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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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