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Current Womens Health Reviews, 2015, 11, 59-67 59

Diastasis Recti Abdominis in Pregnancy and Postpartum Period. Risk

Factors, Functional Implications and Resolution

Patricia Motaa,*, Augusto Gil Pascoala and Kari Bob

a
Univ Lisboa, Fac Motricidade Humana, CIPER, LBMF, P-1499-002 Lisboa, Portugal; bDepartment
of Sports Medicine, Norwegian School of Sports Sciences, Oslo, Norway

Abstract: Diastasis recti abdominis (DRA) or the increased inter rectus distance (IRD) is described as
the separation of the rectus abdominis muscles. It can occur during pregnancy and after childbirth.
Mota et al. (2015) found DRA may affect up 100% of pregnant women [1], and it may persist
separated in the immediate postpartum period in 35% to 60% of women [2]. Reported prevalence of
DRA or increased IRD varies and may be inaccurate due to different cut off points for the diagnosis
[1-7] and use of different measurement methods. P. Mota

To date limited studies about the normal width of the IRD in postpartum women are available [8, 9], and there is scarce
information about risk factors for DRA.
There are some theories stating that failure to treat DRA effectively can lead to long term sequelae [10], including
abnormal posture [1], lumbo-pelvic pain and cosmetic imperfections [10]. Postnatal women are stimulated to resume
abdominal exercises shortly after delivery [3] to improve trunk function and restore abdominal figure and fitness [8]. To
date there is scant knowledge on the most effective abdominal exercises both during pregnancy and after childbirth. In
particular there is little evidence on which exercises are most efficient in the narrowing of the recti diastasis. The aim of
this article is to critically review the literature on the risk factors, functional implications and the effect of exercise on
DRA. This information is expected to be relevant for physiotherapists and exercise professionals.
Keywords: Abdominal exercise, inter-rectus distance, pregnancy, physiotherapy, postpartum, ultrasound.

1. INTRODUCTION to be a common condition in women during pregnancy and

Pregnancy and becoming a mother is one of the most
exciting times in a womens life. Besides all the hormonal
and physiological changes affecting women during this
period, probably the most obvious morphological alteration
during pregnancy is the increasing weight and dimensions of
the uterus, influencing maternal trunk musculoskeletal
morphology, particularly the abdominal musculature.
Many women continue or even begin to exercise during
pregnancy, and Postnatal women are stimulated to resume
abdominal exercises shortly after delivery, to repair their
abdominal figure and fitness.
There is a lot of information available in numerous web
pages about exercise programs for women during pregnancy
and in the postpartum period, and physiotherapists and
exercise instructors prescribe exercises to this population
every day. However, there is little evidence available about
muscular changes and the effect and safety of different
abdominal exercises during and after pregnancy. Diastasis
recti (DRA) or the increased interrectus distance (IRD) seems
*Address correspondence to this author at the Univ Lisboa, Fac Motricidade
Humana, CIPER, LBMF, P-1499-002 Lisboa, Portugal;
E-mail: patimota@gmail.com
postpartum. The lack of evidence for the consequences of
this condition and the effect of abdominal strengthening
exercises in the reduction of DRA indicates a need for
identification of prevalence and risk factors of DRA. Use of
responsive, reliable and valid outcome measures is
mandatory for evaluation of the condition, and ultrasound
imaging has lately been proposed as a valuable method to
measure muscular geometry and to quantify DRA. The aim
of this article is to critically review the literature on the risk
factors, functional implications and the effect of exercise on
DRA. This information is expected to be relevant for
physiotherapists and exercise professionals.
