Original Research

Comparison of Trunk Muscle Function

Between Women With and Without
Diastasis Recti Abdominis at 1 Year
Postpartum
Nicole F. Hills, Ryan B. Graham, Linda McLean

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N.F. Hills, PT, PhD, School of Rehabil-
itation Therapy, Queen’s University,
Background.  A separation of the abdominal muscles at the linea alba, known as dia- Kingston, Ontario, Canada.
stasis recti abdominis (DRA), can occur after childbirth. However, the impact of DRA on
R.B. Graham, PhD, School of Human
abdominal muscle function is not clear. Kinetics, University of Ottawa, Ontario,
Canada.
Objective.  The objective was to determine if differences exist in trunk muscle function L. McLean, PT, PhD, School of Rehabil-
and self-reported pain and low back dysfunction between women with and without DRA itation Sciences, University of Ottawa,
at 12 to 14 months postpartum and if differences that emerge from the data are associated 451 Smyth Road, Ottawa, ON K1H
with the magnitude of the interrectus distance (IRD). 8M5 Canada. Address all correspond-
ence to Dr McLean at: linda.mclean@
uottawa.ca.
Design.  This study was a prospective, observational, case-control study.
[Hills NF, Graham RB, McLean L.
Comparison of trunk muscle func-
Methods.  Women with (IRD ≥2.2 cm; n = 18) and without DRA (IRD <2.2 cm; n = 22) tion between women with and with-
participated. Maximal trunk flexion, extension, and rotation torque-generating capacity out diastasis recti abdominis at 1 year
(Newton-meters), the Sit-Up test (0 to 3 points), and the Sitting-Rising Test (0 to 10 points), postpartum.PhysTher.2018;98:891–901.]
and trunk flexion, extension, and lateral flexion endurance (seconds) were measured. Pain © 2018 American Physical Therapy
and disability were assessed using numerical pain rating scales (0 to 100) and the Roland Association
Morris Low Back Pain Questionnaire (0 to 24 points). Women were compared using inde- Published Ahead of Print:
pendent t tests and Mann-Whitney U Tests. Pearson product-moment and Spearman rank July 16, 2018
correlation coefficients were used to determine associations;  = .05 was used for all tests. Accepted: May 14, 2018
Submitted: October 16, 2017
Results.  Women with DRA demonstrated significantly lower trunk muscle rotation torque
and scored lower on the sit-up test than those without DRA. IRD was negatively correlated
with both trunk rotation torque (rho = –0.367) and sit-up test score (rho = –0.514).

Limitations.  The results of this study should not be generalized to women who present
with moderate-to-severe IRDs or to multiparous women.

Conclusion.  The presence of DRA in primiparous women at 1 year postpartum is asso-

ciated with trunk rotation strength and ability to perform a sit-up.

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October 2018 Volume 98  Number 10  Physical Therapy    891

