model abs give hope to the many moms scrolling mindlessly on our phones passing the wee hours of childcare. These stories are powerful and inspiring, but do not reflect most of our situations, nor answer many elusive questions about diastasis recti abdominus.

What is Diastasis recti abdominis and why do we care?

Diastais recti abominis (DRA) is the excessive separation between the two sides of the rectus abdominis (the six pack muscle), which creates a pooching of the belly, particularly with difficult tasks. For this blog, the background information focuses on pregnancy related DRA while the application of the information can be used for any one with DRA. During the third trimester 100% of women have a DRA, defined as a separation >2 cm below the umbilicus (1). One answer to why we care about DRA is that we want our stomachs to look normal if not flat. The wrinkly skin stomach has not reached mass popularity on the runways. Another reason we care is because DRA has been assumed to predispose a long term sequelae of breakdown in the body. The cosmetic appearance associated with DRA improves as the inter-recti distance (IRD), the width between the bellies of the rectus abdominis, decreases.

As physical therapists, we screen for DRA in order to gain a larger understanding of how the body is working together. Many of us assume that the lack of stability in the front of the body will lead to compensations in other parts of the body—primarily the diaphragm, pelvic floor, and back. Dysfunction in these areas have been documented to be higher during pregnancy and the post-partum period (2). Physical therapists regularly address DRA when patients present with low back pain (LBP), pelvic floor dysfunction, pelvic pain, and urinary incontinence (3). A couple of studies looking at post-partum women seeking medical care for abdominal pain and pelvic floor dysfunction show a higher incidence of DRA in this populations (4,5). However, this is not to say that the DRA causes or predicts these conditions.

In recent prospective studies using ultrasound assessment, the assumption that DRA correlates to pelvic floor dysfunction and low back pain (LBP) is challenged. The findings suggest no relationship but even a possible protective mechanism of DRA during pregnancy, with no difference in LBP symptoms at one year postpartum regardless of DRA status. Of course, this is a statement of generalization to a study population and does not reflect the outliers, individual predispositions and presentation.

DRA During Pregnancy

No differences were found in pelvic floor function or in urinary incontinence between women regardless of DRA status, during or after pregnancy. Women presenting with DRA in their 2nd trimester were more likely to have higher vaginal resting pressures, strong pelvic floor muscles strength, and better endurance of pelvic floor muscles. The set of women with 2nd trimester DRA had lower BMI before pregnancy and during pregnancy with trend increased general physical activity (6)

DRA Post-Partum

Interestingly, women who at 6 weeks postpartum did not have a DRA were more likely to have a pelvic organ prolapse > Stage 2 (6). DRA status (none or mild) had no relationship with low back pain at 6 months (1) and 12 months postpartum (7). This corroborates another study showing no difference for DRA in women reporting LBP and that severity of DRA does not predict intensity of LBP when present (5). Heavy lifting >20x/week was shown to be a risk factor for postpartum DRA, but not age, pre-pregnancy BMI, 2nd trimester BMI, weight gain, caesarean or vaginal delivery, abdominal circumference at 35 weeks, hypermobility (p – 0.06), cardio and strength exercise, general abdominal and pelvic floor exercise (1). From the research available, we cannot predict from a group of postpartum women with DRA who will have symptoms that affect their daily living.

Looking a Little Deeper at Diastasis Recti Abdominis

As assumptions about DRA and its relationship to long term dysfunction start to shift, what is important to identify in a DRA presentation is also changing. The literature and clinical practice related to DRA mainly looks at the IRD, or the separation between the right and left muscle bellies of the rectus abdominis However, the focus on the widening of the linea alba may be less important than the ability of the linea alba to transfer forces and contribute to the stability of the abdominal muscles (8). A wide linea alba that holds tension and stabilizes the front of the abdomen with increased intra-abdominal pressures through functional task may be more desirable than a narrow linea alba with distortions that loses force and allows abdominal pressure to push forward through functional task. A pulled-apart and taut rubber band hold tension better than a relaxed and crumpled band. The width and depth of the linea alba need to be contextualized within the individual’s posture, daily movement, and functional core adaptability. The literature has yet to identify subgroups that would likely explain why some people have DRA that self-resolve and among those who don’t, why it impacts cosmetics and function in some people and not in others, why it seems to be a protective mechanism for some pelvic floor and low back conditions and exacerbating in others.

