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Diastasis recti abdominis - A review of treatment methods

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Diastasis recti abdominis is a condition in which both rectus abdominis muscles disintegrate to the sides, this being ac-companied by the extension of the linea alba tissue and bulging of the abdominal wall. DRA may result in the herniation of the abdominal viscera, but it is not a hernia per se. DRA is common in the female population during pregnancy and in the postpartum period. There is a scant knowledge on the prevalence, risk factors, prevention or management of the abovemen-tioned condition. The aim of this paper is to present the methods of DRA treatment based on the results of recent studies.
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97
REVIEW PAPER / OBSTETRICS
Ginekologia Polska
2018, vol. 89, no. 2, 97–101
Copyright © 2018 Via Medica
ISSN 0017–0011
DOI: 10.5603/GP.a2018.0016
Corresponding author:
Agata Michalska
Jan Kochanowski University, Institute of Physiotherapy,
al. IX Wieków Kielc St. 19, 25–317 Kielce, Poland
tel.: +48 (41) 349 69 54, fax: +48 (41) 349 69 54
e-mail: michalskaagata.reh@gmail.com
Diastasis recti abdominis
— a review of treatment methods
Agata Michalska1, Wojciech Rokita2, Daniel Wolder2, Justyna Pogorzelska1,
Krzysztof Kaczmarczyk3
1Institute of Physiotherapy, Jan Kochanowski University in Kielce, Poland
2Department of Obstetrics and Gynecology, Voivodship Hospital in Kielce, Poland
3Department of General Surgery, Hospital of the Ministry of Internal Affairs and Administration in Kielce, Poland
ABSTRACT
Diastasis recti abdominis is a condition in which both rectus abdominis muscles disintegrate to the sides, this being ac-
companied by the extension of the linea alba tissue and bulging of the abdominal wall. DRA may result in the herniation of
the abdominal viscera, but it is not a hernia per se. DRA is common in the female population during pregnancy and in the
postpartum period. There is a scant knowledge on the prevalence, risk factors, prevention or management of the abovemen-
tioned condition. The aim of this paper is to present the methods of DRA treatment based on the results of recent studies.
Key words: diastasis recti abdominis, conservative treatment, surgical treatment, physiotherapy
Ginekologia Polska 2018; 89, 2: 97–101
INTRODUCTION
The anterior-lateral abdominal wall is formed by muscles
that may be found symmetrically on either side of the linea
alba. These are, situated in the anterior median line, rectus
abdominis muscles with the fibres running vertically and
lateral flat muscles: external oblique, internal oblique and
transversus, with obliquely and perpendicularly running fib-
ers respectively. The tonic activity of the abdominal muscles
supports and protects the viscera; it is essential for maintain-
ing proper posture, including stabilization of the pelvis and
lumbar spine. Shortening of the diagonal and transverse
fibres results in increased intraabdominal pressure during
coughing, laughter, micturition, defecation or childbirth.
Abdominal muscles are also involved in the bending mo-
tion of the trunk (all of the abovementioned ones, and the
rectus abdominis muscle, in particular, during the movement
with resistance), lateral flexion (ipsilateral oblique muscles
with a slight participation of the ipsilateral rectus abdominis
muscle), trunk rotation (the external oblique muscle and con-
tralateral internal oblique muscle). When the aforementioned
muscles shrink during exhalation, they cause the diaphragm
to lift which supports the breathing process [1].
Connected aponeuroses of the muscles of the lateral
abdominal wall form a sheath that encompasses the rec-
tus abdominis muscle. The aponeuroses of opposing sides
cross in the medial line, fusing the medial borders of the
sheaths. In such a way they form the linea alba (LA) running
from the xiphoid process of the sternum to the superior
pubic ligament. The LA performs an important role in main-
taining the stability of the abdominal wall from a mechanical
point of view. Its tension is regulated by pyramidalis muscles
anterior to the rectus abdominis above the pubic symphysis
(they do not occur permanently) [2]. There are three differ-
ent zones of fibre orientation in the LA. Listing from the
ventral to dorsal, these are the lamina fibrae obliquae, the
lamina fibrae transversae and the small lamina fibrae ir-
regularium. The transverse fibres act as a counterpart to
the intraabdominal pressure, whereas the oblique fibers
are involved mainly in movements of the trunk. There exist
sex-dependent differences in the fibre architecture. In fe-
males a larger number of transverse fibres relative to oblique
fibres in infraumbilical regions and a smaller thickness and
increased width of the infraumbilical LA may be observed.
The possible morphological differences in the LA may be
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a form of adaptation to the increasing intraabdominal pres-
sure with pregnancy [2, 3].
During pregnancy, the geometry of abdominal muscles
changes still maintaining their function. The expanding
uterus affects the shape of the abdomen and the lumbar
spine position (deepening of the lumbar lordosis) which
results in an increase in the distance between the attach-
ments, i.e. the elongation of the abdominal muscles and
the change in the angle of the attachment. Functionally,
this is manifested by the reduction of strength, and mainly
affects the rectus abdominis muscles [1]. Besides elon-
gation of the rectus abdominis muscles, it may lead to
the stretching and flaccidity of the linea alba which may
result in the enlargement of the distance between medial
borders of the muscles, and a subsequent loss of their
straightforward course.
DIASTASIS RECTI ABDOMINIS
An impairment characterized by the separation of the
two rectus abdominis muscles along the linea alba has
been defined as diastasis recti abdominis (DRA). However,
in literature, other terms are sometimes used, such as rectus
abdominis diastasis (RAD) or divarication of rectus abdomi-
nal muscles (DRAM) [4, 5].
The separation of the linea alba in DRA results in the
forming of a space referred to as an inter-recti distance
(IRD) (Fig. 1) [5]. According to Beer et al. [6] physiological
parameters of the width of the LA amount to 15 mm at the
height of the xiphoid process, 22 mm at 3 cm above the
umbilicus and 16 mm at 2 cm below the umbilicus. The
width of the LA increases with age. There is no agreement
as to the size of IRD considered to be pathological. The fol-
lowing parameters are given: 10 mm above the umbilicus,
27 mm at the umbilical ring and 9 mm below the umbilicus
(below 45 years of age) and 15 mm, 27 mm and 14 mm
respectively (above 45 years of age) [6], above 2 cm [7], and
in some older studies a less precise parameter — above the
2 — finger width when measured in a crook lying position.
