20 Aug Diastasis Recti Update
Every time I think about diastasis recti of the abdominal muscles (DRAM), I get a little worked up. So do most physical therapists. And moms who are working through their own case of DRAM.
What’s all the angst about? There’s shockingly scant research about DRAM available, and at the same time, there are programs, bloggers, and medical providers adamant that they have the answer. The “answers” are so varied it’s almost paralyzing for someone actually experiencing DRAM – do planks vs. don’t even think about planks, use an abdominal binder vs. binders make it worse, use one program vs. another one…
It’s truly maddening, and the truth is that none of those programs or posts (no matter what they say) actually have a solid answer for everyone that’s backed by research. Nobody does, because there truly isn’t any definitive research available.1 Thankfully, that’s about to change.
There’s a research study underway in Canada comparing abdominal binding versus an exercise program for the treatment of DRAM. The research should be wrapping up this month (August ’17), and then it will take some time for the research to be published. I will post a link to the abstract and a translation of the findings (medical to plain English) on this site as soon as it is available. This study is a long time coming, and there will certainly be more questions once we know the outcomes of the study, but we’ve got to start somewhere.
Here’s where we are now
DRAM, or widening of the rectus abdominis down the center, persists after pregnancy for a large percentage of moms. During pregnancy, the linea alba, or the fibrous tissue that divides the 2 sides of the rectus abdominis (AKA your six-pack muscles), naturally widens to accommodate a growing baby. That happens to everybody, and it’s a natural part of pregnancy.
A gap between the two sides of the rectus abdominis of < 2cm is considered normal, but there is some disagreement about whether 2cm is truly the cutoff. Functionally, if you have a gap that’s 2cm or smaller but you’re seeing that “V” shape when you increase your intra-abdominal pressure by sneezing, planking, exercising, etc., then you have a problematic DRAM that needs to be addressed by a professional. If you have a DRAM that is > 2cm in width and you’re more than 8 weeks postpartum,2 it’s likely affecting your function and you may need to have that checked by a professional.
Immediately after delivery, about 50% of moms will see the widening of their abdominal muscles reduce to under a 2cm gap. The other half will have to wait – most will naturally reduce on their own to under 2cm within the first 8 weeks after delivery. About 1/3 of the moms who still have a gap after delivery will end up needing help from a medical professional (most commonly a physical therapist) to reduce that gap and/or restore proper function of the abdominal muscles.3 DRAM is a big problem because it can negatively impact appearance, physical function, and athletic performance.
How it’s treated
DRAM is typically treated by:
- Retraining your deep abdominal muscles along with your pelvic floor and low back muscles
- Manually bringing together the two sides of your rectus abdominis (6-pack muscle) during rectus abdominis and/or transversus abdominis work
- Wearing a splint or abdominal binder
- Any combination of the above techniques
There is a lot of controversy about what type of treatment is best (it can get really heated, believe it or not – not quite as far as bar-stool-throwing-heated, but almost – among practitioners). Overall though, most physical therapists will use a combination of treatments based upon what they find during the examination and the patient’s goals.
Since there isn’t very much or very high quality research available for the treatment of DRAM, practitioners use the available research in combination with theoretical models and their experience. The treatment will also vary depending upon your functional limitations, functional abilities, and functional goals as well as the particular way you move. Because DRAM treatment is inherently so personalized, the one-size-fits-all programs available on the internet (for example, here and here) are better than nothing and will work for many but are not optimal for everyone.
Occasionally (very occasionally), surgical repair is warranted. And there is debate even among surgeons on the best surgical treatment for DRAM (are you beginning to feel the DRAM angst, too?). 1
A 2012 Survey of 296 physical therapists who were members of the Women’s Health Section of the American Physical Therapy Association currently treating or had treated postpartum DRAM looked at the different types of treatments the therapists used. They got to choose all that applied.4 Here are the numbers:
- General transversus abdominis muscle training (89.2%)
- Pelvic floor training (87%)
- Incorporate transversus abdominis training into functional tasks (82.2%)
- Elizabeth Noble technique (pulling the sides of the muscle together while doing a partial crunch) – (62.5%)
- Manual therapy (59%)
- Abdominal binding (56%)
- General abdominal training (34.8%)
- Tupler technique (29.4%)
- Pilates (7.1%)
Here’s where we’re going
Recent research has shed some light upon the complexity of the abdominal muscles working together when a DRAM is present, highlighting the importance of the deepest abdominal muscle in DRAM treatment (the transversus abdominis).5 Interestingly, this research indicates that it’s not as important to focus on the width of the gap as we previously thought – it’s a lot more important to do exercises that help to increase tension in the gap, even if those exercises temporarily widen the gap. It’s confusing, I know, but it’s actually a big step forward in understanding how to best treat DRAM.
The new research that is wrapping up this month will compare exercise versus abdominal binding (also known as splinting). As you can see in the list above there are so many options that fall under “exercise” that follow-on research will certainly be necessary to start whittling away at the most effective treatment options and for which types of patients.
While you and I may be experiencing DRAM angst, we can at least rest assured that work is underway. I can only imagine how women felt 10-20 years ago when they had the same level of angst – only there were no researchers busily working on solving the problem. In the meantime, I’ll keep my ear to the ground for more research and post updates here!
Here are two great resources for the latest information about DRAM:
- Mommers EHH, Ponten JEH, Omar Al AK, de Vries Reilingh TS, Bouvy ND, Nienhuijs SW. The general surgeon’s perspective of rectus diastasis. A systematic review of treatment options. Surg Endosc. 2017;122(5):1564–16. doi:10.1007/s00464-017-5607-9.
- 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 systematic review. Physiotherapy. 2014;100(1):1-8.
- 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. British Journal of Sports Medicine. 2016;50(17):1092-1096. doi:10.1136/bjsports-2016-096065.
- Keeler J, Albrecht M, Eberhardt L, Horn L. 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. doi:10.1097/JWH.0b013e318276f35f.
- Lee D, Hodges PW. Behavior of the Linea Alba During a Curl-up Task in Diastasis Rectus Abdominis: An Observational Study. Journal of Orthopaedic & Sports Physical Therapy. 2016;46(7):580-589. doi:10.2519/jospt.2016.6536.