The linea alba is often connected to the rectus abdominis because of the focus of the IRD as a marker of DRA. However, the linea alba actually is the anatomical and functional intersection of all the abdominal muscles—the rectus abdominis, the internal and external obliques, and transverse abdominis, which is seen at a microscopic level with different angles of fibers in the linea alba. In a cadaver study looking at the collagen of the linea alba without DRA, previously pregnant women had thinner linea alba, but greater widths. Females who were previously pregnant had higher ratio transverse to oblique fibers—60% for females and 37.5% for males. The female cadaver that had never been pregnant had infraumbilical fibers more similar to males (9). The small size of this study limits its application, but perhaps an increase of transverse abdominis muscle activity in the lower abdominals is represented in the higher number fibers, and that this adapted activity resolved the DRA for these women.

Hormones may possibly play a role of the development of DRA for some women, but because DRA persist well after post-partum hormones return to normal. In men, hormones are unlikely to be the primary driving cause of persistent DRAs. Women who are breastfeeding do have a higher relationship with unresolved DRA until breastfeeding is concluded (5). However, no research has been conducted on this relationship and may add to another subgroup to explain the variance of women who spontaneously resolve and others who never resolved their DRAs.

 

Joanna is a treating therapist at our downtown location. Stay tuned for the next installment on this topic, Mind the Gap Part II: Diastasis Recti Abdominis: What we Can do About it.

To call and make an appointment with our expert PTs call:

212- 354- 2622 (Midtown)

212-267-0240 ( Downtown)

 

References:

1. da Mota PG, Pascoal AG, Carita AI, Bø K. Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Manual therapy. 2015 Feb 1; 20(1):200-5.

2. Lee DG, Lee LJ, McLaughlin L. Stability, continence and breathing: the role of fascia following pregnancy and delivery. Journal of bodywork and movement therapies. 2008 Oct 1; 12(4):333-48.

3. Keeler J, Albrecht M, Eberhardt L, Horn L, Donnelly C, Lowe D. Diastasis recti abdominis: a survey of women’s health specialists for current physical therapy clinical practice for postpartum women. Journal of Women’s Health Physical Therapy. 2012 Sep 1; 36

4. Spitznagle TM, Leong FC, Van Dillen LR. Prevalence of diastasis recti abdominis in a urogynecological patient population. International Urogynecology Journal. 2007 Mar 1; 18(3):321-8

5. Parker MA, Millar LA, Dugan SA. Diastasis Rectus Abdominis and Lumbo‐Pelvic Pain and Dysfunction‐Are They Related?. Journal of Women’s Health Physical Therapy. 2009 Jul 1; 33(2):15-22.

6. Bø K, Hilde G, Tennfjord MK, Sperstad JB, Engh ME. Pelvic floor muscle function, pelvic floor dysfunction and diastasis recti abdominis: Prospective cohort study. Neurourology and urodynamics. 2017 Mar 1; 36(3):716-21.

7. Sperstad JB, Tennfjord MK, Hilde G, Ellström-Engh M, Bø K. Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. Br J Sports Med. 2016 Jun 20:bjsports-2016.

8. Lee D, Hodges PW. Behavior of the linea alba during a curl-up task in diastasis rectus abdominis: an observational study. journal of orthopaedic & sports physical therapy. 2016 Jul; 46(7):580-9.

9. Axer H, Keyserlingk DG, Prescher A. Collagen fibers in linea alba and rectus sheaths: II. Variability and biomechanical aspects. Journal of Surgical Research. 2001 Apr 1; 96(2):239-45.

10. Liaw LJ, Hsu MJ, Liao CF, Liu MF, Hsu AT. 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. 2011 July.

11. Coldron Y, Stokes MJ, Newham DJ, Cook K. Postpartum characteristics of rectus abdominis on ultrasound imaging. Manual therapy. 2008 Apr 1;13(2):112-21.