1.1. Methodology for Research Articles
A search strategy was developed to search the electronic
databases of Medline, PEDro and PubMed to look for
published studies involving assessment of DRA, interventions
to prevent and/or reduce DRA during the ante- and postnatal
periods. These electronic databases were explored from the
earliest date obtainable to 24 June 2015. Manual searching of
the reference lists of included studies and citation tracking
were conducted to ensure that all relevant studies were
found. Studies written in English and Portuguese were
included. No study design restriction was applied. Trials
were not excluded on the basis of quality, but the quality of

1875-6581/15 $58.00+.00 2015 Bentham Science Publishers

60 Current Womens Health Reviews, 2015, Vol. 11, No. 1
the study was taken into account when interpreting the
results.
2. DIASTASIS ABDOMINIS
2.1. Definition
IRD vs DRA Diastasis Recti Abdominis (DRA) is the
excessive separation between both bellies recti abdominis
(RA) muscles. The DRA can occur anywhere along the linea
alba, from the xiphoid process to the public bone, and is
quantified by the inter-recti distance (IRD).
During pregnancy, as the fetus grows, the two muscle
bellies of the rectus abdominis, connected by the linea alba
elongate and curve round as the abdominal wall expands,
with most separation occurring at the umbilicus [1, 3, 11].
The DRA is defined as a modification in the abdominal
musculature, precisely in the linea alba and rectus abdominis
sheath, with beginning in the last trimester of pregnancy and
whose peak of incidence occurs immediately after birth and
the first weeks following childbirth [1, 8, 12-14].
While, some literature proposed that an augmented IRD
could decrease the abdominal integrity and functional strength,
contributing to pelvic instability and back pain [3, 15, 16], no
Fig. (1). The abdominal muscles and their aponeuroses. A. The rectus abdominis (front view). B; C and D shows a common arrangement of
the sheath as seen in horizontal section. In ORahilly, Muller, Carpenter & Sweson (1983). Basic Human Anatomy. Reprinted with
permission from www.dartmouth.edu/~humananatomy/figures/chapter_ 25/25-6. HTM. A technical support from Dartmouth Medical
School, Hanover, United States of America.
Mota et al.
scientific evidence exists about the functional implications of
an augmented IRD or even about the outcome of the exercise
on prevention and/or decrease of IRD.
2.2. Anatomical Framework
The anterolateral wall of the abdomen has a laminar
configuration composed by six layers including, from
surface to depth, the skin, the superficial fascia, fat, the
abdominal muscles, the transversalis fascia and the parietal
peritoneum. The muscular layer comprise four paired
muscles with fibers oriented vertically (rectus abdominis
muscle), obliquely (external and internal oblique muscles)
and horizontally (transversus abdominis muscles) with
skeletal attachments on the thoracic cage, pelvis and the
spinal column via the thoracolumbar fascia [17]. The
aponeuroses of these muscles represent sheet-like tendons
that form the sheath of the rectus abdominis (rectus sheath)
and also serve as the medial insertion of the obliques and
transversus muscles, along the anterior midline of the
abdomen, forming a fibrous structure that connect the right
and the left side of the abdominal wall, the linea alba. The
rectus abdominis (RA) and the pyramidalis are the only
vertical muscles in the abdominal wall. The RA originates
from the 5th through 7th costal cartilages to insert on the
Diastasis Recti Abdominis in Pregnancy and Postpartum Period. Risk Factors
symphysis pubis and crest. Superiorly, the rectus is wide,
broad, and thin, becoming narrow and thick inferiorly.
Segmentation of each rectus muscle occurs by tendinous
intersections that represent attachment of the rectus muscle
with the anterior layer of the rectus sheath [17]. The internal
oblique muscle arises from the anterior two-thirds of the iliac
crest and lateral half of the inguinal ligament to run
essentially at right angles to those of the external oblique.
The fibers run perpendicular to the external oblique muscle
from the thoracolumbar fascia of the lower back, the anterior
iliac crest and the lateral half of the inguinal ligament, to
insert on the 10th to 12th ribs inferiorly and the linea alba
(Fig. 1). The external and internal oblique muscles have both
functions in the support of abdominal viscera as well as
assisting in flexion and rotation of the trunk.