In the clinical practice, different measurement methods
of IRD are applied. There are no strict recommendations as
to the place of measurement (distance from the umbilicus),
the body position (at rest in the supine position or during
contraction in the head lift position) or the method. The
following may be applied: palpation, tape measure, calipers,
ultrasound, CT and MRI [8–10]. Basing on the results analysis
of thirteen studies evaluating measurement properties it
was suggested that the ultrasound and calipers should be
adequate methods to assess DRA [10].
The following are considered to be the risk factors of
DRA: pregnancy (the resulting hormonal changes, the in-
creased size of the uterus, anterior pelvic tilt with or with-
out lumbar hyperlordosis, the increased intraabdominal
pressure), cesarean section, multiple pregnancies, fetal mac-
rosomia, as well as genetically-conditioned defects in col-
lagen structure (including congenital disproportion of the
collagen III/I ratio), considerable body mass losses occurring
spontaneously or after bariatric surgeries, abdominal surgi-
cal procedures [2, 3, 11, 12]. Mota et al. [13] and Sperstad
et al. [14] reported no association between DRA and the
pre-pregnancy body mass index, weight gain, a baby’s birth
weight or abdominal circumference, heavy lifting, lifting and
carrying children, and regular exercise.
DRA can occur in both genders, across age groups, but
it is principally seen in postpartum women. The separation
between the abdominal muscles can be seen in newborns
or infants as a result of the reduced abdominal muscles
activity. It usually disappears spontaneously. In case of con-
genital, abnormal anatomy of the fibers of the LA, infants
may develop a hernia, manifested by the presence of a distal,
non-painful bulge located in the midline of the body be-
tween the umbilicus and the xiphoid process (more often
over the umbilicus, probably due to the upward pulling
of the LA by the attachments of the diaphragm) [15]. DRA
may also occur in men and is thought to be associated with
the increasing age, weight fluctuations, weightlifting, full
sit-ups, familial weakness of abdominal muscles. The male
pattern of DRA more frequently occurs primarily over the
umbilicus in the fifth and sixth decades of life [16].
In the female population, DRA is common with pregnant
and postpartum women. The female pattern of DRA is cen-
tered at the level of the umbilicus, but it can extend to and
encompass the supraumbilical or infraumbilical region [17].
It can persist in approximately 24–70%, even 100% of cases,
during the postpartum period at different sites along the LA
[13, 17–19]. In Brazilian study the prevalence of DRA immedia-
tely after vaginal delivery was 68% above the umbilicus and
Figure 1. Clinical picture of DRA, a 30-year-old patient, 6 months
postpartum (from the authors’ own archives, reprinted with the
patient’s permission)
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32% below the umbilicus. The prevalence of DRA above the
umbilicus among primigravida and multiparae was identical
(68%), and the prevalence below the umbilicus was greater
among multiparae (19.8% and 29.2%) [11].
The inter-recti distance resolves gradually with time
in the postpartum period with individual variability, usu-
ally to approximately eighth week postpartum [13]. Mota
et al. [13] assessed IRD and prevalence of DRA in case of
84 women in 35th gestational week 6–8, 12–14 weeks post-
partum and 6 months postpartum. The size of IRD decreased
from 64.6 mm (SD 19.00) to 15.3 mm (SD 8.4), similarly the
prevalence of DRA decreased from 100% to 39.3%. A higher
percentage of DRA occurrence at 6 months postpartum was
reported by Sperstad et al. [14]. In the group of 300 women
it amounted to 45.4 %, and decreased to 32.6% at 12 months
postpartum.
An increase in the distance between the anterior bor-
ders of the rectus muscles influences the strength of the
abdominal wall musculature and does not usually cause
pain at rest. During physical activities, however, the char-
acteristic bulging of the abdominal wall may appear, this
being due to an increase of the intraabdominal pressure
(Fig. 2). This is why DRA may be associated with epigastric
and umbilical hernias [16].
Taking into account the role of abdominal muscles in
maintaining posture and their engagement in various physi-
cal activities one may suspect that the presence of DRA may
have an impact on the trunk and pelvic stabilization, and
can lead to poor posture, limitations during physical activity,
as well as lumbo-pelvic pain and hip pain [3, 20, 21]. Some
studies, however, deny these statements. Sperstad et al. [14]
reported no difference between women with and without
DRA in prevalence of low back pain, similarly as Mota et al.
[13] and Parker et al. [21]. In Norwegian study, women with
DRA did not have a weaker pelvic floor muscle or more
pelvic floor dysfunctions than women without diastasis [22].
Other study, however, do confirm the relationship between
the presence of DRA and the support-related pelvic floor
dysfunction diagnoses [23].
TREATMENT OF DRA
In the majority of women DRA resolves spontaneously
in the postpartum period. In case of the persistence of the
inter-recti distance, the conservative treatment is applied,
namely physiotherapy. It is considered to be the only treat-
ment method that may potentially result in the decrease
of IRD. Although numerous studies confirm the positive
influence of exercises on reducing the inter-recti distance
[4, 17, 24–28] no generally acceptable protocol of thera-
peutic exercises has been formulated so far. It has not been
assessed which abdominal exercises are the most effective.
The most commonly applied are: an abdominal exercise
programme (strengthening of transversus abdominis muscles
or rectus abdominis muscles), a postural training, education
and training on appropriate mobility techniques and lifting
techniques, methods strengthening transversus abdominis
muscles (Pilates, functional training, the Tupler’s technique
exercises with or without abdominal splinting), the Noble
technique (manual approximation of rectus abdominis mus-
cles during a partial sit-up), a manual therapy (soft tissue
mobilization, myofascial release), abdominal bracing and
taping, the tubigrip or a corset. According to Keeller et al. [17]
abdominal taping is often applied (in 40.8% respondents), but
its effectiveness has not been confirmed so far.
Female patients are advised to avoid exercises which
cause the bulging of the abdominal wall, exercises engaging
oblique abdominal muscles, raising the lower limbs above
the ground while lying on the back, abdominal sit-ups,
crunches, intense coughing without abdominal support,
as well as lifting heavy objects [4, 17].