12. Boissonnault JS, Blaschak MJ. Incidence of diastasis recti abdominis during the childbearing year. Physical therapy. 1988; 68(7):1082-6

13. Chiarello CM, Falzone LA, McCaslin KE, Patel MN, Ulery KR. The effects of an exercise program on diastasis recti abdominis in pregnant women. Journal of Women’s Health Physical Therapy. 2005 Apr 1; 29(1):11-6.

14. Benjamin DR, Van de Water AT, Peiris CL. Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy. 2014 Mar 1; 100(1):1-8.

15. Pascoal AG, Dionisio S, Cordeiro F, Mota P. Inter-rectus distance in postpartum women can be reduced by isometric contraction of the abdominal muscles: a preliminary case–control study. Physiotherapy. 2014 Dec 1; 100(4):344-8.

16. Sancho MF, Pascoal AG, Mota P, Bø K. Abdominal exercises affect inter-rectus distance in postpartum women: a two-dimensional ultrasound study. Physiotherapy. 2015 Sep 1; 101(3):286-91.

17. Litos K. Progressive therapeutic exercise program for successful treatment of a postpartum woman with a severe diastasis recti abdominis. Journal of Women’s Health Physical Therapy. 2014; 38(2):58-73.

18. Gillard S, Ryan CG, Stokes M, Warner M, Dixon J. Effects of posture and anatomical location on inter-recti distance measured using ultrasound imaging in parous women. Musculoskeletal Science and Practice. 2018 Apr 1; 34:1-7.

19. Kirk B, Elliott-Burke T. The Effect of Visceral Manipulation on Diastasis Recti Abdominis (DRA): A Case Series.

Why Do I Still Look Pregnant: Part II

Fiona McMahon, DPT

Diastasis-Recti-Repair

Diastasis recti (DR) can be the bane of many women who are trying to decrease the size of their stomach following pregnancy. DR occurs when the two six pack muscles (rectus abdominus) separate from one another, leaving the appearance of visible gapping and bulging of the stomach, creating the look of a belly or paunch. We most commonly see DR following pregnancy; however, it can be seen in men and women with abdominal obesity, children with bowel issues, and people who have undergone abdominal surgery. Aside from its cosmetic effects, DR can also cause problems with the low back, bowel, and bladder.

Most physical therapists are trained to recognize and treat the musculoskeletal components of DR. We know to release the tight structures that are preventing the full closure of the abs, we correct alignment to reduce pull, we use sports tape to encourage the abs to activate, and we strengthen our patients’ core. It usually works wonderfully, but what if it could work better?

Staff physical therapist and resident “thinker outside of the box”, Melissa Stendahl, PT lead an inservice earlier this May to instruct the crew at BBPT on how to incorporate visceral mobilization to improve the results of traditional DR treatment.

 

If DR is a dysfunction of the musculoskeletal system, why treat the viscera?

In pregnancy the uterus grows and as it enlarges and becomes an abdominal organ. The intestines don’t have much say when this happens and get pushed behind the uterus in order to accommodate their new neighbor. After pregnancy the uterus returns to her old home, however the intestines may remain “sticky” from the trauma of being squashed by the uterus, leading to pull on the abdominals from the inside, which prevents the full closure of the abdomen. By treating the organs (AKA the viscera) we can help reduce one more factor impeding the full closure of the abdominal muscles.

How do I know if my organs are playing a role in the failure of my diastasis to close?

Some of the signs of visceral involvement with DR include low back pain, left sided sciatica, lower extremity joint pain, distention or bulging of the lower abdomen, difficulty digesting raw vegetables, and weakness in the lower extremity following workouts, secondary to reduced bloodflow.

What type of results can I expect from visceral mobilization?

