What is Diastasis Rectus?
Commonly referred to as “The Gap”, and by that I’m not referring to the highstreet clothing chain. In clinic I describe Diastasis Rectus Abdominus (DRA) to my ladies as the widening and stretching of the bit that brings the abs together. That’s pretty much it, I also say bit too. This isn’t the most technical term but I’m not a great believer in over complicating things. I love expanding on this brief explanation and going full anatomy and physiology if my lady in clinic wants more information. Recently I feel there has been more awareness of DRA/ the gap in the public domain and a real focus on closing the gap. I remember watching an episode of The Real Housewives of Cheshire (don’t knock it until you’ve tried it), Christine McGuinness unknowingly referred to DRA as Disastrous Rectum. I was so pleased reference had been made to it I sort of forgave the woeful anatomical error. We all make mistakes, it made me love her a little bit more. I think it’s a positive thing to have increased awareness and opportunity to discuss postpartum rehabilitation. At the same time there is a HUGE amount of misinformation on DRA out there. With this in mind we will of course do the science bit with full reference list at the end. If you do find a reference you like or want to read further into please have a look at it. These articles aren’t half as scary or boring as you might think they can provide some really insightful reading.
Diastis Rectus Abdominis (DRA), is identified by Mommers et al. (2017) as the thinning and widening of the linea alba and is associated with increased laxity of the anterior abdominal wall. The linea alba is the “bit” I described at the start. When we take into consideration the logistics of pregnancy and a growing bump it’s fair to say stretching of the abdominal wall is somewhat unavoidable. DRA tends to appear in the second trimester of pregnancy and is found most frequently in the third trimester and postpartum. Fernandes da Mota et al. (2015) suggests by week 35 of gestation, 100% of women have been shown to have DRA. Boissonnault & Blaschak (1988) state that by the third trimester the incidence of reported DRA is between 66% and 100%. I think it’s safe to say DRA is not uncommon. Below is an image of the linea alba and how the abdominal muscles look with DRA.
nordicfitmama.com
Now we’ve run through what DRA is let’s look at how it’s diagnosed. Technically speaking when trying to measure “the gap” it’s actually the Inter Recit Distance (IRD) and this alters slightly depending where is being palpated (felt) down the midline. If we’re really going to knit pick about it Beer et al (2009) identifies a normal IRD up to 1.5cm at the xiphoid level, up to 2.2cm at 3 cm above the umbilicus (belly button) and up to 1.6 cm at 2 cm below it. Rath et al (1996) identifies diastasis of the rectus abdominal muscle (DRAM) as a widening of >2.7 cm at the level of the umbilicus.
The most precise way of measuring this would be with real time ultrasound. Clinically the most common form of assessment is using finger width to measure the gap. Donnelly (2018) rightfully points out that there can be variation in clinician’s finger width and variation in assessment position which can lead to disparities in measurements. I think this is true of any measurement taken, variables are always going to exist which is why it’s important to see a clinician who is taking notes on measurements and positioning throughout assessment. Below is a short video I filmed on how you can measure the gap.
Our abdominal wall is multifunctional, it’s always on the move with fluctuating Inter Abdominal Pressure (IAP) that comes with lifting babies, shopping, coughing and laughing. The abdominal wall also plays a starring role in that core cylinder I keep taking about. It’s responsible for support and stability of the trunk, pelvis, posture, respiratory function and as I’ve previously said, your day to day movements. I’m sure you’d agree using our abdominal wall is unavoidable, in fact it’s important we use our core after we’ve been pregnant. The ways in which we choose to use our core can vary hugely and if I’ve said it once I’ve said it a thousand times, if you have concerns about DRA, are symptomatic or have had a baby and want to return to exercise please have an assessment with a women’s health/ pelvic health physiotherapist…
September 2020 a year and two months postpartum.
There I am, just me and my DRA all happy after a little garage workout involving thrusters, pull ups, sit-ups and rowing intervals (spicy ones.) I found getting back to doing what I love exceptionally difficult for the first six months for the pure fact that I read some really disheartening instagram posts from personal trainers stressing that you shouldn’t be doing sit ups… I really like sit ups. I really like burpees too. Imagine how it felt reading that and then thinking I had to sign off on doing a large portion of the things I enjoy doing. The really sad thing, is that I floated about believing that for weeks!! Honest to god I should just go and listen to Carol* in admin and her little pearls of wisdom… “Oooh kiss goodbye to that body of yours once you have a baby, you’ll never be the same again!” Thank you for your input Carol. Do you do motivational talks too?
The point I’m trying to make is that unless you have had an assessment and there is a clinically identified risk, there is no reason why you shouldn’t be able to return to the exercise you enjoyed before pregnancy. Even if you have had an assessment and have been advised to avoid certain exercises ask the questions…
What exercises can I do?
What do I need to lift during my day to day activity? (lifting the shopping out of the car whilst being pulled in one direction by a toddler and the other by the dog)
What are the signs of loading my midline and what is my upper limit?
When can I get back to doing what I enjoy?
What do I need to do to improve the situation?