In therapy, two optional treatment methods are used:
engaging transversus abdominis muscles or rectus ab-
dominis muscles. There is no agreement in existing data
which of these methods is more effective in reducing IRD.
According to one, exercises of transversus abdominis mus-
cles (drawing-in exercise) are advised, whereas any exercises
engaging the rectus abdominis muscles are forbidden as
they may potentially increase IRD (abdominal sit-up/ curl-up,
crunch exercise). The other method includes a crunch
Figure 2. Bulging of the abdominal wall in DRA, a 26-year-old patient,
14 months postpartum (from the authors’ own archives, reprinted
with the patient’s permission)
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exercise in the supine position which activates the rectus
abdominis muscles [4, 24]. According to Keller et al. [17]
transversus abdominis training is usually applied (in 89.2%
out of 296 respondents), although in 62.5% cases the Nobel
technique engaging rectus abdominis muscles was applied.
Few studies support these exercise suggestions. Mota et al.
[29] compare the IRD measured in USG at rest and during
drawing in and abdominal crunch exercises. An abdominal
crunch exercise consistently produced a significant nar-
rowing of the IRD, whereas a drawing-in exercise led to
a small widening of the IRD. Similar results were reported
by Sancho et al. [30]. According to Lee and Hodges [31]
an abdominal curl-up results in the narrowing of the IRD
in most women with DRA, although the preactivation of
the transversus abdominis muscles reduces the narrowing
of the IRD. However, the assessment of the linea alba ten-
sion expressed using the distortion index showed that the
distortion index increased from rest during the curl-up, and
the preactivation of the transversus abdominis muscle pre-
vented the distortion of the LA. Proper tension of the linea
alba is indispensable for the transfer of force between sides
of the abdominal muscles, which results in a better control of
abdominal content and better cosmetic outcome. It seems
that the optimal strategy in the DRA therapy is combining
the activity of the two kinds of abdominal muscles, but it
still needs to be confirmed.
Apart from physiotherapy, there are trials of applying
prolotherapy. Prolotherapy is the technique of injection
of small amounts of an irritant solution into injured tis-
sue (degenerated tendon insertions, joints, ligaments). Ir-
ritant solutions most often contain dextrose, phenol-glyce-
rine-glucose (P2G), combinations of polidocanol, manga-
nese, zinc, human growth hormone, pumice, ozone, glycerin,
or phenol. The main aim of prolotherapy is to stimulate
regenerative processes (growth of normal cells and tissues)
[32]. Strauchman and Morningstar [33] report a case of de-
creasing the IRD from 2.7 cm to 0.5 cm after 7 prolotherapy
sessions (injections were administered every two weeks).
The solution used was a combination of dextrose, lidocaine,
and methylcobalamin.
In the absence of efficacy of the conservative treat-
ment, with high aesthetic and/or functional discomfort or
the presence of hernia, surgical intervention is often used.
The reduction of rectus abdominis muscles separation is
also a part of abdominoplasty. Operative repair for DRA is
controversial [34]. According to Emanuelsson et al. [12] the
abdominal wall repair should be considered in patients with
an IRD wider than 3 cm. Brauman [35] states that this deci-
sion should be influenced primarily by the evaluation of the
protrusion rather than diastasis. The operative procedures
include the use of a retromuscular mesh or a double row of
sutures with resorbable/non-resorbable suture material [12].
SUMMARY
Several authors have emphasized that in spite of the
fact that DRA is both a common and significant clinical
problem, little is known about its risk factors, prevention or
management [3, 13, 14]. Undoubtedly, DRA may be treated
as a cosmetic defect, and its presence may cause mental
discomfort. Separation of the linea alba with the accompa-
nying weakening of the anterior abdominal wall may lead
to epigastric and umbilical hernias. In the light of studies
results mentioned above, however, one cannot definitely
confirm the link between DRA and such conditions as the
pelvic floor dysfunction or lumbo-pelvic pain. Taking into
account still unsatisfactory knowledge regarding risk factors,
possible consequences and effective methods of preven-
tive treatment there is still a need of conducting further
research in this field.
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... It can also cause functions such as forward flexion, lateral flexion, and spine rotation [1]. Diastasis recti abdominis (DRA) is a traumatic disease characterized by the separation of two rectus abdominis along the linea alba of the abdomen [2], mainly the sequelae of pregnancy [3]. ...
... A total of 458 parturients who were clinically examined as DRA in Chongqing Maternity and Child Health Care Hospital from December 2017 to September 2020 (when measured by palpation in the supine position, the width of rectus abdominis interval was more than 2 fingers is the clinical criteria for the diagnosis of DRA [2]) and confirmed as DRA by ultrasound examination (rectus abdominis interval of more than 2.0 cm indicates diastasis rectus abdominis [12]) were collected. Informed consent was obtained from all patients, and this study was approved by the Institutional Review Boards (IRB) of Chongqing Medical University. ...
... However, this study still has certain limitations: (1) although the total sample size is large, it is a singlecenter study. (2) This issue of whether the intrinsic reason why the umbilicus becomes the most severe point for the occurrence of postpartum DRA compared with other measurement points is related to human posture, hormone secretion, pelvic floor structure, and mode of delivery needs to be confirmed by further studies. ...
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Objective: Explore the ultrasound characteristics of early postpartum Diastasis Recti Abdominis (DRA) and provide effective data support for its clinical diagnosis and treatment. Method: A total of 458 parturients who were diagnosed with DRA in the Chongqing Maternal and Child Health Hospital from December 2017 to September 2020 underwent postpartum ultrasound examinations. All of which were located at four points: 6 cm above the umbilicus (point 1), 3 cm above the umbilicus (point 2), umbilicus (point 3), and 3 cm below the umbilicus (point 4) to detect the interrectus distance (IRD) in the resting and sit-up state of the parturients postpartum and to study the differences in maternal age, weight, and ultrasound diagnosis of IRD at different stages after delivery. Results: The IRD values of the four measurement points in the resting state of the parturient were significantly greater than the IRD values in the sit-up state. And in the resting state, the IRD value (4.31 ± 1.07 cm) of the point 3 region was the largest, and there were significant differences at different stages of the postpartum women. At the same time, the IRD values of points 3 and 4 have significant differences in parturient of different ages. In addition, the IRD values of the four measurement points of overweight women were higher than those of nonoverweight women. Conclusion: The umbilicus is the best ultrasound evaluation point for early postpartum DRA. The IRD value at this point in the resting state can be used as reference data for evaluating early postpartum DRA, which provides a useful reference for rapid postpartum recovery of parturients.
