General
Abdominal separation after pregnancy
After pregnancy, a visible and tangible gap often develops between the superficial straight abdominal muscles – diastasis recti. Affected individuals find this gap not only visually annoying, but it can also affect the entire body. How does diastasis recti impact your body? And are there therapies or exercise programs that can help your recovery?
Definition
Diastasis recti describes the separation of the two straight abdominal muscles (rectus abdominis) along the vertical midline of the abdomen (linea alba) [1].
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It is diagnosed when a palpable gap of more than two centimeters has formed. Normally, the distance (inter-recti distance) between the two straight abdominal muscles is only about 20mm wide [2]. Diastasis recti can occur in both sexes and in all age groups, but it is most common in pregnant women [3].
Ken Hammond (USDA), PregnantWoman, marked as public domain, details on Wikimedia Commons
This is because during pregnancy, hormones make the abdominal muscles more flexible. The two-bellied rectus abdominis muscle thins out and moves to the side to make room for the growing uterus. Due to this topographical change in position, both straight abdominal muscles to the right and left of the linea alba lose their actual direction of pull. They get out of their alignment, which is predetermined by the straight course of the fibers, and are therefore limited in their function. Since the connection of the rectus sheath is very thin at the end of pregnancy due to connective tissue changes, the rectus muscles can drift outwards unhindered. During the early postpartum period, up to the tenth day after birth, a distance of 1-2 finger widths between the muscle bellies is considered physiological. If the distance is wider, it is referred to as diastasis recti; consequently, the mother loses support. The diastasis recti then becomes visible as a pointed protrusion of the internal organs between the separated rectus muscles during any pressure increase in the abdominal cavity (e.g., during a trunk flexion). If left untreated, such a diastasis recti can persist in some women for months or even years [4].
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Impact and Connections
Diastasis recti already develops during pregnancy and mostly presents in the third trimester. However, it often persists after childbirth [4]. In the study by Blaschak & Boissonnault [5], 66% of the 71 women tested had diastasis recti in the third trimester. Right after birth, it was still 53%, and between the fifth and seventh week postpartum, 36% of the subjects still showed diastasis. This shows that while the occurrence of diastasis recti decreases in the postpartum phase, it does not spontaneously disappear after birth for all women [5]. Existing diastasis recti is often associated with symptoms such as lower back and back pain or incontinence [6]. It is assumed that stabilization of the lower spine can no longer be fully guaranteed. This changes the entire body statics from the feet to the posture of the head, and the chest (thorax) and breathing movements can also be affected. This incorrect breathing and alignment then affect the pelvic floor as well as the abdominal and pelvic organs [4]. However, with the current state of scientific literature, the extent to which diastasis recti influences these symptoms is not yet sufficiently clear [6]. Benjamin et al. [6] investigated in their systematic review whether diastasis recti has an impact on musculoskeletal dysfunction, pain, and the quality of life of those affected. They found a correlation between diastasis recti and the occurrence of pelvic organ prolapse. They also found that diastasis recti can affect health-related quality of life, abdominal muscle strength, and the intensity of lower back pain. However, they found no significant link between diastasis recti and the occurrence of incontinence or pain in the pelvic area [6]. The extent to which diastasis recti is connected to other conditions must therefore be investigated in more detail to make a final statement.
Rehabilitation and Training
For existing diastasis recti, physiotherapy and osteopathy are mentioned as conservative treatment options. However, there is as yet no generally accepted exercise protocol or official treatment guidelines [7]. There are countless different treatment approaches and forms of therapy, but very little research in this area. To this day, it is unresolved whether the diastasis recti should be manually approximated during training or not. The impact of the deep abdominal muscles (transversus abdominis) on diastasis recti is also not yet fully understood. However, it is assumed that when activated, the deep abdominal muscles draw the diastasis recti further apart and are therefore rather counterproductive. A study by Thabet et al. [8] showed that an exercise program with passive approximation of the linea alba, pelvic floor contraction, breathing exercises, and planks leads to a greater reduction in the inter-recti distance than just classic abdominal training. In another study by Gluppe et al. [9], on the other hand, a group of women who performed a weekly exercise program for the abdominal and pelvic floor muscles was compared with a group that received no exercises. No differences could be found between the two groups even after several months. The status of research is therefore highly contradictory. Although there are some promising results, it has not yet been proven that targeted exercise programs can reduce diastasis recti. However, it must be mentioned here that up until now, mostly only the inter-recti distance was examined as a parameter of progress. The latest findings show that not only the distance between the muscle bellies, but also the tension of the linea alba is highly critical. This is because this tension ensures that abdominal content can be held well and the abdominal muscles can function optionally [10]. It could therefore be that while physiotherapeutic exercises do not achieve a change in distance, they do exert an influence on the tension and thus on the essential functions. Besides conservative treatment options, diastasis recti can also be treated surgically. However, this is only medically indicated if, in addition to the diastasis recti, an abdominal hernia has formed [11], or if conservative therapy has yielded no results [7].
Conclusion
Unfortunately, there is very little scientific research in this area so far, and there is a lack of meaningful and standardized testing procedures to externalize the progress of diastasis recti. There are many therapy approaches which are, however, not yet sufficiently evidence-based. If we start from the basic principles of training science, abdominal training should take place in different starting positions and with increasing difficulty, paying special attention to the respective challenges and positions that still cause trouble. Thus, an individual and functionally oriented therapy with specific exercises can increase health-related quality of life and reduce limitations in the daily life of those affected.
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Cover image credit
Ken Hammond (USDA), PregnantWoman, marked as public domain, details on Wikimedia Commons
