Published: Tue, May 30, 2017
World | By Tasha Manning

Diastasis Recti Abdominis: Commentary on Current Research and Our Approach - Shift

Diastasis Recti Abdominis (DRA) is defined as the separation of the two muscle bellies from the rectus abdominis. This is common during and after pregnancy and has been associated with lumbopelvic instability and pelvic floor muscle weakness. DRA occurs due to hormonal changes of the connective tissue, mechanical stress on the abdominal wall by the growing fetus, and displacement of the abdominal organs.

To date, there is a scarcity of studies on DRA's prevalence, risk Factors, consequences, or interventions aimed at preventing or reducing it. This is in marked contrast with the plethora of views on social media, about how to regain "flat tummy", the different exercise programs touted by therapists and fitness professionals, as well as binders and compression garments.

In this blog we will review some bio-mechanical provisions regarding trunk stability and DRA, as well as the conclusions of a few of the most recent studies.

DRA and Trunk Stability

The abdominal canister is a functional and anatomical structure that contains the abdominal and pelvic viscera. It provides thoracolumbar vertebral stability for movement, visceral support and respiration. These functions depend on the interrelation of several myofascial components that bind the structure (1):
  • The diaphragm, which, through the crysta connects with psoas and the fascia of the pelvic floor and obturator internus muscle The deep abdominal wall including transversus abdominis (TrA) and its anterior and posterior fascial connections
  • The linea alba, a complex connective tissue structure which connects the left and right abdominal muscles Li>
  • The deep fibers of the multifidus

Clinical measurement of IRD is performed normally 4.5 cm above, at, and 4.5 below the umbilicus, with categorization as follows: a separation of less than 2 finger breadths is considered non-DRA, mild if it is 2-3 finger breadths , Moderate if 3-4, and severe if more than 4. Observed protrusion along the linea alba is almost always categorized as DRA (2).

Prevalence, risk factors, and correlation with lumbo-pelvic pain or Dysfunction

Studies on prevalence have found that DRA increases through pregnancy. A recent prospective study by Jorun Bakken et al (2) is the first to provide Prevalence data up to 1 year postpartum. The study followed nulliparous pregnant women from pregnancy to 12 months postpartum, and found prevalence to be 33.1%, 60.0%, 45.4% and 32.6%, at week 21, 6 weeks, 6 months and 12 months postpartum, respectively.

On the subject of risk factors, the same study (2) considered a number of them, such as: age, height, weight gain during pregnancy, birth weight, benign joint hyper- Mobility syndrome, heavy lifting, and level of abdominal and pelvic floor muscle exercise training. This study found that there was a greater likelihood of DRA among women reporting to be exposed to heavy lifting 20 times a week or more, but no other risk factors were found to be significant. The authors suggested that carrying and lifting children could explain the high prevalence postpartum, and that this relationship should be investigated further.

It is commonly believed that regular exercise prior to pregnancy and during pregnancy may reduce the risk of developing DRA and reduces its size. Abdominal exercises are also prescribed to postnatal women who have a DRA. A systematic review by Benjamin, DR et al (4) investigated the available evidence on these types of patients, including the use of postural and back care education, and external support (egtubigrip or corset).

Of interventions and found the following:
    • Regarding the use of external compressive garments, the authors did not find conclusive evidence, and state that these garments could be used in addition to TRA exercises to
    • Regarding exercise regimes, the authors found that 5 of The reviewed studies targeted the activation of the transversus abdominis (TrA) muscle. The TrA is the deepest abdominal muscle, and has strong fascial links with the rectus abdominis muscle and the linea alba. Activation of the TrA draws the bellies of the rectus abdominus muscle together, improves the integrity of the linea alba and increases fascial tension, allowing efficient load transference and torque production. The authors concluded that activation of the TrA could be protective of the baseline and help to prevent or reduce the DRA. A recent observational study by Paul Hodges and Diane Lee (5), has confirmed this opinion, studying the behavior of the linea alba during a curl-up task in women with DRA.

After reviewing the current literature, we can summarize that, except in the latter case of severe damage to the linea alba and greater than mean IRD, an effective method to avoid or reduce the DRA is to perform curl-up exercises with pre -activation of the TrA. This provides the appropriate lumbo-pelvic fascial tension, and effective load of the rectus abdominis muscle. This in turn, avoids excessive intra-abdominal pressures that could be damaging for the pelvic floor.

Shift's Physical Therapy Intervention for Diastasis Recti Abdominis

Our approach at Shift is based on the best Conclusions drawn by the literature. Our exercises are based on aforementioned philosophy, drawing from disciplines such as Pilates, Yoga and the Hypopressive method to develop an exercise program that is tailored to the individual. Every patient is different in their needs, and there is no exercise sequence that fits all. During our initial evaluation we assess the core strength, motor control, and activation patterns, pelvic floor muscle and TrA synergy, spinal and pelvic alignment, as well as myofascial tension and posture, and design to core and DRA exercise program tailored to the patient. 1 Lee Lee, Lee LJ, McLaughlin L. Stability, Continence and breathing: the role of fascia following pregnancy and delivery.

Performances in 2012 - Southern Choir
We were asked to choose and perform the bracket of songs of lament and loss, representing moments of blackest despair. The venue was St Luke's Anglican Church at Enmore, and the concert was just shy of being completely sold out.

J Bodyw Mov Ther. 2008; 12 (4): 333-48. [2] Bakken J, Sperstad, K, 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. Br J Sports Med. 2016 Jun

3: Parker, M; Millar, L; Dugan, Sheila A. Diastasis Rectus Abdominis and Lumbo-Pelvic Pain and Dysfunction-Are They Related ?. Journal of Women's Health Physical Therapy; 2009; 33 (2): 15-22

5: Lee D, Hodges PW. Behavior of the Alba Line During a Curl-up Task in Diastasis Rectus Abdominis: An Observational Study. J Orthop Sports Phys Ther. 2016 Jul; 46 (7): 580-9. Mota P, Pascoal AG, Carita AI, BøK. The Immediate Effects on Inter-rectus Distance of Abdominal Crunch and Drawing-in Exercises During Pregnancy and the Postpartum Period. J Orthop Sports Phys Ther. (2): 45-61. [Full text - PDF] ABSTRACT: Abdominal exercises affect inter-rectus distance in postpartum women: a two-dimensional ultrasound study . Physiotherapy. 2015 Sep; 101 (3): 286-91

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