... Palpation of the linea alba to determine diastasis recti has shown good intra-rater reliability and moderate inter-rater reliability. 99 Although there is no strict recommendation as to the place of measurement or method, it is suggested that the patients start in a crooked leg position, 109 lying on their back with hips and knees bent and feet flat on the floor. Hands can be by their side or across their chest. ...
... Ask the patient to perform an abdominal crunch, so that they lift their head and shoulder blades off the surface they are lying on. 107,109 Although other tools can be used to assess DRAM, diagnosis of DRAM is rendered if horizontal palpation of the linea alba is greater than 2 fingerbreadths (or >2.5 cm). 99 Statement 39: Diastasis Recti, Postpartum. ...
... 99 Statement 39: Diastasis Recti, Postpartum. Although for most patients DRAM resolves spontaneously in the postpartum period, 104,109 it can still persist in some women. 109 An increase in the inter-recti abdominal muscle has been suggested to influence the strength of the abdominal wall musculature 109 possibly interfering with the ability of the abdominal muscles to stabilize the trunk; this may lead to poor posture, umbilical hernia, or pain in the low back or hip. ...
Article
Objective The purpose of this project was to develop a best-practices document on chiropractic care for pregnant and postpartum patients with low back pain (LBP), pelvic girdle pain (PGP), or a combination. Methods A modified Delphi consensus process was conducted. A multidisciplinary steering committee of 11 health care professionals developed 71 seed statements based on their clinical experience and relevant literature. A total of 78 panelists from 7 countries were asked to rate the recommendations (70 chiropractors and representatives from 4 other health professions). Consensus was reached when at least 80% of the panelists deemed the statement to be appropriate along with a median response of at least 7 on a 9-point scale. Results Consensus was reached on 71 statements after 3 rounds of distribution. Statements included informed consent and risks, multidisciplinary care, key components regarding LBP during pregnancy, PGP during pregnancy and combined pain during pregnancy, as well as key components regarding postpartum LBP, PGP, and combined pain. Examination, diagnostic imaging, interventions, and lifestyle factors statements are included. Conclusion An expert panel convened to develop the first best-practice consensus document on chiropractic care for pregnant and postpartum patients with LBP or PGP. The document consists of 71 statements on chiropractic care for pregnant and postpartum patients with LBP and PGP.
... A separation of the heads of the rectus abdominis muscle of more than 2 cm is considered pathological. RAD can affect both women and men of any age [3][4][5][6]. However, it is most often diagnosed in pregnant and postpartum women, due to the changes occurring in a woman's body during pregnancy [1,7,8]. ...
... However, it is most often diagnosed in pregnant and postpartum women, due to the changes occurring in a woman's body during pregnancy [1,7,8]. RAD can occur in infants, people with abdominal obesity and those whose jobs involve heavy lifting [2,5,8]. The most common symptom of RAD is (conical) bulging along the midline of the abdomen-which becomes more prominent while abdominal muscles contract-together with a visible depression in the linea alba [1][2][3]5]. ...
... RAD can occur in infants, people with abdominal obesity and those whose jobs involve heavy lifting [2,5,8]. The most common symptom of RAD is (conical) bulging along the midline of the abdomen-which becomes more prominent while abdominal muscles contract-together with a visible depression in the linea alba [1][2][3]5]. ...
Article
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Background: Rectus abdominis diastasis (RAD) is an excessive divarication of the rectus abdominis muscle with concurrent stretching and thinning of the linea alba, which occurs due to mechanical and functional disturbances in the anterior abdominal wall and the whole body. The primary objective of this study is a palpation assessment of RAD in postpartum women before and after the application of KT tapes and a subsequent comparison of the results with those from a sham intervention group. Methods: A randomized clinical trial was conducted in the Physical Therapy Department at Wroclaw Medical University. The participants were randomly assigned to one of two groups: the KT group (intervention), in which KT tapes were applied (48 h intervention) and the sham KT group (control, sham intervention), in which non-stretch tapes were used (cloth surgical tape, 48 h intervention). In all participants, a palpation assessment of RAD was conducted and the inter-recti distance was measured using a digital caliper at three sites: at the umbilicus and 4.5 cm above and below it. Measurements were taken before and after the intervention. Results: The gathered results show a statistically significant reduction in rectus abdominis diastasis at each of the observed sites after the application of KT tapes in the intervention group (p < 0.05). In the intergroup comparison, a statistically significantly lower RAD (at umbilicus) was found after the intervention (p = 0.005) in KT group. Conclusions: the application of KT tapes using the corrective technique can contribute to reducing RAD in women up to 12 months after delivery.
... Secara fungsional, mengurangi kekuatan, dan terutama terjadi pada otototot rektus abdominis. Akibatnya terjadi peregangan dan flacciditas linea alba, sehingga terjadi pembesaran jarak antara batas medial otot-otot dan terjadi DRAM (Michalska, Rokita, Wolder, Pogorzelska & Kaczmarczyk, 2018). ...
... Pemberian latihan banyak dilakukan untuk pengembalian jarak DRAM, tetapi yang dituju tidak hanya satu otot. (Michalska, Rokita, Wolder, Pogorzelska & Kaczmarczyk, 2018). Ada penelitian yang berfokus melatih otot perut, ada penelitian yang berfokus pada latihan otot perut dan otot dasar panggul (Thabet & Alshehri, 2019) dan ada juga penelitian fokus melatih otot dasar panggul. ...
... Secara fungsional, ini dimanifestasikan oleh pengurangan kekuatan, dan terutama mempengaruhi otot-otot rektus abdominis. Hal ini menyebabkan peregangan dan flacciditas linea alba yang dapat menyebabkan pembesaran jarak antara batas medial otot-otot, sehingga memungkinkan terjadi DRAM (Michalska, Rokita, Wolder, Pogorzelska & Kaczmarczyk, 2018). ...
