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Abdominal Separation: The latest literature review

November 14, 2018

Diastasis recti abdominis or abdominal separation is a common musculoskeletal condition that effects almost all women during pregnancy (Benjamin et al., 2014).

 

 The incidence following pregnancy remains high, with between thirty-five and sixty percent of women reported to have separation six months postpartum (Acharry 2015).

 

Although the literature is not definitive, according to Spitznagle (2007) sixty-six percent of women with separation have at least one support-related pelvic floor dysfunction such as stress or bowel incontinence and/or pelvic organ prolapse.

 

Furthermore, while abdominal exercises are frequently prescribed to treat separation, a systematic review by Benjamin (2014) revealed  that the prescription of abdominal exercise programs in the postpartum period is not based on evidence, and very little literature exists about the effect of exercise on abdominal muscle morphology during and after pregnancy.

 

So regardless of what you read online, this suggests that there is limited knowledge to guide exercise prescription and clinical practice.

 

Evidence suggests that long-standing separation is often undiagnosed by physicians as the connection between it and musculoskeletal conditions in the older female is often not considered (Keeler et al., 2012). Women seeking physiotherapy treatment may be diagnosed with a musculoskeletal or neuromuscular condition and possible link to their separation overlooked (Keeler et al. 2012).

 

Although there may be some degree of spontaneous resolution over time, many of the significant cases persist and continue to remain throughout subsequent pregnancies (Acharry & Kutty 2015). Current treatment consists of surgical intervention or exercise (Mommers et al., 2017). Surgery is often considered cosmetic and a large discrepancy in the recurrence rate of divarication is reported with a long-term follow up between 0% and 40% (Mommers et al., 2017).

 

Abdominal exercises are frequently prescribed to treat DRA, and Keeler’s (2012) recent survey of physiotherapists practice, revealed that multiple techniques are used and there is no consensus on exercise selection, with isolated transversus activation, isolated pelvic floor training and functional tasks all prescribed as treatment.

 

Furthermore, modified abdominal crunch exercises were both preferred and avoided by the physiotherapists sampled.

 

The inconsistency in clinical practice is also reflected in the research (Mommers, et al 2017; Keeler 2012; Benjamin et al., 2014). Two recent systematic reviews concluded that very little literature exists about the effect of exercise on abdominal muscle morphology during and after pregnancy and the prescription of abdominal exercise programs in the postpartum period is not based on evidence (Mommers et al 2017; Benjamin et al., 2014).

 

For example,

Both the abdominal crunch and transversus abdominis activation by drawing-in are both recommended and considered contraindicated in the post-natal period.

 

Recently, Mota et al. (2015) and Lee and Hodges (2015) measured inter-rectus distance (IRD) using an ultrasound whilst women performed variations of abdominal contractions and found that isolated TVA contraction increased IRD and that co-contraction of the entire abdominal musculature was the only contraction combination that reduced inter-rectus distance. Overall, treatment for separation is inconsistent re the type of exercises used, the frequency of exercise prescription, the total number of sessions within a training program, and the instruments used to asses and correct IRD (Mommers et al., 2017).

 

This is a very brief overview of the literature (see below for the full reference list).

 

The conclusion is, it appears we don't know very much! And, if you are reading the 'cure' you may be misled.

 

What I can suggest putting it all together is:

 

1. Get your abdominals assessed via ultrasound - while you perform exercises so you can see which ones increase your separation and which ones decrease it.

 

2. Don't do any exercises that cause pain, or where you feel the abdomen is doming or bulging.

 

3. Feel your separation while  you are exercising and become aware of your individual response.

 

4. Posterior tilt with co-contraction of pelvic floor, rectus abdominus and TVA.

 

5. No isolated TVA contraction (no pulling belly to spine without also contracting all abdominals).

 

6. The Noble crunch - Head lift - with rectus approximation does NOT appear harmful and is probably the exercise to do (not a crunch).

 

7. Wear an abdominal binder for 6 weeks post delivery (minimum).

 

8. Progress SLOWLY - avoid excessive load and excessive abdominal stretching. Yoga and Pilates may NOT be the best things for you.

 

 AVOID:

 

Next Pregnancy and Exercise Course is on the 8th and 9th December.

NEW Post Natal course will be arriving NEXT year!

HAPPY TRAINING

 

REFERENCES - And yes I have read them ALL

 

1 Keshwani N, Mathur S, McLean L. Relationship Between Interrectus Distance and Symptom Severity in Women With Diastasis Recti Abdominis in the Early Postpartum Period. Physical Therapy 2017;98:182-190.

2 Noble E. Essential exercises for the childbearing year. Harwich, MA: New Life Images 1995.

3 Spitznagle T, Leong F, Van Dillen L. Prevalence of diastasis recti abdominis in a urogynecological patient population. International Urogynecology Journal 2006;18:321-328.

4 Akram J, Matzen S. Rectus abdominis diastasis. Journal of Plastic Surgery and Hand Surgery 2013;48:163-169.

5 Benjamin D, van de Water A, Peiris C. Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy 2014;100:1-8.

6 Acharry N, Kutty R. Abdominal exercise with bracing, a therapeutic efficacy in reducing diastasis-recti among postpartal females. International Journal of Physiotherapy and Research 2015;3:999-1005

7 da Mota P, Pascoal A. Carita et al. Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Manual therapy, 2015;201:200-205.

8 Lee D, New perspectives from the Integrated Systems Model for treating women with pelvic girdle pain, urinary incontinence, pelvic organ prolapse and/or diastasis rectus abdominis. Journal of the Association of Chartered Physiotherapists in Women’s Health, 2014;114:10-24.

