Diastasis Recti Abdominis-diagnosis, Risk Factors, Effect on Musculoskeletal Function, Framework for Treatment and Implications for the Pelvic Floor

Author(s): Laura Anne Werner* , Marcy Dayan .

Journal Name: Current Women`s Health Reviews

Volume 15 , Issue 2 , 2019

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Graphical Abstract:


Abstract:

Background: Diastasis Recti Abdominis (DRA) can occur during pregnancy and postpartum. It is defined as an increase of the inter-recti distance (IRD) beyond normal values. The diagnosis of DRA is inconsistent within the literature and varies depending on measurement instrument and activity during measurement (rest versus active curl-up). DRA is characterized by the stretching of linea alba (LA) and contributes to a protrusion of the anterior abdominal wall due to increased laxity in the myofascial system that supports abdominal viscera. DRA has been postulated to affect lumbopelvic support and function due to laxity of the LA and altered angle of muscle insertion, but recent studies have not confirmed this. Risk factors for the development of DRA have been investigated in pregnancy to 12-months postpartum.

Objective: Rehabilitation for DRA has been traditionally focused on reducing the IRD, but recent research has proposed that a sole focus on closing the DRA is suboptimal.

Results: It is important alongside the rehabilitation of the abdominal wall that there is the consideration of the pelvic floor (PF). In healthy individuals, with the activation of the transversus abdominis, there is a sub-maximal co-contraction of the PF muscles. This co-contraction can be lost or altered in women with urinary incontinence. An increase in intra-abdominal pressure without simultaneous co-contraction of the PF may cause caudal displacement of the PF.

Conclusion: The aim of this review is to bring the reader up to date on the evidence on DRA and to propose a rehabilitation framework for the whole abdominal wall in DRA with consideration of the impact on the PF.

Keywords: Physiotherapy, inter-recti distance, diastasis recti abdominis, rehabilitation, abdominal exercise, pelvic floor exercise, pregnancy, postpartum.