Article
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p> Latar Belakang: Akibat kehamilan akan menimbulkan Diastasis Recti Abdominal Muscle (DRAM) atau celah yang terbentuk oleh karena terpisahnya otot rectus abdominalis selama pembesaran rahim dan dan setelah melahirkan. DRAM dapat berpengaruh terhadap timbulnya berbagai kasus seperti nyeri punggung bawah, incontinensia urin, instabilitas panggul, sehingga perlu terapi dini. Tujuan: Penelitian ini untuk mengetahui manfaat latihan otot perut terhadap DRAM. Metode: Desain penelitian quasi eksperimen dengan two group pre and post test design . Subjek penelitian adalah ibu pasca melahirkan normal yang terbagi menjadi dua kelompok secara acak. Kelompok perlakuan diberikan latihan otot perut selama 4 minggu. Data dianalisis dengan menggunakan uji chi-square digunakan untuk menguji hasil pengukuran. Hasil: Terdapat perbedaan pengaruh antara kelompok perlakuan dengan kelompok kontrol secara bermakna (p= 0,009; POR=0,714; CI 95%: 0,545-0,936). Latihan otot perut berkontribusi sebesar 41% dalam penutupan DRAM. Simpulan: Latihan otot perut (transversus abdominis) mampu mencegah insiden DRAM pada ibu pasca melahirkan. Ibu setelah melahirkan perlu melakukan latihan dengan mandiri atau dibimbing oleh tenaga kesehatan.</p
... DRA has both psychological and physical effects on post-partum women. Women with DRA primarily receive the application of support band and abdominal band during pregnancy and post-partum (4), electrical stimulation, surgical repair (5), and physical training (6). There is a lack of unified and effective treatment, and there are few studies on the efficacy and safety of DRA physical training (5,7). ...
... Women with DRA primarily receive the application of support band and abdominal band during pregnancy and post-partum (4), electrical stimulation, surgical repair (5), and physical training (6). There is a lack of unified and effective treatment, and there are few studies on the efficacy and safety of DRA physical training (5,7). As a worldwide alternative therapy, acupuncture has received wide attention in preventing and treating diseases related to pregnancy and childbirth. ...
Article
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Background: Diastasis rectus abdominis (DRA) is one of the common complications during pregnancy and post-partum, which has psychological and physical effects on post-partum women. Acupuncture, a worldwide alternative therapy, has attracted wide attention in preventing and treating diseases related to pregnancy and childbirth. This study aims to evaluate the efficacy of acupuncture combined with physical training in treating post-partum rectus muscle dissociation. Methods: This is a randomized, controlled trial of DRA in post-partum conducted at Hangzhou Hospital of Traditional Chinese Medicine Affiliated with Zhejiang University of Chinese Medicine. The primary purpose is to evaluate the effectiveness of acupuncture and physical training on DRA in post-partum women. The study will be conducted from March 2022 to March 2023. The acupuncture group received acupuncture and physical training ( n = 48), the sham acupuncture group received sham acupuncture and physical training ( n = 48), and the physical training group received physical training ( n = 48). These experiments perform once/day, five times a week for 2 weeks, followed up for half a year after the end of the course of treatment. Our tests perform a course of treatment, which includes a total of 10 consecutive treatments. Furthermore, the patient will be followed up for half a year after the treatment. Primary and secondary indicators, including inter recti distance (IRD), linea alba (LA) tension, the MOS item short-form health survey (SF-36), short-form McGill pain questionnaire-2 (SF-MPQ-2), body mass index (BMI), waist-to-hip ratio (WHR), leeds dyspepsia questionnaire (LDQ), menstrual distress questionnaire (MDQ), 10 items of edinburgh post-natal depression scale (EPDS-10), the modified body self-image scale (MBIS), international consultation incontinence questionnaire short-form (ICIQ-SF) and hernia-related quality-of-life survey (HerQles), which will be evaluated before and after treatment and half a year after treatment. Adverse events and side effects during each treatment will be collected and recorded. Discussion: There is evidence that acupuncture and physical training can treat DRA in post-partum. In this study, we evaluate the effectiveness of acupuncture in post-partum with DRA.
... The stretching and thinning of the linea alba favors concomitant hernia defects [2,3] and is associated with low back pain, abdominal wall dysfunctions and decreased quality of life [4][5][6][7]. DRA can resolve spontaneously in the postpartum period, it can be corrected surgically [3,[7][8][9][10][11]. Conservative treatment for DRA has been proposed by various studies but no universally acceptable approach has yet been defined and proofed so far [8,10,12]. ...
... The stretching and thinning of the linea alba favors concomitant hernia defects [2,3] and is associated with low back pain, abdominal wall dysfunctions and decreased quality of life [4][5][6][7]. DRA can resolve spontaneously in the postpartum period, it can be corrected surgically [3,[7][8][9][10][11]. Conservative treatment for DRA has been proposed by various studies but no universally acceptable approach has yet been defined and proofed so far [8,10,12]. ...
Article
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Aim The prevalence and definition of diastasis recti abdominis (DRA) is under debate. This retrospective cross-sectional study evaluated the interrectal distance and the prevalence of DRA in computed tomography (CT) in an asymptomatic population. Materials and methods Patients undergoing CT scans for suspected appendicitis or kidney stones from 01/2016 to 12/2018 were screened retrospectively to participate. A study population with equal distribution according to gender and age (18–90 years) was generated ( n = 329 patients) and the interrectal distance was measured at six reference points. Results DRA (defined as > 2 cm at 3 cm above the umbilicus) was present in 57% of the population. The 80th percentile of the interrectal distance was 10 mm at the xiphoid (median 3 mm, 95% confidence interval (CI) 0–19 mm), 27 mm halfway from xiphoid to umbilicus (median 17 mm, 95% CI 0–39 mm), 34 mm at 3 cm above the umbilicus (median 22 mm, 95% CI 0–50 mm), 32 mm at the umbilicus (median 25 mm, 95% CI 0–45 mm), 25 mm at 2 cm below the umbilicus (median 14 mm, 95% CI 0–39 mm), and 4 mm halfway from umbilicus to pubic symphysis (median 0 mm, 95% CI 0–19 mm). In the multivariate analysis, higher age ( p = 0.001), increased body mass index ( p < 0.001), and parity ( p < 0.037) were independent risk factors for DRA, while split xiphoid, tobacco abuse, and umbilical hernia were not. Conclusion The prevalence of DRA is much higher than commonly estimated (57%). The IRD 3 cm above the umbilicus may be considered normal up to 34 mm. To avoid over-treatment, the definition of DRA should be revised.