The transversus abdominis muscle is the innermost of the
abdominal muscles, being placed immediately beneath the
internal oblique muscle from the 7th to 12th costal cartilages,
iliac crest, and the lateral third of the inguinal ligament. The
muscle bundles run mostly horizontally, except the lower
most medial fibers, which run a more inferomedial course to
their insertion on the pubic crest and pubis [17]. Their
extensive aponeurosis passes horizontally in the middle line
of the abdomen, and is inserted into the linea alba: the upper
portion lie behind the RA muscle and blend with the
posterior rectus sheath while its lower part pass in front of
the RA muscle [18]. The collagenous part of the anterior
abdominal wall includes the linea alba and the rectus
sheaths. The linea alba reaches from the xiphoid process to
the pubic symphysis and is composed of the collagen fibers
(aponeuroses) from the deeper abdominal muscles, i.e., the
transversus and the internal and external oblique muscles [7,
19]. The linea alba includes of a three-dimensional, extremely
structured meshwork of collagen fibers which in conjunction
with rectus sheaths are regarded as the most important
structures for the stability of the anterior abdominal wall
from a mechanical point of view [19-21]. The collagen fibers
in linea alba have the same orientation as the muscle fibers
of the deeper muscles of the anterior abdominal wall, i.e.
transverse and oblique in two directions: 1) directed from
right upward to left downward, and 2) directed from left
upward to right downward. An anatomical model of collagen
fiber architecture in the linea alba has been described based
in confocal laser scanning microscopy images over human
cadaveric specimens [19, 20]. This model is illustrated in
Fig. 2 and comprises three different zones of fiber orientation,
from anterior (ventral) to posterior (dorsal): the oblique fiber
layer, the transverse fiber layer and an irregular fiber layer.
Despite this structure of fibers is the same along length of
linea alba, different regions can also be distinguish in the
craniocaudal direction: supraumbilical part, transition zone
and infraarcuate part. These regions have a close structural
and functional relationship with fiber architecture of rectus
sheaths.
The study of Grassel et al. [20] clearly demonstrated the
anisotropy property in biomechanical behavior of the linea
alba.
The anisotropy means that the tissue exhibits a property
directionally dependent. In fact, the results of Grassel et al.
[20] revealed that the linea alba compliance is high in the
Current Womens Health Reviews, 2015, Vol. 11, No. 1 61
Fig. (2). Fiber architecture in the linea alba. Zones are described
from anterior to posterior as (1) oblique fiber layer, (2) transverse
fiber layer, and (3) irregular fiber layer. Reprinted with permission
from Grassel D, Prescher A, Fitzek S, Keyserlingk DG, & Axer H.
Anisotropy of human linea alba: a biomechanical study. J Surg Res
2005; 124(1): 118-125.
longitudinal direction and lower in transverse direction. This
means that the linea alba tensile strength, i.e., the tissue
ability to resist tensile forces (inverse of compliance) is less
for tension applied along the tissue (longitudinally) and bigger
for transverse tensile forces. The linea alba tension is important
to maintain the abdominal muscles, especially the rectus
muscles, at a certain closeness to each other [4, 7] in order to
optimize abdominal muscles function both as on abdominal
viscera support or producing thorax/pelvis movements.
Tension on the linea alba, particularly below the umbilicus,
seems to be regulated by the pyramidalis, a small paired
triangular-shaped muscle, present in 80% of people, which
lies between the anterior surface of the rectus abdominis and
the posterior surface of the rectus sheath [22]. The exact
function of the pyramidalis muscles is uncertain, nevertheless
together both muscles are believed to assists in tensing the
linea alba [22]. The linea alba compliance is maximum in the
longitudinal direction and minimum in the transverse
direction [7, 23] which determine the great resistance offer
by the LA to rectus abdominis transversal separation. Even
so, the viscoelastic properties inherent to the collagen, makes
the linea alba prone to increase length when the mechanical
stress is prolonged in time [21], namely in the case of a lasting
increased intra-abdominal pressure, such as that resulting
from pregnancy [1, 8, 24, 25]. The mechanical stress on linea
alba is highly associated to the action of the oblique s and
transversus abdominis muscles. The external oblique arises
from the lower 8 ribs posteriorly to interdigitate with both
the serratus and latissimus muscles. The direction of the
fibers is approximately horizontal in the uppermost portion
only to become oblique in the lowest portions.
