WHAT YOU NEED TO KNOW ABOUT DIASTASIS RECTI ABDOMINIS (DRA)

Image DRA © 2017 YogaSpine/Christa Powell

Image DRA © 2017 YogaSpine/Christa Powell

Postnatal separation of the Rectus Abdominis muscles was rarely talked about in public some years ago. It briefly came up in my professional training, and even then seemed to get brushed away on one lecture slide. My granny, who gave birth to six children, had never heard about the condition. Over the past few years, however, the term has gained traction, and an increasing number of body-conscious mums come to me asking if a Diastasis Recti Abdominis (DRA) is the reason why their abdomen looks so different than before their pregnancy. For many the postnatal changes they experienced have caused grief, loss of confidence, and it’s not uncommon for women to feel like they are living in a body that they no longer recognize. So the purpose of this blog is to shed some light on what a DRA actually involves, how to test for it, and where to go from there.

 

Understanding The Anatomy

The Rectus Abdominis (RA) muscles are the vertical muscles that lie either side of the midline. Commonly known as the ‘six pack’, they run from the xiphoid process at the apex of the ribcage down to the pubic bone. The Linea Alba is the taut, white band of connective tissue that runs down the midline of the RA muscles, anchoring the muscles to one another and to the deep abdominal wall. In addition, there are two layers of oblique muscles (picture these as a huge X across the ribcage and abdomen) that help us breathe, side-bend and rotate. Finally, the Transversus Abdominis muscles are the deepest and are like a huge corset that wraps all the way around our waist, attaching on the back. It is important to understand that all the above muscles work in collaboration to draw in, support, move and stabilize the waist and trunk. 

  

What We Know

Diastases are common in pregnancy. In fact, not only are they common, but in the third trimester all women will have some degree of separation as the belly grows (1). Postpartum prevalence is much harder to pinpoint, partly due to inconsistent study methods and because good research is scarce. Sperstad, J. et al. (2016) estimated in their study that at six months postpartum two thirds of mums have a DRA greater than before they got pregnant, compared with only one third at 12 months. This shows us that time itself plays a role, and that actually most mums will see a noteworthy reduction in their DRA at one year postpartum regardless of what exercise they have done.

For the most part, the factors that play a role in severity are often the ones that we can't do so much about. For example, we know that having more babies will result in a more severe DRA, and that after the age of about 25 the body tissues are already less able to cope with the physical changes  of pregnancy (3) (harsh, but true!). In fact perinatal heavyweight lifting is the only manageable factor that has been linked with a more severe DRA. But even here the effects have not been studied long-term, nor do we really know how heavy those weights need to be per individual to make a difference. 

Studies have also failed to consistently link DRA to other common postnatal complaints, such as lumbopelvic pain (4,2), pelvic floor dysfunction (5), and the presence of protrusions or an abdominal pouch (6).  It is possible to have a DRA without dysfunction, pain or visible distortion, but also to have all the above without a DRA. This is not to say that they cannot coincide, but it is important to remember that a DRA is just the visible element of a greater problem, and that all of the muscles must be addressed. Separated RA muscles may contribute to instability, but when there is pain or the waistline is unstable postpartum, the entire support system of the trunk is weakened. All the abdominal muscles are put under great stretch during pregnancy, not just the RA.

To have a tangible concept of how important this relationship is, try this: Lie on your back with your knees bent and perform a curl-up. Notice that your six-pack muscles pop out as they tense to lift the torso off the floor. Now while you hold this, suck your belly button down towards the spine and notice that not only is the abdomen flatter overall, but there is more stability and the pose feels easier to do. You have now activated your Transversus Abdominis muscles (TrA). If you look at the images above you will see that the TrA muscles consist of horizontal fibres. These lie deep to the RA muscles, and literally anchor the RA muscles down and flatten the stomach by pulling laterally.

Unfortunately the relationship between the abdominals if often lost in resources readily available online. One quick Google or Pinterest search will show up a multitude of quick-fix articles with promises, claims and ab exercises that target the six-pack muscles. This is perhaps because some earlier studies focused on which abdominal exercises would be the most successful at narrowing the width of the Linea Alba while performing the exercise. Studies looked at the width of the gap during a curl-up (which mainly activate RA muscles) vs hollowing, pilates-type exercises (stronger focus on TrA). It was suggested that because activation of the TrA muscles creates a lateral pull from the midline, reverse curl-ups that tense the RA muscles without co-activation of the TrA should be favoured (7,8).

The problem is that focusing on narrowing the gap itself isn’t enough to create tension across the whole trunk. Diane Lee and Paul Hodges (9) demonstrated recently that perhaps we should steer the focus away from the width of the Linea Alba and instead look at its quality and appearance during abdominal exercises (9). What they found was that when there is pre-activation of the deeper muscles (TrA) during curl-up exercises, the Linea Alba becomes a taut, smooth band. Without this activation the gap is narrower, but the Linea Alba is rendered unhelpfully distorted. They concluded that what we should be aiming for enhanced tension across the entire trunk rather than narrowing of the muscles. Not only will this create a flatter appearance, but the entire trunk will have more support as the muscles are toned in synergy. 

 

Do I Have a DRA?

Checking for a DRA is a quick and easy manual test which, though not as accurate as an ultrasound measurement (10), will give you some indication. Lie on your back with your knees bent and lift your head off the floor as though to look at your pubic bone. You should see your RA (‘six-pack’) muscles pop up and an indentation down the midline between them. This is your Linea Alba. Place one or two fingers right here just above the umbilicus. There are many variations of DRA’s. Some are greatest at umbilical level, others above or below. As such, ‘normal’ width has been found to vary significantly, but more than approximately 2 cm or two finger widths is considered to be positive for a DRA (11).  