... One study [13] indicated that core muscle group exercise and abdominal breathing could relieve a series of clinical symptoms caused by DRA. Moreover, the total effective rate of early postpartum self-rehabilitation exercise is 100% [14]. Nevertheless, no consensus protocol for abdominal exercises has been proposed and carried out in quality randomized controlled trials. ...
Article
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To investigate the effects of ultrasonic evaluation of a progressive yoga exercise program on reducing the inter-recti distance (IRD) among women in the early postpartum period. Postpartum women ( n = 116 ), free of obstetric complications and in recovery following vaginal delivery between weeks 1 and 12, were recruited. Participants were randomly assigned to the control and yoga exercise group in the pre- and post-intervention design. The control group received no treatment, while the yoga exercise group participated in a guided 12-week progressive yoga exercise program started at postpartum week 1. The IRD was examined using high-frequency ultrasound at postpartum weeks 6 and 12. The results showed that the supraumbilical, umbilical, and subumbilical IRD were significantly decreased in the yoga exercise group after the 12-week progressive yoga exercise intervention compared with the first (week 6) and second (week 12) measurements. The differences in IRD at supraumbilical, umbilical, and subumbilical intervals between weeks 6 and 12 significantly increased in the yoga exercise group. Progressive yoga exercises are effective program that reduce IRD among women in the early postpartum period through ultrasound evaluation. In conclusion, women should advocate combined yoga exercise in the early postpartum days following a supervised program.
... Its tension is regulated by the pyramidal muscles and the rectus abdominis muscles (16). The length of the linea alba (LA) in an adult is ∼33 cm, while its width is at least 10 mm (14). ...
Article
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Introduction Civilization development coupled with contemporary lifestyle leads to a systematic increase in postural disorders. An analysis of factors that may provoke postural disorders indicates that such a stimulus may be the diastasis of the rectus abdominis muscles. Moreover, abnormal activity of the rectus abdominis muscles may affect balance disorders through reduced spinal stabilization and disturbed body statics. There is an increase in body posture abnormalities between the ages of 6 and 9 related to new school duties. Purpose of the Study The purpose of the study was to evaluate the relationship between the shape of the spine and the width of the linea alba in children aged 6–9 years. Material and Method The study was designed to evaluate parameters determining the shape of the spine, and the width of the linea alba in healthy children aged 6–9 years. The study participants were divided into two groups based on the width of the linea alba. The study group with the width of the linea alba >10 mm and the control group with the width of the linea alba ≤ 10 mm. The study group were included 37 children and the control group 24 children. The examination of the linea alba width was performed by a radiology specialist using a linear transducer and SAOTE- My Lab Classc-type ultrasound at rest and during contraction of the rectus abdominis muscles. Parameters describing the shape of the spine were measured using the Diers Formetric 4D system: trunk inclination, trunk imbalance, pelvis tilt, pelvic torsion, kyphotic apex, lordotic apex, kyphotic angle, lordotic angle, rotation angle, trunk torsion, lateral deviation. The obtained results were statistically analyzed using a Paired t test for comparison of differences between the results in the study and control groups and Pearson's test to assess the correlation between the width of the linea alba and parameters describing spinal alignment. Results In both groups, the parameters describing the shape of the spine did not differ from the norms accepted as typical for the age norm. The only statistically significant difference between the study and control group concerned the trunk inclination, which was negative in the study group, signifying a shift of the entire spine axis backwards beyond the vertical. Conclusions There is a correlation between the shape of spine and the width of the linea alba in terms of selected parameters determining the body posture in the sagittal plane, which concern: the position of the lumbar lordotic apex, trunk inclination and the depth of the lumbar lordotic angle. The width of the linea alba is not explicitly related to abnormalities of pelvic and spinal alignment in the frontal and transverse planes.
... Según diferentes estudios, entre el 20% y el 100% de mujeres en la semana 36 pueden presentar diástasis, que se normaliza hasta en un 30% de las mujeres a los 12 meses después del parto. En hombres se suele presentar en pacientes obesos mayores de 50 años y su localización suele ser supra umbilical 19 . ...
Article
Resumen Puntos para una lectura rápida •Las hernias de pared abdominal son un motivo de consulta frecuente en Atención Primaria. La hernia inguinal es el tipo de hernia más frecuente. •Generalmente la patología de pared abdominal se puede diagnosticar con una buena anamnesis y exploración física. Las exploraciones complementarias pueden ser útiles en casos dudosos. •Las complicaciones de la hernia de pared abdominal son una urgencia quirúrgica y pueden conllevar riesgo vital. •La diástasis de los rectos es un motivo de consulta frecuente, principalmente en el posparto. El tratamiento quirúrgico suele tener motivos estéticos. •El dolor de pared abdominal requiere una buena anamnesis y exploración física. Existen diferentes etiologías.
Article
Background Abdominal diastasis (AD) is highly prevalent at post-partum. Although several conservative approaches have been proposed, an effective and protocolized treatment is lacking for this condition. Objective To identify modifications of inter-rectus abdominis distance (IRAD), trunk circumferences and mechanical properties of the AD, transversus abdominis and the pelvic floor (PF) muscles, after the application of hypopressive exercises (HE) and at a two-month follow-up in postpartum AD. Methods Twelve volunteers with post-partum AD followed a four-week (three times a week) tailored program of HE. The main outcome was the IRAD, assessed at four specific supraumbilical points (3, 6, 9, and 12 cm). Abdominal circumference and respiratory expansion were measured at three different locations (axillar, xiphoid, and umbilical), and the mechanical properties of abdomino-pelvic tissues were also assessed using tonometry (MyotonPRO). Four evaluations were performed for all outcomes: at baseline, post-intervention, at a 1-month follow-up, and at a 2-month follow-up. Results The IRAD of participants was reduced (p < .05), furthermore, some participants displayed no AD after the intervention period. In addition, the abdominal circumference increased, mainly at follow-up, whereas the thoracic respiratory expansion decreased a median of 2 cm. The tension and stiffness of the LA decreased, when assessed at 3 and 6 cm supraumbilical. Finally, the tension and elasticity of TA/IO and of the PF, and also the elasticity of the PF decreased after the intervention period. No complaints were identified in relation to the HE program or assessments. Conclusion A program of HE showed positive results for the reduction of post-partum AD. Different study designs should be performed to better explain the effects of HE for AD.