62 Current Womens Health Reviews, 2015, Vol. 11, No. 1
After contributing to the anterior portion of the rectus
abdominis sheath, the residual fibers insert onto the linea
alba. The rectus sheath or rectus abdominal aponeurosis is a
strong connective tissue derived from the aponeuroses of the
deepest abdominal muscles [17], that forms a sheath of dense
collagen fibers that encloses each one of the rectus
abdominis muscles. The function of the rectus sheath is to
protect both rectus abdominis muscle and enables muscles
sliding through neighboring structures. The rectus sheath
comprises an anterior and a posterior layer (lamella) formed
by the aponeuroses of the external and internal oblique and
transversus abdominis muscles (Fig. 3). These aponeuroses
meet at the lateral edge of the rectus along a curved line, the
linea semilunaris, which spreads from 9th costal cartilage to
the pubic tubercle.
Above the umbilicus the anterior and posterior sheaths
comprises the internal oblique muscle aponeurosis. Indeed,
above the umbilicus the internal oblique aponeurosis splits,
allowing one layer to pass anterior and the other posteriorly
to the rectus abdominis muscle. The anterior layer of the
rectus sheath includes also the external oblique aponeurosis
while the posterior layer comprises contributions from
transversus abdominis aponeuroses (transversalis fascia).
Above the umbilicus, approximately halfway between the
umbilicus and the symphysis pubis, the aponeuroses of the
three deeper muscles of the abdomen pass anteriorly to the
rectus muscle that including the internal and external oblique
aponeurosis and transversalis fascia. Below the arcuate line,
the transversalis fascia is the only structure that separates the
rectus abdominis muscle from the parietal peritoneum. The
Fig. (3). The anterior and a posterior layer (lamella) of left rectus sheath (horizontal view).
Mota et al.
anterior displacement of all aponeuroses creates the arcuate
line, a curved line of demarcation in the posterior lamella of
the rectus sheath. In a cadaveric study about the three-
dimensional distribution and orientation of collagen fiber,
using confocal laser scanning microscopy images, found that
the ventral layer of the rectus sheath comprise oblique fibril
bundles while the posterior layer consist mainly of transverse
bundles [19]. The authors also found that, below the
umbilicus, the transverse posterior layer continuously spread
onto the anterior layer of the rectus sheaths. This means that
the place where the posterior layer changes to anterior is not
a sharp line, as subjected by the arcuate line, also known as
falciform edge or linea semicircularis.
Based on this fiber distribution Axer et al. [19] described
three craniocaudal regions on rectus abdominis sheaths:
supraumbilical, transition (corresponding to arcuate line) and
infraarcuate zone. Thickness of the posterior rectus sheaths
layer continuously reduces in the transition zone and
diminishes in the infraarcuate part. On the contrary, the
anterior rectus sheaths layer continuously enhances thicker in
the transition zone wherein the oblique and transverse fibers
mingled one each other to form a three- dimensional
structure with a similar pattern as found in linea [19].
Location of the transition zone has a high inter-individual
variability however is concordant with the transition zone
also described in the architecture of the linea alba [19]. This
seems to be an indicator of how fibers from rectus sheaths
and linea alba function as a cooperating system of fibers with
some functional meaning. Gender differences were observed
in the relation between transverse and oblique layers of
Diastasis Recti Abdominis in Pregnancy and Postpartum Period. Risk Factors
collagen fibers layers in the linea alba (Fig. 3) such that
females showed a large amount of transverse fibers relative
to the oblique fibers in the proportion of 60% versus 40%
[19].
