Diastasis Rectus Abdominis (Part 1): What is it? Do you have it?
If you've been pregnant before, you know the feeling of going out and having everyone comment on your beautiful belly. Of course, we all get the occasional, "wow, are you sure you're not having twins?" "When are you due? You're not going to make it there!" (And can we collectively just tell those people to leave us alone!!) BUT, the majority of the comments are, "you look amazing!" "Wow, she is really growing!" "How are you feeling? Congratulations on your baby!" Honestly, my own body self confidence was at a high during pregnancy. But then, our sweet little love muffins are born. And society expects us to very quickly bounce back to our pre-baby state (and I have so many thoughts on that...because we just went through this transformative, incredible experience, that took nearly 10 months to build! And often times mamas are left alone to figure things out after birth).
As an aside, this was one of the BIG reasons that my friend and colleague, Sara Reardon, and I decided to partner together to create live & on-demand classes! We recognized that soooo many people are struggling with pelvic health problems. While individualized pelvic PT is so beneficial, it's not always possible for people at the time they need it. For one... ummm... coronavirus/social distancing. But also, some people prefer trying to learn and work independently, may feel too nervous to discuss their problems with a provider, or may have a schedule/time constraints/financial constraints/geographical constraints that just don't allow individualized care at the time they are wanting it. SO, these are our classes. We have 2 LIVE postpartum classes coming up-- TOMORROW 4/14 is our "Postpartum Recovery After a Vaginal Birth" Class, and the following Wednesday 4/22 is our "Postpartum Recovery After a Cesarean Birth" Class (SO excited about this one as a mama of 2 Cesarean babies!). These classes are built for the consumer---BUT, if you are a health care provider, I can guarantee that you'll learn a bunch also! We sold out before the start of our "Pelvic Floor Prep for Birth" class, so if you're on the fence, register soon and reserve your spot!
Anyways...back to our topic at hand: Diastasis Rectus Abdominis.
The abdominal wall is stretched during pregnancy to accommodate the sweet growing munchkin, and in some cases (most cases, according to some research!), this leads to a stretching at a structure called the linea alba- the connection between the two sides of the rectus abdominis or "6-pack" muscle group. When this becomes larger than about 2 fingers in width, it is known as diastasis rectus abdominis (DRA). This is what it looks like:
The two "+" marks indicate each side of the lines alba, and you can see that it is wider than it likely was previously. Note, this is an ultrasound image of a 38 year old mom who had diastasis after her pregnancy. DRA is different than a hernia. When a hernia occurs, there is a defect that allows an organ or tissue to protrude through the muscle/tissue that normally contains it. So, someone could have a DRA and not a hernia. Or, they could have a DRA and a hernia. Make sense?
Diastasis rectus abdominis is common during and after pregnancy, and varies in severity. For some moms, they may not really realize it's even there. Others may feel a complete lack of support at their belly, notice a bulge, or even worry that they still look pregnant. A recent study published in 2016 found that among 300 women who were pregnant and gave birth, 33.1% had a DRA at 21 weeks gestation. At 6 weeks postpartum, 60.0% had a DRA. This decreased to 45.4% at 6 months postpartum and 32.6% at 12 months postpartum. So, basically, many pregnant folk get this, and while for some it gradually improves over time, for others it can persist.
The link between DRA and musculoskeletal dysfunction is not confirmed. A recent systematic review published in 2019 found "weak evidence that DRAM presence may be associated with pelvic organ prolapse, and DRAM severity with impaired health-related quality of life, impaired abdominal muscle strength and low back pain severity." This makes a lot of sense to me. Conditions like pelvic organ prolapse and low back pain are complicated, but in some cases do have components related to pressure management. The abdominal wall is very crucial in helping to modulate intraabdominal pressure, so it makes sense that when it is not functioning optimally, a person could struggle with managing pressure well.
The intra-abdominal pressure system involves coordination between the respiratory diaphragm, low back muscles, transverse abdominis, and pelvic floor muscles. These muscles need to work together to control pressures through to abdomen and pelvis and create dynamic postural stability. When the abdominal wall has a loss of support, this system can be impacted and contribute to pressure problems like prolapse and low back pain. However, those diagnoses are complicated. There are many other factors involved (like connective tissue support, amongst other things), so this is why a comprehensive examination is often very beneficial. This is also why not everyone who has DRA has pain.
I think it's important to note here, that for some people, their DRA may not be contributing to things like back pain or prolapse, but it may still be a huge problem for them. People can feel guilty about caring about the cosmetic component involved in some instances of DRA...you know...the pooch. But, you know what-- if this matters to you, then it matters! Feeling confident and strong is so important! So, don't let anyone tell you what is or isn't important for you to care about!
So, how do you find out if you have a diastasis?
The best thing to do if this is sounding like you is to see a pelvic PT to be evaluated comprehensively. There are many different things that can contribute to a loss of support at the abdomen, so looking at the complete picture is the best option. We're going to talk about some of those pieces and how we as pelvic PTs evaluate DRA in Part 2 of this blog series. However, there are ways you can examine yourself and find out if you have a diastasis rectus. First, lie down on your back with your knees bent.
In this image, my two fingers are at my belly button, and my other hand is over the top, reinforcing what I feel.
Start by placing two of your fingers at your belly button. Next, lift your head and your shoulders up (like doing an abdominal crunch) and sink your fingers in, gently moving them back and forth to feel the sides of your rectus abdominis. Notice if your fingers sink in, and if you feel a gap between your muscles. Repeat this a few inches above your belly button, and again a few inches below your belly button. Also notice how you feel as you do this-- do you feel tension at your fingers? Do your muscles feel strong? When you lift up, are your fingers pushed out or do they sink in? What do you notice? (This is great information for you to understand how much force you can generate through your "gap" and will be important as we start discussing how we treat this!)
How can you help a diastasis?
Well, the good news is that there is so much we can do to help improve diastasis, make your belly stronger, and help you feel better. In part two of this series, we'll discuss the ways pelvic PTs can best evaluate someone who has a diastasis, and the methodology we use to treat this problem. The method of treating this has changed over time, so I'm going to give you my best understanding of the research as it's available today! Stay tuned to learn more!
Stay healthy during this time my friends-- and wash your hands!
~ Jessica