According to Brandi Kirk, pioneer of this approach for DR, resolution of DR using visceral techniques can take from 12 visits to 1 visit depending on the severity of the separation.  She was able to demonstrate in her visceral mobilization class the following closures:

 

Class 1

Patient Diastasis Width Before Diastasis Width After
A 2 finger widths 0.5 finger widths
B 3 finger widths 0.5 finger widths
C 1 finger widths 0 finger widths

 

Class 2

 

Patient Diastasis Width Before Diastasis Width After
A 2 finger widths 1 finger widths
B 3 finger widths 1.5 finger widths
C 2 finger widths 0.5 finger widths

 

If you have struggled in closing your diastasis independently or are experiencing some of the symptoms mentioned above, it is time for a little extra help. Come see the physical therapists at Beyond Basics, who are trained to give you the most complete treatment for your DR. You deserve it!

Prevention: Diastasis Recti, Part II

By Stephanie Stamas

So now that you’ve learned how a Diastasis Recti (DR) can be created during pregnancy, how can you prevent it from happening to you? There is currently a lot of available information on the positive benefits of aerobic exercise for the pregnant mother and the fetus, but little research focuses on the effects of exercises on abdominal muscle strength, function during pregnancy and exercises to prevent linea alba separation. While studying at Columbia University I had the privilege of conducting research with Dr. Cynthia Chiarello, who is a pioneer in examining the relationship between diastasis recti, exercise, function and prevention. A research article published by Dr. Chiarello, “The Effects of an Exercise Program on Diastasis Recti Abdominis on Pregnant Women” found a significant difference in the presence of a DR between women involved in an abdominal exercise program (12.5%) versus non-exercising women (90%)1. This conflicted with results reported in an article by Gillard & Brown that found no difference between the exercising and non-exercising groups2. Dr. Chiarello argues that the key difference between the two prescribed exercises protocols was the purposeful activation of the transversus abdominis (TA), a deep abdominal muscle that acts as the body’s natural corset (the circumference of the Coke can discussed in part I), and promotes continued linea alba approximation throughout pregnancy.

Activation of the TA is implicated in the prevention and resolution of a DR for several reasons. First, contraction of the TA acts like an internal splint, helping to stabilize your core and decrease the width of the linea alba from the inside out.  Secondly, because the linea alba is made of two fascial layers (deep & superficial), targeted strengthening for separation prevention of both layers is required. Typical abdominal exercises – crunches, curls, etc – target the rectus abdominis and oblique muscles which only strengthens the superficial fascial layer. The deep fascial layer and inner abdominal wall, which is mainly formed by the TA, is not addressed with these exercises and is under the most tensile stress with a growing uterus. The inclusion of rectus abdominis and oblique exercises should only be introduced once the TA has become adequately strengthened. In summary, strengthening the TA first should be the foundation of any pre-natal or post-natal exercise program (also, an added bonus – the TA aids in the pushing phase of labor!).

To help you begin strengthening your TA, I have created a two-phase abdominal exercise program. The first phase focuses on isolated TA activation (week 1-2) and the second phase begins to add dynamic activities on top of TA stabilization exercises (week 2-6). Click on the links below and then enter the corresponding codes to gain access to the exercise programs.

Phase 1TA activationCODE: W9KNTZK

Phase 2TA activation with dynamic activitiesCODE: HDQ7JN2

Adaptions for Pregnant Mothers
For those in their second trimester – It is recommended that you don’t lie onto your back more than 5 minutes at a time as there is a (low) chance of decreased blood flow to the uterus. So either do the exercises with your back elevated on a wedge, in modified squat position against a wall or take breaks lying on your back by switching to another exercise in a different position. If you notice that you are starting to develop a diastasis recti, be sure to splint your rectus abdominals during all exercises – cross your arms around your waist as if you were hugging yourself and pull the muscles towards midline in sync with the TA contractions.

Adaption for post-natal mothers with DR
Start with the phase I exercises all supine (lying on your back), making sure to splint your abdominals with either the sheet wrapped around your abdomen (See Part I), using your hands to manually bring the edges of the muscle bellies together or while wearing an abdominal binder. These are by no means the only exercises out there, but are foundational stepping stones required to return to crunches, planks, bicycles, etc diastasis-free and pain-free!

