Mindset
Abdominal separation after pregnancy
After pregnancy, a visible and touchable gap often forms between the superficial straight abdominal muscles – diastasis recti. Those affected don't just find this visually bothersome; it can impact the entire body. How does diastasis recti affect the body? And are there therapies or exercise programs that can improve the recovery process?
Definition
Diastasis recti describes the separation of the two straight abdominal muscles (M. rectus abdominis) along the vertical midline of the abdomen (Linea alba) [1].
Henry Vandyke Carter creator QS:P170,Q955620 Mysid (SVG) Henry Gray author QS:P50,Q40319, Gray399, designated as public domain, details on Wikimedia Commons
It is diagnosed when a palpable gap of more than two cm 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, designated as public domain, details on Wikimedia Commons
This is because, during pregnancy, hormonal influences make the abdominal muscles more flexible. The two-bellied M. rectus abdominis becomes thinner and moves to the side to make room for the growing uterus. Due to this topographical shift in position, both straight abdominal muscles to the right and left of the linea alba lose their actual direction of pull. They fall out of their alignment predetermined by the straight course of the fibers and are therefore restricted in their functions. 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. In the early postpartum period, up to the tenth day after birth, a gap of 1-2 finger widths between the muscle bellies is considered physiological. If the distance is wider, it is referred to as diastasis recti; at this point, the affected woman loses core support. The diastasis recti then becomes visible as a pointed protrusion of the internal organs between the separated rectus muscles whenever intra-abdominal pressure increases (e.g., during a sit-up). If such diastasis recti remains untreated, it 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 is most commonly seen 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. Immediately after birth, it was still 53%, and between the fifth and seventh week postpartum, 36% of the subjects still showed diastasis. This demonstrates that while the occurrence of diastasis recti decreases in the postpartum phase, it does not spontaneously disappear for all women after childbirth [5]. An existing diastasis recti is often associated with symptoms such as lower back pain or incontinence [6]. It is assumed that stabilization of the lower spine can no longer be fully guaranteed. This alters the entire body statics from the feet up to the head posture, and the chest (thorax) as well as breathing movements can be affected. This dysfunctional breathing and poor alignment then impact the pelvic floor, abdominal, and pelvic organs [4]. However, given 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 discovered that diastasis recti can influence health-related quality of life, abdominal muscle strength, and the intensity of lower back pain. However, they found no significant association between diastasis recti and the occurrence of incontinence or pelvic pain [6]. Therefore, the exact relationship between diastasis recti and other symptoms needs further investigation to reach a definitive conclusion.
Rehabilitation and Training
When diastasis recti is present, physiotherapy and osteopathy are recommended as conservative treatment methods. However, there is currently no universally accepted exercise protocol or official treatment guidelines [7]. Countless treatment approaches and therapy methods exist, but very little research has been done in this area. To this day, it is unclear whether diastasis recti should be manually approximated during training or not. The impact of the deep core muscles (transversus abdominis) on diastasis recti is also not yet fully understood. However, it is assumed that activating the deep core muscles pulls the diastasis recti further apart, which could be 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 inter-recti distance than classic abdominal training alone. In a study by Gluppe et al. [9], on the other hand, a group of women who completed 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 study situation is therefore very contradictory. Although some results are promising, it has not yet been proven that targeted exercise programs can reduce diastasis recti. However, it must be mentioned here that until now, mostly only the inter-recti distance has been studied as a parameter. The latest findings show that not only the distance between the muscle bellies but also the tension of the linea alba is highly crucial. This tension ensures that the abdominal contents are held securely and that the abdominal muscles can function optimally [10]. It is therefore possible that while physiotherapeutic exercises do not change the distance, they do influence the tension and thus the crucial functions. In addition to conservative treatment options, diastasis recti can also be treated surgically. However, this is only medically indicated if an abdominal hernia has formed in addition to the diastasis recti [11], or if conservative therapy has yielded no results at all [7].
Conclusion
Unfortunately, there is currently little scientific research in this area, and meaningful, standardized testing procedures to track the progress of diastasis recti are lacking. There are many therapeutic approaches, but they are not yet sufficiently evidence-based. However, based on the basic principles of training science, abdominal muscle training should be performed in different starting positions and with increasing levels of difficulty, paying special attention to the specific requirements and positions that still present difficulty. In this way, an individual and function-oriented therapy with specific exercises can increase health-related quality of life and reduce limitations in the daily lives of those affected.
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References
D. R. Benjamin, A. T. M. van de Water, and C. L. Peiris
Physiother. (United Kingdom), vol. 100, no. 1, pp. 1–8, 2014, doi: 10.1016/j.physio.2013.08.005.
[2] The normal width of the linea alba in nulliparous women
G. Beer, A. Schuster, and B. Seifert
Clin Anat., vol. 22, no. 6, pp. 706–711, 2009, doi: 10.1002.
[3] Management Strategies for Diastasis Recti
M. Y. Nahabedian
Semin. Plast. Surg., vol. 32, no. 3, pp. 147–153, 2018, doi: 10.1055/s-0038-1661380.
[4] Nach der Geburt Wochenbett und Rückbildung
A. Heller
1st ed. D-70469 Stuttgard: Georg Thieme Verlag, 2002.
[5] Incidence of diastasis recti abdominis during the childbearing year
M. J. Blaschak and J. S. Boissonnault
Phys. Ther. 1988 Jul;68(7):1082-6. doi: 10.1093/ptj/68.7.1082.
D. R. Benjamin, H. C. Frawley, N. Shields, A. T. M. van de Water, and N. F. Taylor
Physiotheerapy. 2019 Mar;105(1):24-34. doi: 10.1016/j.physio.2018.07.002. Epub 2018 Jul 24.
[7] Diastasis recti abdominis – A review of treatment methods
A. Michalska, W. Rokita, D. Wolder, J. Pogorzelska, and K. Kaczmarczyk
Ginekol. Pol., vol. 89, no. 2, pp. 97–101, 2018, doi: 10.5603/GP.a2018.0016.
A. A. Thabet and M. A. Alshehri
J. Musculoskelet. Neuronal Interact., vol. 19, no. 1, pp. 62–68, 2019.
S. L. Gluppe, G. Hilde, M. Tennfjord, and E. Engh
Annu. Rev. CyberTherapy Telemed., vol. 11, no. 4, p. 63, 2013, doi: 10.1097/01.numa.0000435373.80608.40.
D. Lee and P. W. Hodges
J. Orthop. Sports Phys. Ther., vol. 46, no. 7, pp. 580–589, 2016, doi: 10.2519/jospt.2016.6536.
W. Reinpold et al.
Front. Surg., vol. 6, no. January, pp. 1–6, 2019, doi: 10.3389/fsurg.2019.00001.
Cover Photo Credits
Ken Hammond (USDA), PregnantWoman, designated as public domain, details on Wikimedia Commons