9 Hagen S & Stark D. Conservative prevention and management of pelvic organ prolapse in women. Cochrane Database of Systematic Reviews, 2011;12.

10 Keeler J, Albrecht M, Eberhardt L.et al. Diastasis recti abdominis: a survey of women's health specialists for current physical therapy clinical practice for postpartum women. Journal of women’s health physical therapy, 2012;36:3,131-142.

11 Coldron Y, Stokes M, Newham DJ, et al. Postpartum characteristics of rectus abdominis on ultrasound imaging. Man Ther. 2008;13:112-121.

12 Banerjee A, Mahalakshmi V, & Baranitharan R. Effect of Antenatal Exercise Program with and without Abdominal Strengthening Exercises on Diastasis Rectus Abdominis-A Post-Partum Follow Up. Indian Journal of Physiotherapy and Occupational Therapy, 2013;7:4,123.

13 Wallden M. The primal nature of core function: In rehabilitation & performance conditioning. Journal Of Bodywork And Movement Therapies, 2013;17:2, 239-248.

14 Gunnarsson U. Stark B. Dahlstrand U. et al. Correlation between abdominal rectus diastasis width and abdominal muscle strength. Digestive surgery. 2015;32:2,112-6.

15 Gilleard W, Brown J. Structure and function of the abdominal muscles in primigravid subjects during pregnancy and the immediate postbirth period. Physical therapy. 1996;76:7,750-62.

16 Cholewicki J, Lee A, Popovich J, et al. Degenerative Spondylolisthesis Is Related to Multiparity and Hysterectomies in Older Women. Spine. 2017;42:21,1643-7.

17 Spitznagle T, Leong F, Van Dillen L. Prevalence of diastasis recti abdominis in a urogynecological patient population. International Urogynecology Journal. 2007;18:3,321-8.

18 Bliddal M, Pottegård A, Kirkegaard H, et al. Association of pre‐pregnancy body mass index, pregnancy‐related weight changes, and parity with the risk of developing degenerative musculoskeletal conditions. Arthritis & Rheumatology. 2016;68:5,1156-64.

19 Mommers E, Ponten J, Al Omar A et al. The general surgeon’s perspective of rectus diastasis. A systematic review of treatment options. Surgical endoscopy. 2017;31:12,4934-49.

20 Hickey F, Finch J, Khanna A. A systematic review on the outcomes of correction of diastasis of the recti. Hernia. 2011;15:6,607-14.

21 Keeler J, Albrecht M, Eberhardt L, et al. Diastasis recti abdominis: a survey of women's health specialists for current physical therapy clinical practice for postpartum women. Journal of women’s health physical therapy. 2012;36:3,131-42.

22 Benjamin D, Van de Water A, Peiris C. Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy. 2014; 1;10:1,1-8.

23 Bø K, Artal R, Barakat R. et al. Exercise and pregnancy in recreational and elite athletes: 2016/17 evidence summary from the IOC Expert Group Meeting, Lausanne. Part 3-exercise in the postpartum period. Br J Sports Med. 2017;22:bjsports-2017.

24 Mota P, Pascoal A, Carita A, et al. The immediate effects on inter-rectus distance of abdominal crunch and drawing-in exercises during pregnancy and the postpartum period. journal of orthopaedic & sports physical therapy. 2015;45:10,781-8.

25 Lee D, Hodges P. Behaviour of the linea alba during a curl-up task in diastasis rectus abdominis: a new interpretation with clinical implications. Physiotherapy. 2015;1:101,e580-1.

26 Litos K. Progressive therapeutic exercise program for successful treatment of a postpartum woman with a severe diastasis recti abdominis. Journal of Women’s Health Physical Therapy. 2014;38:2,58-73.

27 Gluppe S, Hilde G, Tennfjord M, et al. Effect of a Postpartum Training Program on the Prevalence of Diastasis Recti Abdominis in Postpartum Primiparous Women: A Randomized Controlled Trial. Physical therapy. 2018;98:4,260-8.

28 Mahalakshmi V, Sumathi G, Chitra T, et al. Effect of exercise on diastasis recti abdominis among the primiparous women: a quasi-experimental study. International Journal of Reproduction, Contraception, Obstetrics and Gynecology. 2016;5:12,4441-6.

29 Mottola M. Exercise in the postpartum period: practical applications. Current sports medicine reports. 2002;1:6,362-8.

30 CONSORT Schulz K, Altman D, Moher D. CONSORT Group. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. BMJ 2010;340:c332

31 Chan A, Tetzlaff J, Altman D, et al. SPIRIT 2013 Statement: Defining standard protocol items for clinical trials. Ann Intern Med 2013;158:200-207.

32 Stafne S, Salvesen K, Romundstad P. et al. Does regular exercise including pelvic floor muscle training prevent urinary and anal incontinence during pregnancy? A randomised controlled trial. BJOG: An International Journal of Obstetrics & Gynaecology. 2012;119:10,1270-80.

33 Roy B. Postpartum Exercise. ACSM's Health & Fitness Journal 2014;18:6,3-4.

34 Boissonnault J. and Blaschak M. Incidence of diastasis recti abdominis during the childbearing year. Physical therapy.1988;68:7,1082-1086.

35 Mota P, Pascoal A, Sancho F. Reliability of the inter-rectus distance measured by palpation. Comparison of palpation and ultrasound measurements. Manual Therapy. 2013;18:4,294-8.

36 Ingram M, Symmons D. The burden of musculoskeletal conditions. Medicine. 2018;46:3,152-155

 

 

 

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