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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


postpartum. The lack of evidence for the consequences of
Pregnancy and becoming a mother is one of the most this condition and the effect of abdominal strengthening
exciting times in a womens life. Besides all the hormonal exercises in the reduction of DRA indicates a need for
and physiological changes affecting women during this identification of prevalence and risk factors of DRA. Use of
period, probably the most obvious morphological alteration responsive, reliable and valid outcome measures is
during pregnancy is the increasing weight and dimensions of mandatory for evaluation of the condition, and ultrasound
the uterus, influencing maternal trunk musculoskeletal imaging has lately been proposed as a valuable method to
morphology, particularly the abdominal musculature. measure muscular geometry and to quantify DRA. The aim
Many women continue or even begin to exercise during of this article is to critically review the literature on the risk
pregnancy, and Postnatal women are stimulated to resume factors, functional implications and the effect of exercise on
abdominal exercises shortly after delivery, to repair their DRA. This information is expected to be relevant for
abdominal figure and fitness. physiotherapists and exercise professionals.
There is a lot of information available in numerous web 1.1. Methodology for Research Articles
pages about exercise programs for women during pregnancy
and in the postpartum period, and physiotherapists and A search strategy was developed to search the electronic
exercise instructors prescribe exercises to this population databases of Medline, PEDro and PubMed to look for
every day. However, there is little evidence available about published studies involving assessment of DRA, interventions
muscular changes and the effect and safety of different to prevent and/or reduce DRA during the ante- and postnatal
abdominal exercises during and after pregnancy. Diastasis periods. These electronic databases were explored from the
recti (DRA) or the increased interrectus distance (IRD) seems 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
*Address correspondence to this author at the Univ Lisboa, Fac Motricidade
Humana, CIPER, LBMF, P-1499-002 Lisboa, Portugal; included. No study design restriction was applied. Trials
E-mail: patimota@gmail.com 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 Mota et al.

the study was taken into account when interpreting the scientific evidence exists about the functional implications of
results. an augmented IRD or even about the outcome of the exercise
on prevention and/or decrease of IRD.
2. DIASTASIS ABDOMINIS
2.2. Anatomical Framework
2.1. Definition
The anterolateral wall of the abdomen has a laminar
IRD vs DRA Diastasis Recti Abdominis (DRA) is the configuration composed by six layers including, from
excessive separation between both bellies recti abdominis surface to depth, the skin, the superficial fascia, fat, the
(RA) muscles. The DRA can occur anywhere along the linea abdominal muscles, the transversalis fascia and the parietal
alba, from the xiphoid process to the public bone, and is peritoneum. The muscular layer comprise four paired
quantified by the inter-recti distance (IRD). muscles with fibers oriented vertically (rectus abdominis
During pregnancy, as the fetus grows, the two muscle muscle), obliquely (external and internal oblique muscles)
bellies of the rectus abdominis, connected by the linea alba and horizontally (transversus abdominis muscles) with
elongate and curve round as the abdominal wall expands, skeletal attachments on the thoracic cage, pelvis and the
with most separation occurring at the umbilicus [1, 3, 11]. spinal column via the thoracolumbar fascia [17]. The
The DRA is defined as a modification in the abdominal aponeuroses of these muscles represent sheet-like tendons
musculature, precisely in the linea alba and rectus abdominis that form the sheath of the rectus abdominis (rectus sheath)
sheath, with beginning in the last trimester of pregnancy and and also serve as the medial insertion of the obliques and
whose peak of incidence occurs immediately after birth and transversus muscles, along the anterior midline of the
the first weeks following childbirth [1, 8, 12-14]. abdomen, forming a fibrous structure that connect the right
and the left side of the abdominal wall, the linea alba. The
While, some literature proposed that an augmented IRD rectus abdominis (RA) and the pyramidalis are the only
could decrease the abdominal integrity and functional strength, vertical muscles in the abdominal wall. The RA originates
contributing to pelvic instability and back pain [3, 15, 16], no from the 5th through 7th costal cartilages to insert on the

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.
Diastasis Recti Abdominis in Pregnancy and Postpartum Period. Risk Factors Current Womens Health Reviews, 2015, Vol. 11, No. 1 61