2.3. Diastasis Recti Abdominis and Pregnancy
The functional role of the abdominal muscles during
pregnancy appears to be similar to those in the non- pregnant
state [1] and is suggested to be important for trunk movement,
pelvic stabilization, and restraint of the abdominal contents
[17]. However, the musculoskeletal morphology of the
anterolateral wall of the abdomen changes as pregnancy
progresses [3, 26]. The weight and dimensions of the uterus
and its contents increases from 40 to 1000 grams and its
capacity from 4 ml in non-pregnant state to 4000 ml at term
[27]. The maternal inferior thoracic diameter is increased
[15, 28] as well as the anterior and lateral dimensions of the
abdomen.
These changes modify the spatial connection between the
superior and the inferior abdominal muscle connections [27]
increasing the length of the abdominal muscles, particularly
the rectus abdominis [11]. At 38 weeks of gestation the
length of the abdominal muscles increased a mean of 115%
with respect to the beginning of pregnancy [3]. The increment
of the anterior abdominal dimensions may alter the angle of
the abdominal muscle attachment in the sagittal plane [3].
Alterations in the spatial relationship of muscle attachment
and the muscles angle of insertion may alter the muscles
line of action and therefore their ability to produce torque
[3,15].
3. DIAGNOSE OF DIASTASIS RECTI ABDOMINIS
Criteria and IRD cut-off value for the diagnosis of DRA
vary in the literature [1-4, 6, 7, 10, 24, 29], and to date there
is no international agreement on the measurement place. In a
cadaver study, Rath et al. [4] described a widening of the
IRD more than 10 mm above the umbilicus, 27 mm at the
level of the umbilicus and 9 mm below the umbilicus, as
pathological DRA. Others stated DRA as a widening of the
IRD more than 2.5 cm at one or more assessment points
using digital calipers [5].
In a more recent ultrasound study Beer et al. [7] suggest
that in nulliparous women, the linea alba should be considered
normal when the IRD width is less than 15 mm, at the
xiphoid level, 22 mm at 3 cm above the umbilicus, and
16 mm at 2 cm below the umbilicus.
3.1. Instruments and Protocol Measurement
The most common methods to assess IRD are palpation
[1, 2, 30, 31] and calipers [32, 33]. However, the stated
prevalence of DRA (or augmented IRD) may be imprecise
because of the lack of reliability, the low responsiveness
(ability of a tool to detect small differences or small changes)
and lack of validity (ability of an instrument to measure what
it is supposed to measure) [34] in the methods and instruments
used to measure the IRD. Recently, ultrasound imaging has
been suggested as a useful method to assess muscular
geometry and as an indirect measure of muscle activation via
changes in muscle thickness during contraction [35, 36].
Current Womens Health Reviews, 2015, Vol. 11, No. 1 63
Coldron et al. [8] used ultrasound to characterize RA
modifications throughout the first 12 months postpartum and
Mendes et al. [37] et al. declared ultrasonography to be an
precise method to qauntify diastasis recti when compared
with surgical compass during abdominoplasty.
Across-days reliability is important to physiotherapists
who perform repeated evaluations of abdominal muscle
function over time [38]. Aspects such as repositioning of the
original imaging site, reproduction of the same transducer
pressure and orientation, as well as preservation of a
relatively stationary transducer position during muscle
contraction, might negatively affect reliability [38] and
accurate interpretation of ultrasound imaging and lead to
erroneous conclusions [39-41]. The 2D ultrasound imaging
showed to be a reliable technique to measure IRD in women.
A recent study from our research team [42] demonstrates
that palpation and finger width palpation method can be used
in clinical practice, but ultrasound is a more reliable and
valid method and should be used in research of IRD.
