Abdominal Separation After Pregnancy
March 27, 2022
After pregnancy, there often forms a visible and palpable gap between the superficial straight abdominal muscles - the rectus diastasis. Those affected not only find this visually disturbing, but it can also impact the entire body. How does rectus diastasis affect the body? Are there therapeutic methods or exercise programs that can influence its healing process?
Definition
Rectus diastasis 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, marked as public domain, details on Wikimedia Commons
It is diagnosed when a palpable gap of more than two cm has formed. Normally, the distance (interrectus distance) between the two straight abdominal muscles is only about 20mm wide [2]. Rectus diastasis can occur in both genders and all age groups, but is most common in pregnant women [3].
Ken Hammond (USDA), PregnantWoman, marked as public domain, details on Wikimedia Commons
During pregnancy, the abdominal muscles become more flexible due to hormonal influences. The two-bellied M. rectus abdominis becomes thinner and moves to the side to make room for the growing uterus. Due to this change in topographical position, both straight abdominal muscles on the right and left of the Linea alba lose their original direction of pull. They deviate from their predetermined alignment by the straight fiber course and are therefore limited in their functions. As the connection of the rectus sheath becomes very thin towards the end of pregnancy due to connective tissue changes, the rectus muscles can widen unhindered outward. In the early postpartum period, until the tenth day after birth, a distance of 1-2 finger breadths between the muscle bellies is considered physiological. If the distance is wider, it is referred to as rectus diastasis; the affected person loses stability. Rectus diastasis then becomes visible during all increases in abdominal pressure (e.g., during a trunk flexion) as a pointed pouch-like protrusion of the intestines between the separated rectus muscles. If such rectus diastasis remains untreated, it can persist in some women for months or even years [4].
Photo by www.localfitness.com.au, Ronnie Coleman 8 x Mr Olympia – 2009 – 5, CC BY-SA 3.0
Effects and Connections
Rectus diastasis develops during the course of pregnancy and is usually most evident from the third trimester. However, it often remains even after childbirth [4]. In the study by Blaschak & Boissonnault [5], 66% of the 71 tested women had rectus diastasis in the third trimester. Immediately after birth, it was still 53%, and between the fifth and seventh week postpartum, 36% of the participants still had diastasis. This shows that although the occurrence of rectus diastasis decreases in the postpartum phase, it does not spontaneously disappear for all women after childbirth [5]. An existing rectus diastasis is often associated with complaints such as lower back pain or incontinence [6]. It is assumed that the stabilization of the lower spine can no longer be fully ensured. This changes the entire body statics from the feet to the head position, the chest (thorax) and even breathing movements can be affected. This incorrect breathing and incorrect posture then affects the pelvic floor and abdominal and pelvic organs [4]. However, with the current state of scientific literature, it is not sufficiently clarified to what extent rectus diastasis influences the mentioned complaints [6]. Benjamin et al. [6] examined in their systematic review whether rectus diastasis has an impact on musculoskeletal dysfunctions, pain and the quality of life of those affected. They found a connection between rectus diastasis and the occurrence of a pelvic organ prolapse. They also discovered that rectus diastasis can affect health-related quality of life, abdominal muscle strength, and the intensity of lower back pain. However, they found no significant connection between rectus diastasis and the occurrence of incontinence or pain in the pelvic area [6]. Therefore, further investigation is needed to determine to what extent rectus diastasis is related to other complaints.
Rehabilitation and Training
For an existing rectus diastasis, physiotherapy and osteopathy are mentioned as conservative treatment methods. However, there is still no generally accepted exercise protocol or official treatment guidelines [7]. There are numerous different treatment approaches and therapy forms, but very little research in this area. Until today, it is unclear whether rectus diastasis should be manually approached in training or not. The effects of deep abdominal muscles (M. transversus abdominis) on rectus diastasis are also not fully clarified. However, it is assumed that the deep abdominal muscles, when activated, further pull apart the rectus diastasis and thus work counterproductively. A study by Thabet et al. [8] showed that an exercise program with passive approximation of the Linea alba, pelvic floor tension, breathing exercises and planks leads to a greater reduction of the interrectus distance than just classic abdominal muscle training. In another study by Gluppe et al. [9], a group of women who conducted a weekly exercise program for the abdominal and pelvic floor muscles was compared with a group that received no exercises. Even after several months, no differences could be found between the two groups. The study situation is therefore very contradictory. Although there are partly promising results, it is still not proven that targeted exercise programs can reduce rectus diastasis. However, it should be mentioned that until now, as a progress parameter, mostly only the interrectus distance has been examined. Recent findings show that not only the distance between the muscle bellies, but also the tension of the Linea alba is very crucial. As this tension ensures that the abdominal content can be held well and the abdominal muscles can function optimally [10]. It could thus be that physiotherapeutic exercises might not change the distance, but influence the tension and thereby impact the decisive functions. Besides the conservative treatment options, rectus diastasis can also be treated surgically. However, this is only medically indicated when an abdominal hernia has formed in addition to the rectus diastasis [11] or when no successes have been achieved with conservative therapy [7].
Conclusion
Unfortunately, there is still little scientific research in this area and meaningful and standardized test methods to objectify the course of rectus diastasis are lacking. There are many therapy approaches, but they are not yet sufficiently evidence-based. However, if one considers the basic principles of training science, abdominal muscle training should be carried out in different starting positions and with increasing difficulty level, specially addressing the respective requirements and positions that still pose challenges. This way, an individual and function-oriented therapy with specific exercises can enhance health-related quality of life and reduce limitations in the everyday life of those affected.
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Title Image Credits
Ken Hammond (USDA), PregnantWoman, marked as public domain, details on Wikimedia Commons