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 Fig. (2). Fiber architecture in the linea alba. Zones are described
portion lie behind the RA muscle and blend with the from anterior to posterior as (1) oblique fiber layer, (2) transverse
posterior rectus sheath while its lower part pass in front of fiber layer, and (3) irregular fiber layer. Reprinted with permission
the RA muscle [18]. The collagenous part of the anterior from Grassel D, Prescher A, Fitzek S, Keyserlingk DG, & Axer H.
abdominal wall includes the linea alba and the rectus Anisotropy of human linea alba: a biomechanical study. J Surg Res
sheaths. The linea alba reaches from the xiphoid process to 2005; 124(1): 118-125.
the pubic symphysis and is composed of the collagen fibers
(aponeuroses) from the deeper abdominal muscles, i.e., the longitudinal direction and lower in transverse direction. This
transversus and the internal and external oblique muscles [7, means that the linea alba tensile strength, i.e., the tissue
19]. The linea alba includes of a three-dimensional, extremely ability to resist tensile forces (inverse of compliance) is less
structured meshwork of collagen fibers which in conjunction for tension applied along the tissue (longitudinally) and bigger
with rectus sheaths are regarded as the most important for transverse tensile forces. The linea alba tension is important
structures for the stability of the anterior abdominal wall to maintain the abdominal muscles, especially the rectus
from a mechanical point of view [19-21]. The collagen fibers muscles, at a certain closeness to each other [4, 7] in order to
in linea alba have the same orientation as the muscle fibers optimize abdominal muscles function both as on abdominal
of the deeper muscles of the anterior abdominal wall, i.e. viscera support or producing thorax/pelvis movements.
transverse and oblique in two directions: 1) directed from Tension on the linea alba, particularly below the umbilicus,
right upward to left downward, and 2) directed from left seems to be regulated by the pyramidalis, a small paired
upward to right downward. An anatomical model of collagen triangular-shaped muscle, present in 80% of people, which
fiber architecture in the linea alba has been described based lies between the anterior surface of the rectus abdominis and
in confocal laser scanning microscopy images over human the posterior surface of the rectus sheath [22]. The exact
cadaveric specimens [19, 20]. This model is illustrated in function of the pyramidalis muscles is uncertain, nevertheless
Fig. 2 and comprises three different zones of fiber orientation, together both muscles are believed to assists in tensing the
from anterior (ventral) to posterior (dorsal): the oblique fiber linea alba [22]. The linea alba compliance is maximum in the
layer, the transverse fiber layer and an irregular fiber layer. longitudinal direction and minimum in the transverse
Despite this structure of fibers is the same along length of direction [7, 23] which determine the great resistance offer
linea alba, different regions can also be distinguish in the by the LA to rectus abdominis transversal separation. Even
craniocaudal direction: supraumbilical part, transition zone so, the viscoelastic properties inherent to the collagen, makes
and infraarcuate part. These regions have a close structural the linea alba prone to increase length when the mechanical
and functional relationship with fiber architecture of rectus stress is prolonged in time [21], namely in the case of a lasting
sheaths. increased intra-abdominal pressure, such as that resulting
from pregnancy [1, 8, 24, 25]. The mechanical stress on linea
The study of Grassel et al. [20] clearly demonstrated the alba is highly associated to the action of the oblique s and
anisotropy property in biomechanical behavior of the linea transversus abdominis muscles. The external oblique arises
alba. from the lower 8 ribs posteriorly to interdigitate with both
The anisotropy means that the tissue exhibits a property the serratus and latissimus muscles. The direction of the
directionally dependent. In fact, the results of Grassel et al. fibers is approximately horizontal in the uppermost portion
[20] revealed that the linea alba compliance is high in the only to become oblique in the lowest portions.
62 Current Womens Health Reviews, 2015, Vol. 11, No. 1 Mota et al.