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An increased inter-recti distance is a common problem in late pregnancy and during postpartum period. According to researches diastasis recti abdominis’ occurs in 35-60% of the cases. There are only assumptions about the risk factors, treatment and consequences. The aim of this study was to determine the effect of the treatment in the postpartum period using a single case study. A 33-year-old woman, six weeks after her first delivery, was recruited to the research. She complained about abdominal muscle weakness and low back pain. The patient got a three-months-long physical therapy in which the strengthening of the transverse abdominal muscles was primary. After the intervention the pathological inter-recti distance achieved the normal range almost at each reference point. This study found that the inter-recti distance was reduced when isometric contraction of the transverse abdominal muscle was performed. This suggests that this type of exercise could be effective in treating the postpartum diastasis recti and preventing the possible sequelae.
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Abstract This case report detailed the history and treatment of a female postpartum patient with diastasis recti. Treatment for this patient included the use of prolotherapy, an injection-based therapy using dextrose as the active compound. The solution used during the course of therapy was composed of 6 mL of 50% dextrose, 3 mL of 1% li- docaine, and 1 mL of methylcobalamin (1000 mcg/mL). Injections were administer- ed every 2 weeks for a total of 7 prolotherapy sessions. Following the series of prolo- therapy injections, there was a marked closure observed in the diastasis, decreasing from 2.7 cm to 0.5 cm. The patient did not report any side effects, and no complica- tions were observed or recorded. This appears to be the first case report documenting an improvement in abdominal diastasis recti following a course of prolotherapy. Within the limitations of the study design, further research is recommended to eva- luate prolotherapy for diastasis recti in postpartum patients.
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Objective: The aim of this study was to systematically review dextrose (d-glucose) prolotherapy efficacy in the treatment of chronic musculoskeletal pain. Data sources: Electronic databases PubMed, Healthline, OmniMedicalSearch, Medscape, and EMBASE were searched from 1990 to January 2016. Study selection: Prospectively designed studies that used dextrose as the sole active prolotherapy constituent were selected. Data extraction: Two independent reviewers rated studies for quality of evidence using the Physiotherapy Evidence Database assessment scale for randomized controlled trials (RCTs) and the Downs and Black evaluation tool for non-RCTs, for level of evidence using a modified Sackett scale, and for clinically relevant pain score difference using minimal clinically important change criteria. Study population, methods, and results data were extracted and tabulated. Data synthesis: Fourteen RCTs, 1 case-control study, and 18 case series studies met the inclusion criteria and were evaluated. Pain conditions were clustered into tendinopathies, osteoarthritis (OA), spinal/pelvic, and myofascial pain. The RCTs were high-quality Level 1 evidence (Physiotherapy Evidence Database ≥8) and found dextrose injection superior to controls in Osgood-Schlatter disease, lateral epicondylitis of the elbow, traumatic rotator cuff injury, knee OA, finger OA, and myofascial pain; in biomechanical but not subjective measures in temporal mandibular joint; and comparable in a short-term RCT but superior in a long-term RCT in low back pain. Many observational studies were of high quality and reported consistent positive evidence in multiple studies of tendinopathies, knee OA, sacroiliac pain, and iliac crest pain that received RCT confirmation in separate studies. Eighteen studies combined patient self-rating (subjective) with psychometric, imaging, and/or biomechanical (objective) outcome measurement and found both positive subjective and objective outcomes in 16 studies and positive objective but not subjective outcomes in two studies. All 15 studies solely using subjective or psychometric measures reported positive findings. Conclusion: Use of dextrose prolotherapy is supported for treatment of tendinopathies, knee and finger joint OA, and spinal/pelvic pain due to ligament dysfunction. Efficacy in acute pain, as first-line therapy, and in myofascial pain cannot be determined from the literature.
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Background/aim Diastasis recti abdominis (DRA) is defined as a separation of the 2 muscle bellies of rectus abdominis. To date there is scant knowledge on prevalence, risk factors, and consequences of the condition. The present study aimed to investigate the prevalence of DRA during pregnancy and post partum, presence of possible risk factors, and the occurrence of lumbopelvic pain among women with and without DRA. Methods This prospective cohort study followed 300 first-time pregnant women from pregnancy till 12 months post partum. Data were collected by electronic questionnaire and clinical examinations. DRA was defined as a palpated separation of ≥2 fingerbreadths either 4.5 cm above, at or 4.5 cm below the umbilicus. Women with and without DRA were compared with independent samples Student's t-test and χ2/Fisher exact test, and OR with significance level >0.05. Results Prevalence of DRA was 33.1%, 60.0%, 45.4%, and 32.6% at gestation week 21, 6 weeks, 6 months and 12 months post partum, respectively. No difference in risk factors was found when comparing women with and without DRA. OR showed a greater likelihood for DRA among women reporting heavy lifting ≥20 times weekly (OR 2.18 95% CI 1.05 to 4.52). There was no difference in reported lumbopelvic pain (p=0.10) in women with and without DRA. Conclusions Prevalence of mild DRA was high both during pregnancy and after childbirth. Women with and without DRA reported the same amount of lumbopelvic pain 12 months post partum.
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Purpose: To investigate the interrater reliability of inter-rectus distance (IRD) measured from ultrasound images acquired at rest and during a head-lift task in parous women and to establish the standard error of measurement (SEM) and minimal detectable change (MDC) between two raters. Methods: Two physiotherapists independently acquired ultrasound images of the anterior abdominal wall from 17 parous women and measured IRD at four locations along the linea alba: at the superior border of the umbilicus, at 3 cm and 5 cm above the superior border of the umbilicus, and at 3 cm below the inferior border of the umbilicus. The interrater reliability of the IRD measurements was determined using intra-class correlation coefficients (ICCs). Bland-Altman analyses were used to detect bias between the raters, and SEM and MDC values were established for each measurement site. Results: When the two raters performed their own image acquisition and processing, ICCs(3,5)ranged from 0.72 to 0.91 at rest and from 0.63 to 0.96 during head lift, depending on the anatomical measurement site. Bland-Altman analyses revealed no systematic bias between the raters. SEM values ranged from 0.23 cm to 0.71 cm, and MDC values ranged from 0.64 cm to 1.97 cm. Conclusion: When using ultrasound imaging to measure IRD in women, it is acceptable for different therapists to compare IRDs between patients and within patients over time if IRD is measured above or below the umbilicus. Interrater reliability of IRD measurement is poorest at the level of the superior border of the umbilicus.