Selecting a gold standard technique to test criterion
validity is not a simple task. Computed tomography (CT) and
magnetic resonance imaging (MRI) are presently considered
the procedures of choice to examine the abdominal wall.
Nevertheless, these procedures are expensive and CT exposes
the patient to radiation [37], making it unmanageable to use
in pregnant women. Hence, ultrasonography has been
suggested as a safe and non-invasive method that can be
repeated numerous times [37] during pregnancy. Ultrasound
measures the IRD in a scale of millimeters and such levels of
evaluation are hard to distinguish by palpation.
The dynamic nature of ultrasound imaging studies
undertaken during abdominal exercises may compromise the
interpretation of data and it is logical to assume that accurate
measurement and interpretation will be influenced by
changes on the orientation of the transducer [41]. Transducer
motion during image collection when muscles are under
contraction could compromise accuracy of IRD measurements.
Recently, acceptable amounts of transducer motion was
found (<10 of angular and 8 mm of inward/outward motion)
when ultrasound images were collected during abdominal
crunch and drawing- in exercise [43].
4. PREVALENCE AND RISK FACTORS OF DIASTASIS
RECTI ABDOMINIS
4.1. Prevalence of Diastasis Recti Abdominis
DRA has been found to affect between 30% and 70% of
pregnant women [1], and the increased IRD can persist
separated in the immediate postpartum period in 35% to
60% of women [2]. Nevertheless the situation has also been
found in 39% of older, parous women undergoing abdominal
hysterectomy [29] and in 52% of urogynecological
menopausal patients [6]. Reported prevalence of DRA or
increased IRD varies and might be inaccurate due to
different IRD cut-off values for the diagnosis [1-7] and use
of different measurement assessment methods (Table 1).
Mota et al. [43] using the same definition for DRA as used by
Beer et al. [7], i.e. IRD > 2.3 cm, found that the prevalence
of DRA at 2 cm below the umbilicus decreased from 100%
in late pregnancy to 39% at 6 months postpartum.
64 Current Womens Health Reviews, 2015, Vol. 11, No. 1
Table 1. Prevalence of Diastasis Recti Abdominis (DRA) in general population. Synopsis of the most representative studies and
respective results.
Boissonnault & Blaschak, 1988
Pregnancy
(1)
(2)
(3)
Posrpartum
(4)
(5)
(6)
DRA criteria
IRD measurement instrument/protocol Finger width palpation method
IRD: inter-recti distance
(1) Early postpartum: Within 48 hours after delivery
(2) Early postpartum::between 2 day after delivery and 4 weeks postpartum
(3) Late postpartum: between week 5th and week 12th postpartum
(4) Late postpartum: between week 6th and week 8th postpartum
(5) Late postpartum: between week 12th and week 14th postpartum
(6) Late postpartum: between week 24th and week 26th postpartum
The cut-off value for normal IRD proposed by Beer et al.
[7] was set for nulliparous women, and might be considered
limited for women during pregnancy and in the postpartum
period.
4. RISK FACTORS FOR DIASTASIS
ABDOMINIS
There is Limited Information about the Risk Factors for
DRA. Two studies analyzed several variables such as, age,
ethnicity, body mass index, height, weight gain during
pregnancy, pre-pregnancy weight, gestational age at
delivery, type and duration of birth [10, 14]. An association
of DRA during pregnancy with Caucasian ethnicity and
absence of regular exercise through pregnancy was
suggested [10]. It is considered that women with DRA have
a greater number of pregnancies and deliveries [6, 14], and
among multiparous women, it is suggested that there is a
strong relationship concerning provision of childcare and
DRA in pregnancy [10].
No significant risk factors were found for the presence of
DRA at 6 months postpartum [43].
Candido et al. (2005) showed that women with and
without DRA did not differ significantly with respect to age,
ethnicity, height, weight gain during pregnancy, pre-
pregnancy weight, gestational age at delivery, however this
study was also limited by the small sample size [10].