I’ve had great feedback from Part 1 and a lot of excited expectation for this post on prevention. I knew a lot of my friends would benefit from this series, but I couldn’t not have imagined how hungry people were for this information. I have received some excellent questions that I was not able to address in these two posts, therefore you can now look forward to Part 3! I will be answering questions that I have received and have not been able to address. Feel free to reach out to me if also you have any questions: stephanie@beyondbasicspt.com

*While abdominal exercises are generally safe during normal pregnancies, it is important to observe the ACOG precautions for exercise & consult with your physician prior to starting a new exercise program.

References
Gilleard WL, Brown J Mark M. Structure and function of the abdominal muscles in primigravid subjects during pregnancy and the immediate post-birth period. Phys Ther. 1996; 76(7):750-762

Chiarello CM, et al. The Effects of an Exercise Program on Diastasis Recti Abdominis on Pregnant Women. J Women Health Phy Ther. 2005; 29(1):19-24

Why Do I Still Look Pregnant?!: Diastasis Recti, Part I

By Stephanie Stamas

Is it just me, or does it seem like everyone is having a baby this summer? My Facebook feed is filled with pregnant belly time lapses and newborn pictures. I’m at the age where a lot of my friends are starting families and knowing that I am a pelvic floor therapist, I have been getting a lot of phone calls. One of the top questions that I have been asked is – I’ve had my baby, so why do I still look pregnant?

Here is the scoop – When you are pregnant, your abdominal muscles expand in length by the addition of more muscle fibers (sarcomeres) to accommodate your growing belly. After birth, it typically takes 6-8 weeks for the muscles to re-organize and shrink in length to a size that best supports your abdominal contents. This is how the body is designed to adjust to the changing abdominal circumference. Some women, however, grow very quickly and the muscles are not able to expand quick enough. When this occurs, the linea alba (the vertical line of the much-desired six-pack) stretches and the abdominal muscles move away from the midline. This is a more common occurrence in women with more than one pregnancy, multiples (twins, triplets, etc) or a non-exercising lifestyle prior to pregnancy. The stretched linea alba does not typically return to its previous length in a 6-8 week time frame and can allow the abdominal contents (your organs) to bulge through the thin tendonous structure, leading to the look of being pregnant.

Having a diastasis recti may not only result in the mother continuing to look pregnant, but it can also lead to low back pain, pelvic pain, constipation and pelvic organ prolapse. I like to compare the core to a closed canister (you can think of a Coke can) – The diaphragm is on top, the pelvic floor muscles are the bottom and the abdominal musculature – specifically the transversus abdominus and multifidi – are the circumference of the can. These muscles create a tight-knit closed environment that allow for proper support of the viscera (organs), stabilization of the spine with functional activities, and normal function of the bowel, bladder and sexual systems. Having a diastasis recti is similar to having a split along the side of the coke can, and therefore can compromise all systems that rely on that closed environment.

Great, so I think I have a diastasis recti – now what do I do?
Most separations can return to normal with progressive exercises. First off – stop all crunches and abdominal exercises you are doing.  If you have a separation, doing crunches will actually contribute to the muscles being pulled away from the midline and worsen the diastasis. We need to promote approximation, not separation. Some women benefit from wearing an abdominal binder to counteract distraction forces across the linea alba with physical activity. This is helpful for active mothers who are required to use their abdominal muscles, specifically the rectus abdominus, throughout the day (lifting, carrying, etc). The abdominal binder often gives mothers immediate abdominal support, but should not take the place of strengthening. Below is a basic foundational exercise that will begin to allow the rectus abdominus muscle to return to midline.

-2

If the muscles are not coming together within 4-6 weeks of starting the exercises, see your local women’s health physical therapist (like us!). Sometimes abdominal scars, muscle tightness (especially internal & external oblique) and thoracolumbar fascia tightness can prevent the muscles coming together in the front because of adhesions elsewhere in the core. Also, if you are experiencing low back pain, pelvic pain or dysfunction with bowel, bladder or sexual function, then seeing a women’s health physical therapist is highly recommended.

Just found out you were pregnant or trying to get pregnant soon? Stay tuned for Part 2, where we will discuss preventative measures to prevent a diastasis recti!