For over 8 years I have been checking tummy muscles as part of routine post-natal check ups in the Maternity Hospital and in the last year I have read and reviewed all the studies and literature related to Diastasis Recti as part of my Masters ( when I escaped from acupuncture for 2 modules!). This sounds like a good thing but sometimes in physio, the more you study the less you are sure about things! I could talk about this forever but these are the important things to know:
Diastasis Recti Abdominis (DRA) is a common condition that occurs during and after pregnancy. An incidence of 66% in the third trimester of pregnancy and 58% in post-natal women has been reported (Boissonnault & Blaschak,1988).
It can be defined as an excessive widening or separation between the two bellies of the rectus abdominis muscles (Boissonnault & Blaschak,1988). During pregnancy, hormonal changes caused by relaxin, progesterone and estrogen combined with uterine growth cause stretching of the abdominal wall, affecting mainly the rectus abdominis and the linea alba (El Makawy, Eldeeb, El-Lythy & El-Begawy 2013).
The procedure that is most commonly utilised as a diagnostic tool in clinical practice is the finger width measure (Mota et al 2013). Other methods used are dial calipers and realtime ultrasound. The horizontal distance between the Rectus Abdominis borders is measured 4.5cm above and below the umbilicus, and at the umbilicus. An Inter-rectal distance (IRD) at the level of the umbilicus of more than 2.7cm has been suggested to be pathological of DRA (Rath et al 1996) and in clinical practice, an IRD of 2 or more fingers on partial sit-up at the umbilicus is used as diagnostic of DRA (Keeler et al 2012). Severity of DRA ranges from mild, 2.5 to 3.4 cm wide and up to 12cm long with or without bulging, to severe greater than 5 cm wide and up to the entire length of the rectus muscles (Polden and Mantle 1990).
Currently there are many treatment approaches used in treating DRA, from various exercise programs, to support belts. The evidence for most treatment programs is not great but there are some interesting studies that encourage us to be sensible about the whole business of DRA.
There is evidence to suggest that DRA occurs in many pregnancies and that, despite natural post-natal recovery, the distance between the abdominal muscles ( IRD)in post-natal women remains greater than those who have not had a baby ( nulliparous women):
- Liaw et al 2011 measured the IRD and both static and dynamic abdominal muscle strength using realtime ultrasound at 7 weeks post-natal and 6 months post-natal in a group of post-partum women who were not exercising and compared the results to a group of nulliparous women. All values of IRD at 6 months remained above those of the control group. In addition, while some aspects of abdominal muscle function, strength, and static endurance improved during that period, they remained below the values of their nulliparous counterparts (Liaw et al 2011).
- Coldron et al 2008 measured the distance between the rectus muscles, their cross-section and diameter in post-natal females (n=115) at various stages during the first year post-natal and compared the values with nulliparous females (n=69). At 12 months after delivery the RA was significantly thinner, wider and had a larger IRD than the controls.
Stretching of the linea alba, which is what we are feeling between the bellies of the rectus muscles, may have an effect on the abdominal muscle function because of its role as insertion to the deep abdominal muscles. Under normal circumstances, the abdominal muscles function in a coordinated manner, along with the diaphragm, lumbar multifidus, and pelvic floor muscles, to produce and control intra-abdominal pressure and transfer loads around the trunk through their associated connective tissues (Brown et al 2011, Richardson et al 2002).
When the insertion of the muscles has become lengthened, it reduces the ability of the core muscles to function at their best and this can lead to problems down the line e.g low back pain and pelvic floor dysfunction.
When do you need physio?
- If you are concerned and don’t know what you are feeling when you self-check your tummy muscles post-natally.
- If your tummy is bulging forwards and you feel like you still look pregnant months after baby was born, despite getting back to your usual exercise program
- If you have other symptoms as well as your DRA such as low back pain, pelvic girdle dysfunction or pelvic floor issues such as incontinence.
It is important to know that you can live happily ever after with a DRA. If you are strong, have good posture, are pain-free and don’t have issue with your pelvic floor, you are doing fine and you can have a little gap between the bellies of your tummy muscles.
If you have DRA and have other problems associated with your core, then it is important to address your DRA as part of your overall post-natal return to you. An assessment of all aspects of your core and a tailored exercise program will address the underlying factors contributing to or caused by your Diastasis Recti.
Sometimes, despite all efforts, your Diastasis may remain and the decision becomes one of living with it or considering surgery. The surgery ( abdominoplasty or tummy tuck as it commonly called) is considered to be cosmetic at present, in the absence of a clinical condition such as a hernia, so as far as I know it will be not be covered by your Health Insurance.