After contributing to the anterior portion of the rectus anterior displacement of all aponeuroses creates the arcuate
abdominis sheath, the residual fibers insert onto the linea line, a curved line of demarcation in the posterior lamella of
alba. The rectus sheath or rectus abdominal aponeurosis is a the rectus sheath. In a cadaveric study about the three-
strong connective tissue derived from the aponeuroses of the dimensional distribution and orientation of collagen fiber,
deepest abdominal muscles [17], that forms a sheath of dense using confocal laser scanning microscopy images, found that
collagen fibers that encloses each one of the rectus the ventral layer of the rectus sheath comprise oblique fibril
abdominis muscles. The function of the rectus sheath is to bundles while the posterior layer consist mainly of transverse
protect both rectus abdominis muscle and enables muscles bundles [19]. The authors also found that, below the
sliding through neighboring structures. The rectus sheath umbilicus, the transverse posterior layer continuously spread
comprises an anterior and a posterior layer (lamella) formed onto the anterior layer of the rectus sheaths. This means that
by the aponeuroses of the external and internal oblique and the place where the posterior layer changes to anterior is not
transversus abdominis muscles (Fig. 3). These aponeuroses a sharp line, as subjected by the arcuate line, also known as
meet at the lateral edge of the rectus along a curved line, the falciform edge or linea semicircularis.
linea semilunaris, which spreads from 9th costal cartilage to
Based on this fiber distribution Axer et al. [19] described
the pubic tubercle.
three craniocaudal regions on rectus abdominis sheaths:
Above the umbilicus the anterior and posterior sheaths supraumbilical, transition (corresponding to arcuate line) and
comprises the internal oblique muscle aponeurosis. Indeed, infraarcuate zone. Thickness of the posterior rectus sheaths
above the umbilicus the internal oblique aponeurosis splits, layer continuously reduces in the transition zone and
allowing one layer to pass anterior and the other posteriorly diminishes in the infraarcuate part. On the contrary, the
to the rectus abdominis muscle. The anterior layer of the anterior rectus sheaths layer continuously enhances thicker in
rectus sheath includes also the external oblique aponeurosis the transition zone wherein the oblique and transverse fibers
while the posterior layer comprises contributions from mingled one each other to form a three- dimensional
transversus abdominis aponeuroses (transversalis fascia). structure with a similar pattern as found in linea [19].
Above the umbilicus, approximately halfway between the Location of the transition zone has a high inter-individual
umbilicus and the symphysis pubis, the aponeuroses of the variability however is concordant with the transition zone
three deeper muscles of the abdomen pass anteriorly to the also described in the architecture of the linea alba [19]. This
rectus muscle that including the internal and external oblique seems to be an indicator of how fibers from rectus sheaths
aponeurosis and transversalis fascia. Below the arcuate line, and linea alba function as a cooperating system of fibers with
the transversalis fascia is the only structure that separates the some functional meaning. Gender differences were observed
rectus abdominis muscle from the parietal peritoneum. The in the relation between transverse and oblique layers of

Fig. (3). The anterior and a posterior layer (lamella) of left rectus sheath (horizontal view).
Diastasis Recti Abdominis in Pregnancy and Postpartum Period. Risk Factors Current Womens Health Reviews, 2015, Vol. 11, No. 1 63