[1]
Bø K, Sherburn M, Allen T. Transabdominal measurement of pelvic floor muscle activity when activated directly or via a transverus abdominis muscle contraction. Neurourol Urodyn 2003; 22: 582-8.
[2]
Mota P, Pascoal AG, Bø K. Diastasis recti abdominis in pregnancy and postpartum period. Risk factors, functional implications and resolution. Curr Womens Health Rev 2015; 11: 59-67.
[3]
Kahle W, Leonahardt H, Platzer W. Anatomie Appareil Locomoteur. Paris: Flammarion Medecine-Science 1991.
[4]
Turatti RC, Moira VMde, Cabral RH, Simionato-Netto D, Sevillano MM, Leme PLS. Sonographic aspects and anatomy of the aponeurosis of transversus abdominis muscle. Arq Bras Cir Dig 2013; 26(3): 184-9.
[5]
Axer H, von Keyserlingk DG, Prescher A. Collagen fibres in linea alba and rectus sheaths. I. General scheme and morphological aspects. J Surg Res 2001; 96: 127-34.
[6]
Axer H, von Keyserlingk DG, Prescher A. Collagen fibres in linea alba and rectus sheaths. II. Variability and biomechanical aspects. J Surg Res 2001; 96: 239-45.
[7]
Grassel D, Prescher A, Fitzek S, Keyserlingk DGV, Axer H. Anisotropy of human linea alba: A biomechanical study. J Surg Res 2005; 124(1): 118-25.
[8]
Beer GM, Schuster A, Seifert B, Manestar M, Mihic-Probst D, Weber SA. The normal width of the linea alba in nulliparous women. Clin Anat 2009; 22(6): 706-11.
[9]
Tesh KM, Dunn JS, Evans JH. The abdominal muscles and vertebral stability. Spine 1987; 12: 501-8.
[10]
Hernandez-Gascon B, Mena A, Pena E, Pascual G, Bellon JM, Calvo B. Understanding the passive mechanical behaviour of the human abdominal wall. Ann Biomed Eng 2012; 41(2): 433-44.
[11]
Benjamin DR, van de Water ATM, Peiris CL. Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: A systemic review. Physiotherapy 2014; 100: 1-8.
[12]
Rath AM, Attali P, Dumas JL, Goldlust D, Zhang J, Chevrel JP. The abdominal linea alba: An anatomo-radiologic and biomechanical study. Surg Radiol Anat 1996; 18(4): 281-8.
[13]
Liaw L-J, Hsu M-J, Liao C-F, Liu M-F, Hsu A-T. The relationships between inter-recti distance measured by ultrasound imaging and abdominal muscle function in postpartum women: A 6-month follow-up study. J Orthop Sports Phys Ther 2011; 41(6): 435-43.
[14]
Lo T, Candido G, Janssen P. Diastasis of the recti abdominis in pregnancy: Risk factors and treatment. Physiother Can 1999; 51: 32-7.
[15]
Spitznagle TM, Leong FC, Van Dillen LR. Prevalence of diastasis recti abdominis in a urogynecological patient population. Int Urogynecol J Pelvic Floor Dysfunct 2007; 18(3): 321-8.
[16]
Boissonnault JS, Kotarinos RK. Diastasis Recti. In: Wilder E, Ed. Obstetric and Gynaecology Physical Therapy. Edinburgh: Churchill Livingstone 1988; pp. 63-82.
[17]
Cunningham F, Leveno K, Bloom S, Hauth JC, Rouse DJ, Spong CY. Williams Obstetrics. 23rd ed. New York, (NY): McGraw-Hill 2009.
[18]
Gilleard W, Crosbie J, Smith R. Effect of pregnancy on trunk range of motion when sitting and standing. Acts Obstet Gynecol Scand 2002; 81(11): 1011-20.
[19]
Gilleard WL, Brown JM. Structure and function of the abdominal muscles in primigravid subjects during pregnancy and the immediate postbirth period. Phys Ther 1996; 76(7): 750-62.
[20]
Lockwood T. Rectus muscle diastasis in males: Primary indication for endoscopically assisted abdominoplasty. Plast Reconstr Surg 1998; 101: 1685-94.
[21]
Nahas FX, Ferreria LM, Mendez JA. An efficient way to correct recurrent rectus diastasis. Aesthet Plast Surg 2004; 28: 189-96.
[22]
Nahas FX. An aesthetic classification of the abdomen based on the myoaponeurotic layer. Plast Reconstr Surg 2001; 108: 1787-95.
[23]
Brauman D. Diastasis recti: Clinical anatomy. Plast Reconstr Surg 2008; 122(5): 1564-9.
[24]
Ranney B. Diastasis recti and umbilical hernia causes, recognition and repair. S D J Med 1990; 43(10): 5-8.
[25]
Hickey F, Finch JG, Khanna A. A systematic review of the outcomes of correction of diastasis of the recti. Hernia 2011; 15: 607-14.
[26]
Mommers E, Ponten J, Al Omar A, Bouvy N, de Vries Reilingh T, Nienhuijs S. The general surgeon’s perspective of rectus diastasis: A systematic review of treatment options. Surg Endosc 2017; 31(12): 4934-49.
[27]
Akram J, Matzen SH. Rectus abdominis diastasis. J Plast Surg Hand Surg 2014; 48: 163-9.
[28]
Boissonnault JS, Blanchard MJ. Incidence of diastasis recti abdominis during the childbearing year. Phys Ther 1988; 68(7): 1082-6.
[29]
Bursch SG. Interrater reliability of diastasis recti abdominis measurement. Phys Ther 1987; 67(7): 1077-9.
[30]
Mota PGFD, Pascoal AGBA, Carita AIAD, Bø K. Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Man Ther 2015; 20(1): 200-5.
[31]
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: 1092-6.
[32]
Candido G, Lo T, Janssen P. Risk factors for diastasis of the recti abdominis. J Assoc Chart Physiother Women’s Health 2005; 97: 49-54.