Weir et al (2006) conducted a study into post operative activity restrictions and the evidence for the restrictions being in place, they found…
“Mean maximal IAP was greater with standing up from a chair than it was for abdominal crunches, climbing stairs, sit-ups and many lifting activities. ”
So to blanket ban women from doing sit ups because our midline has been stretched isn’t a good idea. In actual fact discouraging women from exercising may progressively make day to day activities harder, babies are heavy and only get heavier. If we’re stopping doing sit ups then should we also stop standing up from sitting on a chair?!
The scientific/researched/you can’t bend it management of DRA is interesting. Not wanting to fall into the “it worked for me so it’ll work for you,’”trap because we all know that’s not true I’ve been doing some reading. As with so many areas in womens health, studies are limited and as ever, ALL the studies I read concluded with the fact that more research is needed. There are of course general modalities of treatment that are associated with the treatment of DRA. Targeted exercises can lessen the effect of DRA and rehabilitate post pregnancy. Benjamin et al (2014) found that potentially, transversus abdominis (TvA) muscle activation could be protective of the linea alba and may help to prevent or reduce DRA and speed up recovery. This is expanded upon further by Lee & Hodges (2016) who point out that TvA should be accompanied by Rectus Abdominis (RA) activation to establish better load transfer across the Linea Alba. RA is key in the rehabilitation of Diastasis It is the transferring of load and encouraging tension across the gap that we want.
During pregnancy our breathing space is somewhat compromised and this has an effect on our midline. Remember how the core muscles are synergistic. Donnelly (2018) makes reference to this relationship, it has been well established that the diaphragm, abdominal wall and pelvic floor are intimately linked. These muscles are all responsible for managing IAP which can be affected by DRA. Breathing patterns can play a role in the management of DRA. Hodges et al (2007) points out that breathing encourages a natural recruitment of the TVA during exhalation.We may never actually physically close the gap but we can make it functional. This is what we are looking to achieve, it’s that magic word FUNCTION. Is there tension across the gap when there needs to be? Are we managing our IAP well? Are we symptomatic? This is different for everybody at all different stages of their postnatal journey.
Look and listen to your body, do you notice when sitting up and getting out of bed your tummy domes or sinks in the middle? Mine does! I saw it mid workout when I went to do toes to bar but thanks to lock down I didn’t have a bar so I did V-ups and I noticed right at the very start when the full load of my legs is transferred into my abdominal wall I dip in the middle. No problem, I went to single legs for a time until I was strong enough to manage a few double legs under fatigue and I built up from there. The dipping or doming was my body’s way telling me that I was working super had and of course I was showing signs of IAP.
An assessment with a women’s health physio will give you opportunity to ask questions about DRA and have a check of your abdominal wall, pelvic floor, breathing, posture and general musculoskeletal review. They will also look at your ability to complete functional movements like a lunge and squat or anything you specifically would like assessed. I really took the time in my rehabilitation, I found things hard other people shouldn’t bat an eyelid at and equally I can do things you maybe would find a challenge. It’s so important to remember, anatomically we are all COMPLETELY DIFFERENT it’s the functionality of the abdominal wall rather than the gap itself. I don’t think it’s fair to blanket ban women from doing what they love, I’d prefer an honest and frank conversation about the importance of assessment and building strength where they feels most vulnerable. Like I’ve said before I think the importance of loading in postpartum rehabilitation is often overlooked and women’s fitness goals are dismissed.
Don’t be dismissed ladies! Your health and postpartum goals are important. In the long term building a healthy functional body that enables you to do what you enjoy is now just important for your mental health it’s important for our physical health as we age. The ability to load the body is super important for some density but that’s another pst in itself. We must invest the time in understanding doming and coning isn’t a bad thing, it’s your body doing what it needs to do. Give yourself some grace, you deserve it Mama. Big love V.
*Carol isn’t her real name, it’s …. HAAAA I’M NOT TELLING!
References;
Benjamin D.R, Van de Water A. T.M, Peiris C.L., 2014. Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Accessed online at https://www.physiotherapyjournal.com/article/S0031-9406(13)00083-7/pdf Accessed on 20/11/2020.
Boissonnault JS, Blaschak MJ. Incidence of diastasis recti abdominis during the childbearing year. Phys Ther 1988;68:1082–6.
Donnelly G. (2018) Diastasis Rectus Abdominus: Physiotherapy Management. Accessed on 16/11/2020. Accessed online at:https://thepogp.co.uk/_userfiles/pages/files/journals/124/don3l3w21sx8.pdf
Fernandes da Mota P. G., Pascoal A. G. B. A., Carita A. I. A. D. & Bø K. (2015) Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Manual Therapy 20 (1), 200–205.
Hodges P. W., Sapsford R. & Pengel L. H. M. (2007) Postural and respiratory functions of the pelvic floor muscles. Neurourology and Urodynanics 26 (3), 362–371.
Mommers E. H. H., Ponten J. E. H., Al Omar A. K., et al. (2017) The general surgeon’s perspective of rectus dia- stasis. A systematic review of treatment options. Surgical Endoscopy 31 (12), 4934–4949.
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;18:281–8.
Weir LF, Nygaard IE, Wilken J, Brandt D, Janz KF. Postoperative activity restrictions: any evidence? Obstet Gynecol. 2006;107(2 Pt 1):305–9.