Boissonnault & Blaschak [1] found an absence of DRA in
women who exercised before pregnancy which seems to
support the theory that pre- pregnancy abdominal physical
fitness influence the incidence of DRA. The positive effects
of physical activity before and during pregnancy were also
supported by the shorter time to DRA resolution reported by
Lo et al. [44] in women with the higher levels of activity.
Overall the previous mentioned studies were limited by the
Mota et al.
Lo et al., 1999 Mota, et al., 2015
66%
35%
53%
38%
52.4%
53.6%
39.3%
>2 fingers >2.5 cm >2.3 cm
Caliper/Palpation Ultrasound images
sample size, reliability of the instruments used, and were not
conclusive in its capability to describe risk factors.
5. FUNCTIONAL IMPLICATIONS OF DIASTASIS
RECTI ABDOMINIS
RECTI Some authors suggest that DRA compromise the integrity
of female abdominal wall [10] which can potentially affect
the capacity of the abdominal muscles to generate force and
would be the cause of some disorders such as lumbopelvic
pain. In fact, only two studies [3, 9] analyze the relationship
between the increase width of IRD and the abdominal
muscles dysfunction. Gilleard & Brown [3] in a sample of 6
primiparous women, physically active, aged between 28 and
33 years, related some morphological parameters inherent to
the perinatal period with changes in abdominal muscles
functional capacity. The authors reported IRD changes in 9
time-moment of the period between the 14th week of
pregnancy and the 8th week postpartum. Those changes were
correlated with abdominal muscle function in two
conditions: the curl-up exercise and the abdominal muscle
test (AMT). The abdominal muscles capacity during curl-up
exercise was assessed according to an ordinal scale of
functionality, from minor to major. In the AMT subject is
asked to keep a backward pelvic tilt position while perform
lower limb flexion-to-extension action, in supine position.
The results of Gilleard & Brown [3] shown that the curl-up
capacity and the ability to stabilize the pelvis in a backward
pelvic tilt position are compromised in pregnant women and
up to 8 weeks after delivery, particularly in women with a
IRD higher that 3.5 cm measured by palpation at the end of
pregnancy. More recently, Liaw et al. [9] compared a group
of 40 post-partum women (primiparous and multiparous)
with an age matched nulliparous group regarding the ability
of the abdominal muscles to produce and maintain high
strength levels. The abdominal muscle function was assessed
Diastasis Recti Abdominis in Pregnancy and Postpartum Period. Risk Factors
by the capacity to perform the curl-up exercise and by the
abdominal endurance test. Like Gilleard & Brown [3]
also Liaw et al. [9] analyzed the abdominal function using a
four-level functionality of scale: low ("poor"), sufficient
("fair"), good ("good") and normal. The results of the
abdominal endurance test refers to the time, in seconds, that
women can maintain the trunk flexion position (45). The
abdominal strength values, magnitude and strength were
also correlated with the supra and infraumbilical IRD. The
results showed that compared postpartum women had lower
levels of abdominal strength. The authors also found a
negative correlation between abdominal function and the
IRD, with exception of the association at 6 months
postpartum. The progressively reduction of IRD during the
postpartum period was accompanied by a significant
increase in strength of the abdominal muscles. 5.1 DRA and
lumbopelvic pain.
Earlier reported studies showed that 10% of pregnant
women have severe lumbo-pelvic pain that interferes with
daily activities [11] and the prevalence of pregnant women
suffering from lumbo-pelvic pain is about 20% [45, 46].
Reported lumbo-pelvic pain is expected to be high In the
postpartum period [16] and it may affect between 9% and
48% [16] of women.
Women with DRA were not more likely to report lumbo-
pelvic pain than women without DRA (p>0.05). In our study,
the prevalence of this condition was within the range of other
prevalence studies (27.3% and 27.5% respectively). This is
in line with the results found by Parker et al. [16].