[33]
Rett MT, Braga MD, Bernardes NO, Andrade SC. Prevalence of diastasis of the rectus abdominis muscles immediately postpartum: Comparison between primipare and multipare. Braz J Phys Ther 2009; 13(4): 275-80.
[34]
Sancho MF, Pascoal AG, Mota P, Bø K. Abdominal exercises affect inter-rectus distance in postpartum women – a two-dimensional ultrasound study. Physiotherapy 2015; 101: 286-91.
[35]
Bø K, Hilde G, Tennfjord MK, Sperstad JB, Engh ME. Pelvic floor muscle function, pelvic floor dysfunction, and diastasis recti abdominis: Prospective cohort study. Neurourol Urodyn 2017; 36: 716-21.
[36]
Barton S. The postnatal period. In: Mantle J, Haslam J, Barton S, Eds. Physiotherapy in Obstetrics and Gynaecology. 2nd ed. Oxford: Butterworth-Heinemann 2004; pp. 205-47.
[37]
Sheppard S. The role of the transversus abdominis in postpartum correction of gross divarication recti. Man Ther 1996; 1(4): 214-6.
[38]
Coldron Y, Stokes MJ, Newham DJ, Cook K. Postpartum characteristics of rectus abdominis on ultrasound imaging. Man Ther 2008; 13: 112-21.
[39]
Parker MA, Millar LA, Dugan SA. Diastasis rectus abdominis and pelvic pain and dysfunction – are they related? J Womens Health Phys Ther 2009; 33(2): 15-22.
[40]
Chiarello CM, Falzone LA, McCaslin KE, Patel MN, Ulery KR. The effects of an exercise program on diastasis recti abdominis in pregnant women. J Womens Health Phys Ther 2005; 29(1): 11-6.
[41]
El-Mekawy HS, Eldeeb AM, El-Lythy MA, El-Begawy AF. Effect of abdominal exercises versus abdominal supporting belt on post-partum abdominal efficiency and rectus separation. World Acad Sci Eng Technol 2013; 7(1): 75-9.
[42]
Litos K. Progressive therapeutic exercise program for successful treatment of a postpartum woman with a severe diastasis recti abdominis. J Womens Health Phys Ther 2014; 38: 58-73.
[43]
Keshwani N, Mather S, McLean L. Validity of inter-rectus distance measurement in postpartum women using extended field-of-view ultrasound imaging techniques. J Orthop Sports Phys Ther 2015; 45(10): 808-13.
[44]
Strigård K, Clay L, Stark B, Gunnarsson U. Predictive factors in the outcome of surgical repair of abdominal rectus diastasis. Plast Reconstr Surg Glob Open 2016; 4(702): 1-6.
[45]
Escamilla RF, Lewis C, Bell D, et al. Core muscle activation during Swiss ball and traditional abdominal exercises. J Orthop Sports Phys Ther 2010; 40: 265-76.
[46]
Pascoal AG, Dionisio S, Cordero F, Mota P. Inter-rectus distance in postpartum women can be reduced by isometric contraction of the abdominal muscles: A preliminary case-control study. Physiotherapy 2014; 100: 344-8.
[47]
Mota P, Pascoal AG, Carita AI, Bø K. The immediate effects on inter-rectus distance of abdominal crunch and drawing in exercises during pregnancy and the postpartum period. J Orthop Sports Phys Ther 2015; 45(10): 781-8.
[48]
Chiarello CM, McAuley JA, Hartigan EH. Immediate effect of active abdominal contraction on inter-recti distance. J Orthop Sports Phys Ther 2016; 46(3): 177-83.
[49]
Lee D, Hodges PW. Behaviour of the linea alba during a curl-up task in diastasis rectus abdominis: An observational study. J Orthop Sports Phys Ther 2016; 46(7): 580-9.
[50]
Boxer S, Jones S. Intra-rater reliability of rectus abdominis diastasis measurement using dial calipers. Aust J Physiother 1997; 43: 109-44.
[51]
Chiarello CM, McAuley JA. Concurrent validity of caliper and ultrasound imaging to measure interrecti distance. J Orthop Sports Phys Ther 2013; 43(7): 495-503.
[52]
van de Water AT, Benjamin DR. Measurement methods to assess diastasis of the rectus abdominis muscle (DRAM): a systematic review of their measurement properties and meta-analytic reliability generalisation. Man Ther 2016; 21: 41-53.
[53]
Mota P, Pascoal AG, Sancho F, Carita AI, Bø K. Reliability of the inter-rectus distance measured by palpation. Comparison of palpation and ultrasound measurements. Man Ther 2013; 18: 294-8.
[54]
Mendes DA, Nahas FX, Veiga DF, et al. Ultrasonography for measuring rectus abdominis muscles diastasis. Acta Cir Bras 2007; 22(3): 182-6.
[55]
Mota P, Pascoal AG, Sancho F, Bø K. Test-retest and intrarater reliability of 2-dimensional ultrasound measurements of distance between rectus abdominis in women. J Orthop Sports Phys Ther 2012; 42(11): 940-6.
[56]
Keshwani N, McLean L. Ultrasound imaging in postpartum women with diastasis recti: intrarater between-session reliability. J Orthop Sports Phys Ther 2015; 45(9): 713-8.
[57]
Keshwani N, Hills N, McLean L. Inter-Rectus distance measurement using ultrasound imaging: Does the rater matter? Physiother Can 2016; 68(3): 223-9.
[58]
Hills NF, Keshwani N, McLean L. Influence of ultrasound transducer tilt in the cranial and caudal directions on measurements of inter-rectus distance in parous women. Physiother Can 2018; 70(1): 6-10.