collagen fibers layers in the linea alba (Fig. 3) such that Coldron et al. [8] used ultrasound to characterize RA
females showed a large amount of transverse fibers relative modifications throughout the first 12 months postpartum and
to the oblique fibers in the proportion of 60% versus 40% Mendes et al. [37] et al. declared ultrasonography to be an
[19]. precise method to qauntify diastasis recti when compared
with surgical compass during abdominoplasty.
2.3. Diastasis Recti Abdominis and Pregnancy
Across-days reliability is important to physiotherapists
The functional role of the abdominal muscles during who perform repeated evaluations of abdominal muscle
pregnancy appears to be similar to those in the non- pregnant function over time [38]. Aspects such as repositioning of the
state [1] and is suggested to be important for trunk movement, original imaging site, reproduction of the same transducer
pelvic stabilization, and restraint of the abdominal contents pressure and orientation, as well as preservation of a
[17]. However, the musculoskeletal morphology of the relatively stationary transducer position during muscle
anterolateral wall of the abdomen changes as pregnancy contraction, might negatively affect reliability [38] and
progresses [3, 26]. The weight and dimensions of the uterus accurate interpretation of ultrasound imaging and lead to
and its contents increases from 40 to 1000 grams and its erroneous conclusions [39-41]. The 2D ultrasound imaging
capacity from 4 ml in non-pregnant state to 4000 ml at term showed to be a reliable technique to measure IRD in women.
[27]. The maternal inferior thoracic diameter is increased A recent study from our research team [42] demonstrates
[15, 28] as well as the anterior and lateral dimensions of the
that palpation and finger width palpation method can be used
abdomen.
in clinical practice, but ultrasound is a more reliable and
These changes modify the spatial connection between the valid method and should be used in research of IRD.
superior and the inferior abdominal muscle connections [27] Selecting a gold standard technique to test criterion
increasing the length of the abdominal muscles, particularly validity is not a simple task. Computed tomography (CT) and
the rectus abdominis [11]. At 38 weeks of gestation the magnetic resonance imaging (MRI) are presently considered
length of the abdominal muscles increased a mean of 115% the procedures of choice to examine the abdominal wall.
with respect to the beginning of pregnancy [3]. The increment Nevertheless, these procedures are expensive and CT exposes
of the anterior abdominal dimensions may alter the angle of the patient to radiation [37], making it unmanageable to use
the abdominal muscle attachment in the sagittal plane [3]. in pregnant women. Hence, ultrasonography has been
Alterations in the spatial relationship of muscle attachment suggested as a safe and non-invasive method that can be
and the muscles angle of insertion may alter the muscles repeated numerous times [37] during pregnancy. Ultrasound
line of action and therefore their ability to produce torque measures the IRD in a scale of millimeters and such levels of
[3,15]. evaluation are hard to distinguish by palpation.
3. DIAGNOSE OF DIASTASIS RECTI ABDOMINIS The dynamic nature of ultrasound imaging studies
undertaken during abdominal exercises may compromise the
Criteria and IRD cut-off value for the diagnosis of DRA interpretation of data and it is logical to assume that accurate
vary in the literature [1-4, 6, 7, 10, 24, 29], and to date there measurement and interpretation will be influenced by
is no international agreement on the measurement place. In a changes on the orientation of the transducer [41]. Transducer
cadaver study, Rath et al. [4] described a widening of the motion during image collection when muscles are under
IRD more than 10 mm above the umbilicus, 27 mm at the contraction could compromise accuracy of IRD measurements.
level of the umbilicus and 9 mm below the umbilicus, as Recently, acceptable amounts of transducer motion was
pathological DRA. Others stated DRA as a widening of the found (<10 of angular and 8 mm of inward/outward motion)
IRD more than 2.5 cm at one or more assessment points when ultrasound images were collected during abdominal
using digital calipers [5]. crunch and drawing- in exercise [43].
In a more recent ultrasound study Beer et al. [7] suggest
4. PREVALENCE AND RISK FACTORS OF DIASTASIS
that in nulliparous women, the linea alba should be considered
RECTI ABDOMINIS
normal when the IRD width is less than 15 mm, at the
xiphoid level, 22 mm at 3 cm above the umbilicus, and 4.1. Prevalence of Diastasis Recti Abdominis
16 mm at 2 cm below the umbilicus.
DRA has been found to affect between 30% and 70% of
3.1. Instruments and Protocol Measurement pregnant women [1], and the increased IRD can persist
separated in the immediate postpartum period in 35% to
The most common methods to assess IRD are palpation 60% of women [2]. Nevertheless the situation has also been
[1, 2, 30, 31] and calipers [32, 33]. However, the stated found in 39% of older, parous women undergoing abdominal
prevalence of DRA (or augmented IRD) may be imprecise hysterectomy [29] and in 52% of urogynecological
because of the lack of reliability, the low responsiveness menopausal patients [6]. Reported prevalence of DRA or
(ability of a tool to detect small differences or small changes) increased IRD varies and might be inaccurate due to
and lack of validity (ability of an instrument to measure what different IRD cut-off values for the diagnosis [1-7] and use
it is supposed to measure) [34] in the methods and instruments of different measurement assessment methods (Table 1).
used to measure the IRD. Recently, ultrasound imaging has Mota et al. [43] using the same definition for DRA as used by
been suggested as a useful method to assess muscular Beer et al. [7], i.e. IRD > 2.3 cm, found that the prevalence
geometry and as an indirect measure of muscle activation via of DRA at 2 cm below the umbilicus decreased from 100%
changes in muscle thickness during contraction [35, 36]. in late pregnancy to 39% at 6 months postpartum.
64 Current Womens Health Reviews, 2015, Vol. 11, No. 1 Mota et al.

Table 1. Prevalence of Diastasis Recti Abdominis (DRA) in general population. Synopsis of the most representative studies and
respective results.