Nevertheless we did not perform an exhaustive pain- history
[47] and we did not make any clinical evaluation to assess
the condition, which could underestimate the results. On the
other hand, the sample was drawn from a population
attending pre-natal courses in private centers, and
consequently was not conclusive in its ability to delineate
prevalence of lumbo- pelvic pain in other populations.
6. RESOLUTION OF DIASTASIS RECTI ABDOMINIS
6.1. Natural Resolution
Some studies hypothesized that there would be a natural
decrease in the IRD from pregnancy until 12 months
postpartum [1, 33]. Despite the variability, a general
decrease in the IRD is observed when comparing the IRD
measured during pregnancy with the IRD measured on the
postpartum period [1, 33]. However, the values of IRD on
the postpartum period remain wider than in nulliparous
women, and the prevalence of DRA was still very high at 6
months postpartum, suggesting that recuperation may still be
in development.
6.2. Abdominal Supporting Belts
There are some theories stating that the regular use of a
postpartum support belt can reduce back pain and strain on
muscles and ligaments, suggesting it could be of use to
reduce IRD in postpartum period [1, 8, 33, 43].
Conversely, to our information there are no high quality
clinical studies to support these statements.
Current Womens Health Reviews, 2015, Vol. 11, No. 1 65
6.3. The Effect of Exercise on Diastasis Abdominis
It has been suggested that antepartum activity level may
have a protective effect on DRA and exercise may improve
post-partum symptoms of DRA [25].
To date there is scant knowledge on the most effective
abdominal exercises both during pregnancy and after
childbirth. In particular there is little evidence on which
exercises are most efficient in decreasing of the recti
diastasis. According to Wolfe and Davies [48], abdominal
strengthening exercises should be done in pregnancy to
promote good posture, strengthen the muscles for labor, and
prevent low back pain and diastasis recti. Nevertheless, the
authors defend the need to stop abdominal exercise if
diastasis recti develops [48].
The justification following the abdominal strengthening
programs is the hypothesis that the contraction of all
abdominal muscles will reduce the horizontal abdomen
diameter in such a way that a horizontal force will be
generated producing the approximation of both rectus
abdominis, particularly at the umbilicus level [3, 28].
Abdominal crunch has been considered a risk exercise
for development of diastasis recti [48], but it has also been
used to assess abdominal muscle strength and endurance in
women during the postpartum period [49]. Lately core
training with the drawing in exercise has been recommended
both in the general population [9] and during pregnancy and
after childbirth [50-52]. It has been proposed that transversus
abdominis muscle activation could protect the linea alba and
may help to prevent or reduce DRA and speed up recovery
[25]. However there are no data to support this suggestion.
Two studies [53, 54] suggested that the IRD narrowed when
the abdominal crunch exercise was performed, and the
drawing in resulted in widening of the IRD compared to rest
in all locations measured on the linea alba.
These results do not support the hypothesis that the
drawing in maneuver is an effective exercise during
pregnancy and in the post-partum period. There is an urgent
need for more basic and experimental studies to understand
the mechanisms of different abdominal exercises. In
addition, high quality randomized controlled trials on the
effect of different abdominal exercises to prevent and treat
diastasis recti abdominis are warranted.
CONCLUSIONS
No significant risk factors were found for the presence of
DRA at 6 months postpartum. Women with DRA were not
more likely to report lumbo-pelvic pain than women without
DRA.
There is an urgent need for more basic and experimental
studies to understand the mechanisms of different abdominal
exercises. In addition, high quality randomized controlled
trials on the effect of different abdominal exercises to
prevent and treatdiastasis recti abdominis are warranted.
CONFLICT OF INTEREST
The authors confirm that this article content has no
conflict of interest.
66 Current Womens Health Reviews, 2015, Vol. 11, No. 1
ACKNOWLEDGEMENTS
Declared none.
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