Article
Background: The primary aim of this prospective, randomized, clinical, 2-armed trial was to evaluate the risk for recurrence using 2 different operative techniques for repair of abdominal rectus diastasis. Secondary aims were comparison of pain, abdominal muscle strength, and quality of life and to compare those outcomes to a control group receiving physical training only. Methods: Eighty-six patients were enrolled. Twenty-nine patients were allocated to retromuscular polypropylene mesh and 27 to double-row plication with Quill technology. Thirty-two patients participated in a 3-month training program. Diastasis was evaluated with computed tomography scan and clinically. Pain was assessed using the ventral hernia pain questionnaire, a quality-of-life survey, SF-36, and abdominal muscle strength using the Biodex System-4. Results: One early recurrence occurred in the Quill group, 2 encapsulated seromas in the mesh group, and 3 in the suture group. Significant improvements in perceived pain, the ventral hernia pain questionnaire, and quality of life appeared at the 1-year follow-up with no difference between the 2 operative groups. Significant muscular improvement was obtained in all groups (Biodex System-4). Patient perceived gain in muscle strength assessed with a visual analog scale improved similarly in both operative groups. This improvement was significantly greater than that seen in the training group. Patients in the training group still experienced bodily pain at follow-up. Conclusion: There was no difference between the Quill technique and retromuscular mesh in the effect on abdominal wall stability, with a similar complication rate 1 year after operation. An operation improves functional ability and quality of life. Training strengthens the abdominal muscles, but patients still experience discomfort and pain.
Article
Fisheye STUDY DESIGN: Cross-sectional repeated measures. Fisheye BACKGROUND: Rehabilitation of diastasis rectus abdominis (DRA) generally aims to reduce the inter-rectus distance (IRD). We tested the hypothesis that activation of the transversus abdominis (TrA) before a curl-up would reduce IRD narrowing, with less linea alba (LA) distortion/deformation, which may allow better force transfer between sides of the abdominal wall. Fisheye OBJECTIVES: This study investigated behavior of the LA and IRD during curl-ups performed naturally and with preactivation of the TrA. Fisheye METHODS: Curl-ups were performed by 26 women with DRA and 17 healthy control participants using a natural strategy (automatic curl-up) and with TrA preactivation (TrA curl-up). Ultrasound images were recorded at 2 points above the umbilicus (U point and UX point). Ultrasound measures of IRD and a novel measure of LA distortion (distortion index: average deviation of the LA from the shortest path between the recti) were compared between 3 tasks (rest, automatic curl-up, TrA curl-up), between groups, and between measurement points (analysis of variance). Fisheye RESULTS: Automatic curl-up by women with DRA narrowed the IRD from resting values (mean U-point between-task difference, -1.19 cm; 95% confidence interval [CI]: -1.45, -0.93; P<.001 and mean UX-point between-task difference, -0.51 cm; 95% CI: -0.69, -0.34; P<.001), but LA distortion increased (mean U-point between-task difference, 0.018; 95% CI: 0.0003, 0.041; P = .046 and mean UX-point between-task difference, 0.025; 95% CI: 0.004, 0.045; P = .02). Although TrA curl-up induced no narrowing or less IRD narrowing than automatic curl-up (mean U-point difference between TrA curl-up versus rest, -0.56 cm; 95% CI: -0.82, -0.31; P<.001 and mean UX-point between-task difference, 0.02 cm; 95% CI: -0.22, 0.19; P = .86), LA distortion was less (mean U-point between-task difference, -0.025; 95% CI: -0.037, -0.012; P<.001 and mean UX-point between-task difference, -0.021; 95% CI: -0.038, -0.005; P = .01). Inter-rectus distance and the distortion index did not change from rest or differ between tasks for controls (P≥.55). Fisheye CONCLUSION: Narrowing of the IRD during automatic curl-up in DRA distorts the LA. The distortion index requires further validation, but findings imply that less IRD narrowing with TrA preactivation might improve force transfer between sides of the abdomen. The clinical implication is that reduced IRD narrowing by TrA contraction, which has been discouraged, may positively impact abdominal mechanics.
Article
Aims: Compare vaginal resting pressure (VRP), pelvic floor muscle (PFM) strength, and endurance in women with and without diastasis recti abdominis at gestational week 21 and at 6 weeks, 6 months, and 12 months postpartum. Furthermore, to compare prevalence of urinary incontinence (UI) and pelvic organ prolapse (POP) in the two groups at the same assessment points. Methods: This is a prospective cohort study following 300 nulliparous pregnant women giving birth at a public university hospital. VRP, PFM strength, and endurance were measured with vaginal manometry. ICIQ-UI-SF questionnaire and POP-Q were used to assess UI and POP. Diastasis recti abdominis was diagnosed with palpation of ≥2 fingerbreadths 4.5 cm above, at, or 4.5 cm below the umbilicus. Results: At gestational week 21 women with diastasis recti abdominis had statistically significant greater VRP (mean difference 3.06 cm H2 O [95%CI: 0.70; 5.42]), PFM strength (mean difference 5.09 cm H2 O [95%CI: 0.76; 9.42]) and PFM muscle endurance (mean difference 47.08 cm H2 O sec [95%CI: 15.18; 78.99]) than women with no diastasis. There were no statistically significant differences between women with and without diastasis in any PFM variables at 6 weeks, 6 months, and 12 months postpartum. No significant difference was found in prevalence of UI in women with and without diastasis at any assessment points. Six weeks postpartum 15.9% of women without diastasis had POP versus 4.1% in the group with diastasis (P = 0.001). Conclusions: Women with diastasis were not more likely to have weaker PFM or more UI or POP. Neurourol. Urodynam. © 2016 Wiley Periodicals, Inc.