Boissonnault & Blaschak, 1988 Lo et al., 1999 Mota, et al., 2015

Pregnancy 66%

(1) 35%

(2) 53%

(3) 38%
Posrpartum
(4) 52.4%

(5) 53.6%

(6) 39.3%

DRA criteria >2 fingers >2.5 cm >2.3 cm

IRD measurement instrument/protocol Finger width palpation method Caliper/Palpation Ultrasound images

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. sample size, reliability of the instruments used, and were not
[7] was set for nulliparous women, and might be considered conclusive in its capability to describe risk factors.
limited for women during pregnancy and in the postpartum
period. 5. FUNCTIONAL IMPLICATIONS OF DIASTASIS
RECTI ABDOMINIS
4. RISK FACTORS FOR DIASTASIS RECTI Some authors suggest that DRA compromise the integrity
ABDOMINIS of female abdominal wall [10] which can potentially affect
There is Limited Information about the Risk Factors for the capacity of the abdominal muscles to generate force and
DRA. Two studies analyzed several variables such as, age, would be the cause of some disorders such as lumbopelvic
ethnicity, body mass index, height, weight gain during pain. In fact, only two studies [3, 9] analyze the relationship
pregnancy, pre-pregnancy weight, gestational age at between the increase width of IRD and the abdominal
delivery, type and duration of birth [10, 14]. An association muscles dysfunction. Gilleard & Brown [3] in a sample of 6
of DRA during pregnancy with Caucasian ethnicity and primiparous women, physically active, aged between 28 and
absence of regular exercise through pregnancy was 33 years, related some morphological parameters inherent to
suggested [10]. It is considered that women with DRA have the perinatal period with changes in abdominal muscles
a greater number of pregnancies and deliveries [6, 14], and functional capacity. The authors reported IRD changes in 9
among multiparous women, it is suggested that there is a time-moment of the period between the 14th week of
strong relationship concerning provision of childcare and pregnancy and the 8th week postpartum. Those changes were
DRA in pregnancy [10]. correlated with abdominal muscle function in two
conditions: the curl-up exercise and the abdominal muscle
No significant risk factors were found for the presence of test (AMT). The abdominal muscles capacity during curl-up
DRA at 6 months postpartum [43]. exercise was assessed according to an ordinal scale of
Candido et al. (2005) showed that women with and functionality, from minor to major. In the AMT subject is
without DRA did not differ significantly with respect to age, asked to keep a backward pelvic tilt position while perform
ethnicity, height, weight gain during pregnancy, pre- lower limb flexion-to-extension action, in supine position.
pregnancy weight, gestational age at delivery, however this The results of Gilleard & Brown [3] shown that the curl-up
study was also limited by the small sample size [10]. capacity and the ability to stabilize the pelvis in a backward
Boissonnault & Blaschak [1] found an absence of DRA in pelvic tilt position are compromised in pregnant women and
women who exercised before pregnancy which seems to up to 8 weeks after delivery, particularly in women with a
support the theory that pre- pregnancy abdominal physical IRD higher that 3.5 cm measured by palpation at the end of
fitness influence the incidence of DRA. The positive effects pregnancy. More recently, Liaw et al. [9] compared a group
of physical activity before and during pregnancy were also of 40 post-partum women (primiparous and multiparous)
supported by the shorter time to DRA resolution reported by with an age matched nulliparous group regarding the ability
Lo et al. [44] in women with the higher levels of activity. of the abdominal muscles to produce and maintain high
Overall the previous mentioned studies were limited by the strength levels. The abdominal muscle function was assessed
Diastasis Recti Abdominis in Pregnancy and Postpartum Period. Risk Factors Current Womens Health Reviews, 2015, Vol. 11, No. 1 65