Know that even if your gap is two finger widths or wider, conservative treatment is still the way forward. Rarely, and as a last resort, surgery can be an option, but this is usually only indicated where a) there has been no improvement at one year postpartum, b) abdominal content can actually be felt through the skin and fascia, and c) there is impaired movement function (11,12). In fact, surgery is most commonly opted for due to cosmetic reasons (13). Many confuse a DRA with an abdominal pouch, and  patients are sometimes surprised at how narrow their DRA is, compared with the appearance of their abdomen. Understanding that a pouch can exist without a significant DRA (and vice versa!) is helpful. An abdominal pouch, especially in the absence of dysfunction or pain, is usually a consequence of extra abdominal fat, loose skin and muscle weakness. Unfortunately skin does not have the elastic recoil property that muscles have, though again time will help, as will a good diet and healthy lifestyle.

 

So, What Can I Do About It?

Below are three easy steps to get you on your way. Please note my blogs are for educational purposes only and are never meant to replace advice or consultancy with a medical professional in person. 

 

1. Get to know your deep abdominal muscles: 

Lie on your back and find your frontal hip points (those bony points on your pelvis). Slide two fingers just medial to this point and cough. You will feel the deep the lower TrA muscles contracting below your fingers. Now take a big deep breath and relax. As you exhale, gently imagine you are drawing the belly button to meet the spine, and simultaneously drawing the pelvic floor up into your pelvis. As you do this, see if you can feel the activation of those TrA muscle points. This simple breathing and deep abdominal muscle activation exercises gets the brain – trunk support connection working well again and is an integral part of moving forward. I often spend a while doing these exercises with patients, so it’s worth visiting a professional who can work on breath and deep abdominal work with you in more detail to make sure you are doing it right.

 

2. Restore muscle recruitment during movement:

Understand how to move this way in everyday situations. It’s great that you learn to breathe and move well on the floor, but now it’s time to transfer those new skills to your regular movement patterns. Yoga sun salutations and standing yoga sequences are useful because they allow you to intelligently consider your use of breath and trunk during conscious movement. Eventually this will start to translate into your subconscious movement habits too. For the same reasons it is best to avoid belts that give support to the trunk throughout the day. If they are used for pain relief, they can be helpful every now and then, but they certainly will not tone your muscles nor tighten your ligaments, and will in due course lead to more weakness and instability.

 

3. Make your  lifestyle choices work for you:

Thirdly, it is so very important to incorporate lifestyle changes, and perhaps even more important to be honest about whether or not that is something that may be helpful in the long-run. People often find this the hardest to do, and frankly, it’s hard to talk to people about this because most of us believe we are doing enough, eating well, challenging ourselves. The truth is we probably aren’t. I’d like to refer to a blog written by the author of the website, and host of the podcast Stop Chasing Pain, Dr Perry Nickelston, on habits. I find it to be a well-written, honest text on how good and bad habits form our day to day life, but which can actually live our lives if we pay attention to them. Read it here!

About The Author:
 Christa Powell is a London-based osteopath and a registered yoga teacher. She has been teaching yoga, movement anatomy and working with the body in London and New York City for nearly 15 years. She is a mum, a wife and lives in London where the pulse is contagious and the parks are beautiful. She writes blogs for her clients and for her sanity.

 

REFERENCES

1. Gilleard W, Brown J. Structure and Function of the Abdominal Muscles in Primigravid Subjects During Pregnancy and the Immediate Postbirth Period. Physical Therapy. 1996;76(7):750-762.

2. Sperstad J, Tennfjord M, 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. British Journal of Sports Medicine. 2016;50(17):1092-1096.

3. Fitzgerald C, Segal N. Musculoskeletal Health in Pregnancy and Postpartum. Cham: Springer International Publishing; 2015.

4. Mota P, Pascoal A, Carita A, 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;20(1):200-205.

5. Bø K, Hilde G, Tennfjord M, Sperstad J, Engh M. Pelvic floor muscle function, pelvic floor dysfunction and diastasis recti abdominis: Prospective cohort study. Neurourology and Urodynamics. 2016;36(3):716-721.

6. Brauman D. Diastasis Recti: Clinical Anatomy. Plastic and Reconstructive Surgery. 2008;122(5):1564-1569.

 7. Chiarello C, McAuley J, Hartigan E. Immediate Effect of Active Abdominal Contraction on Inter-recti Distance. Journal of Orthopaedic & Sports Physical Therapy. 2016;46(3):177-183.

 8. Mota P, Pascoal A, Carita A, Bø K. The Immediate Effects on Inter-rectus Distance of Abdominal Crunch and Drawing-in Exercises During Pregnancy and the Postpartum Period. Journal of Orthopaedic & Sports Physical Therapy. 2015;45(10):781-788.

 9. Lee D, Hodges P. Behavior of the Linea Alba During a Curl-up Task in Diastasis Rectus Abdominis: An Observational Study. Journal of Orthopaedic & Sports Physical Therapy. 2016;46(7):580-589.

10. Mendes D, Nahas F, Veiga D, Mendes F, Figueiras R, Gomes H et al. Ultrasonography for measuring rectus abdominis muscles diastasis. Acta Cirurgica Brasileira. 2007;22(3):182-186.

11. Beer G, Schuster A, Seifert B, Manestar M, Mihic-Probst D, Weber S. The normal width of the linea alba in nulliparous women. Clinical Anatomy. 2009;22(6):706-711.

 12. Lee D, Lee L, McLaughlin L. Stability, continence and breathing: The role of fascia following pregnancy and delivery. Journal of Bodywork and Movement Therapies. 2008;12(4):333-348.

 13. Akram J, Matzen SH. Rectus Abdominis Diastasis. Journal of Plastic Surgery and Hand Surgery. 2014;48(3):163-9