[59]
Blazevich AJ, Cannavan D, Waugh CM, et al. Range of motion, neuromechanical, and architectural adaptations to plantar flexor stretch training in humans. J Appl Physiol 2014; 117: 452-62.
[60]
Veríssimo P, Nahas FX, Barbosa MVJ, Gomes HFC, Ferreira LM. Is it possible to repair diastasis recti and shorten the aponeurosis at the same time? Aesth Plast Surg 2014; 38: 379-86.
[61]
Sapsford RR, Hodges PW, Richardson CA, Cooper DH, Markwekk SJ, Jull GA. Co-activation of the abdominal and pelvic floor muscles during voluntary exercises. Neurourol Urodyn 2001; 20: 31-42.
[62]
Bø K, Mørkved S, Frawley H, Sherburn M. Evidence for benefit of transversus abdominis training alone or in combination with pelvic floor muscle training to treat female urinary incontinence: A systematic review. Neurourol Urodyn 2009; 28: 368-73.
[63]
Dumoulin C, Lemieux M, Bourbonnais D, Gravel D, Bravo G, Morin M. Physiotherapy for persistent postnatal stress urinary incontinence: A randomized controlled trial. Obstet Gynecol 2004; 104: 504-10.
[64]
Sriboonreung T, Wongtra-ngan S, Eungpinichpong W, Laopaiboon M. Effectiveness of pelvic floor muscle training in incontinent women at Maharaj Nakorn Chiang Mai Hospital: A randomized controlled trial. J Med Assoc Thai 2011; 94: 1-7.
[65]
Bø K, Herbert RD. There is not yet strong evidence that exercise regimens other than pelvic floor muscle training can reduce stress urinary incontinence in women: A systematic review. Physiotherapy 2013; 59(3): 159-68.
[66]
Martin C, Sun W. Fatigue damage of collagenous tissues: Experiment, modeling and simulation studies. J Long Term Eff Med Implants 2015; 25(1-2): 55-73.
[67]
Gasser TC, Holzapfel GA. A rate-induced elastoplastic constitutive model for biological fibre-reinforced composites at finite strains: continuum basis, algorithmic formulation and finite element implementation. Comput Mechan 2002; 29(4-5): 340-60.
[68]
Hsia M, Jones S. Natural resolution of rectus abdominis diastasis. Two single case studies. Aust J Physiother 2000; 46(4): 301-7.
[69]
Oneal RM, Mulka JP, Shapiro P, Hing D, Cavaliere C. Wide abdominal rectus plication abdominoplasty for the treatment of chronic intractable low back pain. Plast Reconstr Surg 2011; 127: 225-31.
[70]
Davies GAL, Wolfe LA, Mottola MF, MacKinnon C. Joint SOGC/SCEP clinical practice guideline: exercise in pregnancy and the postpartum period. Can J Appl Physiology 2003; 28(3): 330-41.
[71]
Lee DG, Lee LJ, McLaughlin L. Stability, continence and breathing: the role of fascia following pregnancy and delivery. J Bodywork Move Ther 2008; 12: 333-48.
[72]
Tupler J. Save the sutures with the Tupler technique. Hernia 2012; 16(suppl. 1): S176-7.
[73]
Podwojewski F, Ottenio M, Beillas P, Guerin G, Turquier F, Mutton D. Mechanical response of human abdominal walls ex vivo: Effect of an incisional hernia and a mesh repair. J Mech Behav Biomed Mater 2014; 38: 126-33.
[74]
Urquhart DM, Hodges PW. Differential activity of regions of transversus abdominis during trunk rotation. Euro Spine J 2005; 14: 393-400.
[75]
Franchi M, Trire A, Quaranta M, Orsini E, Ottani V. Collagen structure of tendon relates to function. Sci World J 2007; 7: 404-20.
[76]
Kjaer M, Langberg H, Heinemeier K, et al. From mechanical loading to collagen synthesis, structural changes and function in human tendon. Scand J Med Sci Sports 2009; 19: 500-10.
[77]
Lee D, Hodges P. Diastasis rectus abdominis – should we open or close the gap? Musculoskelet Sci Pract 2017; 28: e16.
[78]
Sapsford R. The pelvic floor. A clinical model for function and rehabilitation. Physiotherapy 2001; 87: 620-30.
[79]
Sapsford R, Hodges P. Contraction of the pelvic floor muscles during abdominal maneuvers. Arch Phys Med Rehabil 2001; 82: 1081-8.
[80]
Sapsford R. Rehabilitation of the pelvic floor muscles utilizing trunk stabilization. Manual Ther 2004; 9: 3-12.
[81]
Devreese A, Staes F, De Weerdt W, et al. Clinical evaluation of pelvic floor muscle function in continent and incontinent women. Neuroruol Urodyn 2004; 23: 190-7.
[82]
Bø K, Berghmans B, Mørkved S, Van Kampen M, Eds. Evidence-based physical therapy for the pelvic floor: Bridging science and practice. 2nd ed. Edinburgh: Elsevier Churchill Livingstone 2015; pp. 27-, 116, 226.
[83]
Arab AM, Chehrehrazi M. The response of the abdominal muscles to pelvic floor muscle contraction in women with and without stress urinary incontinence using ultrasound imaging. Neurourol Urodyn 2011; 30: 117-20.


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Article Details

VOLUME: 15
ISSUE: 2
Year: 2019
Page: [86 - 101]
Pages: 16
DOI: 10.2174/1573404814666180222152952

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