Diastasis Rectus Abdominis

Every single one of us has a six-pack muscle. Whether it is clearly defined or not is a different issue. It is called the Rectus Abdominis (RA). Underneath the RA are your obliques and then your deepest abdominal muscle called the Transversus Abdominis (TA). Diastasis Rectus Abdominis (DRA) is the separation of the RA muscle. It happens routinely during and after pregnancy, but can also happen in males and females of all ages with obesity. ​

About DRA.

The center line of the RA muscle is made of connective tissue called the linea alba. When the RA is stretched with pregnancy or obesity, the linea alba thins and creates a gap between the two sides of the RA. This is not the same as an umbilical hernia where the abdominal contents protrude out around the belly button. However, DRA can increase your chances of having an umbilical hernia. 

According to one study, at week 21 of pregnancy, DRA was prevalent in 33% of women. This makes sense because your baby is growing and the muscles stretch and separate to make room. However, during the postpartum stages, DRA continued to exist 6 weeks later (60% prevalence), 6 months later (46%), and a year later (33%). 

For my ladies who have back and hip pain even a year after pregnancy, can you imagine why now? Almost a third of you may be moving around with part of your abdominal muscles still separated from your pregnancy!              

Having a DRA is closely related to having other pelvic floor issues like stress urinary incontinence and prolapse. In fact, nearly half of patients with urogynecological disorders also have a DRA. This is likely because of the lack of deep core stability that is the basis of all of these disorders. Heavy lifting is also closely associated with increased DRA. With continued core weakness, you may not be able to stabilize your trunk as well, which can further result in poor posture, upper back and neck pain, pubic symphysis pain, or sacroiliac joint pain.

DRA Clinical Signs:

1. A gap in between the muscle of more than 2 fingerbreadths during a crunch. 
This is tested clinically by a specialist. A mild DRA is 2-3 fingerbreadths, moderate is 3-4, and severe is greater than 4. Since the width of everyone’s fingers vary slightly, DRA is objectively diagnosed if there is a 2cm gap at the belly button or 4.5cm above/below the belly button. 

2. Bulging or tenting of your abdominal area when you do a crunch. 
This happens when there is so much separation, that the organs are pushing out when you exert pressure at the muscle.

3. Low back or hip pain. 
Lack of proper core stability, especially of the deeper TA muscle, can result in poor movement patterns and pain.                     
Some tips and tricks:

Specific corrective exercises for DRA postpartum have routinely shown improvements in DRA. Studies reveal that by activating the deepest ab muscle (recall this is the TA!) can reduce back and hip pain along with the concomitant postural dysfunctions that may come with a DRA. Studies also show that these exercises should be performed as soon as you are cleared for exercise to maximize recovery. 

1. Stop your valsalva.
A valsalva is when you forcibly try to exhale with a closed windpipe. You are not actually letting the air pass naturally but are causing pressure to build up in the abdomen. Imagine the big guys at the gym...heavy lifting, grunting noises, turning red in the face. People do this at the gym and when they are having bowel movements if they are constipated. A valsalva is not good for a DRA because it adds even more pressure to the abdomen from the inside. 

2. Stack your body.
Posture, posture, posture. Stand tall and look at yourself in the mirror sideways with your hands on your hips. Check if your back is excessively arching and if your ribs are flaring. If they are, you are continuing to increase the stretch at the RA and linea alba. Instead, think of gently tucking your tailbone underneath you as you come to a slightly flatter spine. Remember, an arched back with shoulders thrown way back is not actually good posture. 

3. Don’t crunch to get out of bed.
Instead of doing a massive crunch (lifting your head to your knees) as you get out of bed or off the couch, roll over sideways and use your arms to get up. This reduces the pressure exerted at the RA. 

​4. Learn from a pelvic floor physical therapist (PFPT).
Too many people I have treated come to me months or years postpartum with the same issues. They have tried the youtube videos and IG exercises. But they are still in pain. A PFPT can show you how to coordinate your entire core unit: your diaphragm, your pelvic floor, and your TA. 

Last Thoughts.

Studies show that few women seek out pelvic health specialists after pregnancy. They may only show interest if they experience pain or dysfunction. However, with DRA, symptoms of back pain may not show up immediately. Instead, the poor movement habits and lack of strength can compound over time slowly and present itself later. 

This is why seeing a pelvic floor physical therapist postpartum is important! Your specialist will perform a full-body evaluation to check how all parts of your core unit are working (or not working) together. 

References:

1. Sperstad JB, Tennfjord MK, 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; 50(17):1092–1096.
2. Lawson S, Sacks A. Pelvic Floor Physical Therapy and Women’s Health Promotion. J Midwifery Womens Health. 2018; 63(4):410-417. ​