by the capacity to perform the curl-up exercise and by the 6.3. The Effect of Exercise on Diastasis Abdominis
abdominal endurance test. Like Gilleard & Brown [3]
It has been suggested that antepartum activity level may
also Liaw et al. [9] analyzed the abdominal function using a
have a protective effect on DRA and exercise may improve
four-level functionality of scale: low ("poor"), sufficient
post-partum symptoms of DRA [25].
("fair"), good ("good") and normal. The results of the
abdominal endurance test refers to the time, in seconds, that To date there is scant knowledge on the most effective
women can maintain the trunk flexion position (45). The abdominal exercises both during pregnancy and after
abdominal strength values, magnitude and strength were childbirth. In particular there is little evidence on which
also correlated with the supra and infraumbilical IRD. The exercises are most efficient in decreasing of the recti
results showed that compared postpartum women had lower diastasis. According to Wolfe and Davies [48], abdominal
levels of abdominal strength. The authors also found a strengthening exercises should be done in pregnancy to
negative correlation between abdominal function and the promote good posture, strengthen the muscles for labor, and
IRD, with exception of the association at 6 months prevent low back pain and diastasis recti. Nevertheless, the
postpartum. The progressively reduction of IRD during the authors defend the need to stop abdominal exercise if
postpartum period was accompanied by a significant diastasis recti develops [48].
increase in strength of the abdominal muscles. 5.1 DRA and The justification following the abdominal strengthening
lumbopelvic pain. programs is the hypothesis that the contraction of all
Earlier reported studies showed that 10% of pregnant abdominal muscles will reduce the horizontal abdomen
women have severe lumbo-pelvic pain that interferes with diameter in such a way that a horizontal force will be
daily activities [11] and the prevalence of pregnant women generated producing the approximation of both rectus
suffering from lumbo-pelvic pain is about 20% [45, 46]. abdominis, particularly at the umbilicus level [3, 28].
Reported lumbo-pelvic pain is expected to be high In the Abdominal crunch has been considered a risk exercise
postpartum period [16] and it may affect between 9% and for development of diastasis recti [48], but it has also been
48% [16] of women. used to assess abdominal muscle strength and endurance in
women during the postpartum period [49]. Lately core
Women with DRA were not more likely to report lumbo- training with the drawing in exercise has been recommended
pelvic pain than women without DRA (p>0.05). In our study, both in the general population [9] and during pregnancy and
the prevalence of this condition was within the range of other after childbirth [50-52]. It has been proposed that transversus
prevalence studies (27.3% and 27.5% respectively). This is abdominis muscle activation could protect the linea alba and
in line with the results found by Parker et al. [16]. may help to prevent or reduce DRA and speed up recovery
Nevertheless we did not perform an exhaustive pain- history [25]. However there are no data to support this suggestion.
[47] and we did not make any clinical evaluation to assess Two studies [53, 54] suggested that the IRD narrowed when
the condition, which could underestimate the results. On the the abdominal crunch exercise was performed, and the
other hand, the sample was drawn from a population drawing in resulted in widening of the IRD compared to rest
attending pre-natal courses in private centers, and in all locations measured on the linea alba.
consequently was not conclusive in its ability to delineate
prevalence of lumbo- pelvic pain in other populations. These results do not support the hypothesis that the
drawing in maneuver is an effective exercise during
6. RESOLUTION OF DIASTASIS RECTI ABDOMINIS pregnancy and in the post-partum period. There is an urgent
need for more basic and experimental studies to understand
6.1. Natural Resolution the mechanisms of different abdominal exercises. In
addition, high quality randomized controlled trials on the
Some studies hypothesized that there would be a natural
effect of different abdominal exercises to prevent and treat
decrease in the IRD from pregnancy until 12 months
diastasis recti abdominis are warranted.
postpartum [1, 33]. Despite the variability, a general
decrease in the IRD is observed when comparing the IRD CONCLUSIONS
measured during pregnancy with the IRD measured on the
postpartum period [1, 33]. However, the values of IRD on No significant risk factors were found for the presence of
the postpartum period remain wider than in nulliparous DRA at 6 months postpartum. Women with DRA were not
women, and the prevalence of DRA was still very high at 6 more likely to report lumbo-pelvic pain than women without
months postpartum, suggesting that recuperation may still be DRA.
in development. There is an urgent need for more basic and experimental
studies to understand the mechanisms of different abdominal
6.2. Abdominal Supporting Belts
exercises. In addition, high quality randomized controlled
There are some theories stating that the regular use of a trials on the effect of different abdominal exercises to
postpartum support belt can reduce back pain and strain on prevent and treatdiastasis recti abdominis are warranted.
muscles and ligaments, suggesting it could be of use to
reduce IRD in postpartum period [1, 8, 33, 43]. CONFLICT OF INTEREST
Conversely, to our information there are no high quality The authors confirm that this article content has no
clinical studies to support these statements. conflict of interest.
66 Current Womens Health Reviews, 2015, Vol. 11, No. 1 Mota et al.

ACKNOWLEDGEMENTS [24] Akram J, Matzen SH. Rectus abdominis diastasis. J Plast Surg
Hand Surg 2014; 48(3): 163-9.
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Received: February 12, 2015 Revised: June 25, 2015 Accepted: August 24, 2015