Diastasis Recti Abdominis
D
iastasis recti abdominis (DRA)
is a separation of the abdominal
muscles at the linea alba (LA).1
DRA can occur as the result of prolonged
transverse stresses on the linea alba in
men,2 in postmenopausal women,3 and
in women during pregnancy.4,5 As the
abdomen expands during pregnancy,
the LA (the fascia between the rectus
abdominis [RA] heads) must soften and
expand to accommodate the growing
fetus.6 This process increases the width
of the LA, which is reflected in the
interrectus distance (IRD). DRA is expe-
rienced by some women during their
third trimester of pregnancy and imme-
diately after a full-term pregnancy; how-
ever, to date, research does not present
a consensus on how many women are
affected by DRA.
Currently, the literature suggests 33% to
74% of women present with DRA after
childbirth,3,6–9 with this large range
in incidence likely being the result of
variation regarding the definition of
DRA. Although ultrasound imaging
(USI) is a valid and reliable means of
measuring IRD in women,10–14 different
research groups have reported IRD
values at different measurement sites
(ie, below the umbilicus, at the supe-
rior border of the umbilicus) and have
used different IRD values ranging from
1.5 to 2.5 cm1,9,15–18 as cut-off values
to define DRA. The current literature
is discrepant regarding the relevance
of IRD as a means of evaluating DRA
severity.
There is some evidence that shows that
the magnitude of the IRD is associ-
ated with the severity of self-reported
abdominal pain;8,19 yet, there is no
evidence to support the contention that
there is an association between IRD and
lumbopelvic pain.9,18 Despite sugges-
tions that DRA may be associated with
pelvic floor dysfunction, women with
DRA have not been shown to demon-
strate pelvic floor muscle weakness or
higher-incident urinary incontinence
or pelvic organ prolapse.20 In terms
of trunk function, a woman’s ability
to perform a sit-up was found to be
reduced during pregnancy and at 8
weeks after delivery;1 and, IRD was
found to be negatively correlated with
trunk flexor strength and trunk flexor
892    Physical Therapy  Volume 98  Number 10
endurance in a small sample of women
who did not present with DRA at
6 months postpartum.21 However, these
associations have not been investigated
after DRA has persisted for some time,
in this case, at 1 year postpartum.
Despite the lack of robust evidence
to support the need for intervention
when women present with DRA, a
sample of physical therapists in the
United States who practiced specif-
ically in the area of women’s health
believed that DRA should be managed
through therapeutic exercises, specifi-
cally those aimed at training the trans-
verse abdominis muscle.22 The results
of 3 small exercise intervention studies
have suggested that targeted exer-
cise performed during pregnancy can
prevent postpartum DRA.23–25 However,
it is not clear whether or not DRA
caused by pregnancy that persists post-
partum is associated with any physical
impairment.9,26 Because the physical
and functional impacts of DRA have not
been established, it is premature to test
exercise protocols for their effective-
ness. First, we must understand if func-
tional implications of postpartum DRA
exist before directing interventions
toward resolving specific impairments
associated with this condition.
The objective of this prospective, obser-
vational, case-control study was to
investigate the impact of DRA on trunk
muscle function at 1 year postpartum,
and to determine whether the severity
of impairments found in trunk strength
and endurance and/or self-reported
pain and low back dysfunction were
correlated with the magnitude of the
IRD.
Methods
The study was found to comply with
the standards for the ethical conduct
of research by Queen’s University
Health Sciences Research and Ethics
Board (REH-636–15), and all volunteers
provided written informed consent
before participating.
Participants
Women who were approaching the end
of their first postpartum year (12 to
14 months from the delivery of their
first child) were recruited for this study
through convenience sampling from
the Kingston, Ontario, community.
Recruitment was done through word
of mouth and through advertising via
study posters at local mother and baby
groups, gyms, allied health clinics, and
family physician offices. Recruitment
posters were also placed on social
media in local mother support groups.
There were limited data in the liter-
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ature on which to base estimates of
power and sample size. Liaw and
colleagues21 measured timed trunk
flexion and found significant differ-
ences in mean static trunk flexion
endurance times between nulliparous
women and women at 6 months post-
partum. By using the group means and
pooled standard deviations reported
by Liaw and colleagues,21 an effect
size of 0.8, an alpha level of .05, and
power set at 0.8, we estimated that
52 women (26  women in each group)
would be required in order to detect a
group difference in endurance between
women with and without DRA. At the
end of the predetermined recruitment
period, we had recruited 40 women.
A preliminary analysis was done, and
significant group differences were
found regarding some variables. Power
analyses were then completed on the
variables that did not reach statistical
significance, the outcome of which
suggested that continuing recruitment
to n  =  52 would not have any mean-
ingful impact on the power to detect
differences in these variables. There-
fore, recruitment was terminated at
this point. Effect size analyses and post
hoc power analyses can be found in
eTable 1 (available at https://academic.
oup.com/ptj).27
Potential participants were excluded
if they had a history of: (1) more than
1 pregnancy and/or were pregnant;
(2)  carrying more than 1 child during
their first pregnancy; (3) any form of
vulvovaginal pain, pelvic pain, prolapse,
or incontinence prior to their preg-
nancy; (4) abdominal, gynecological, or
urological surgery prior to pregnancy;
(5) a neuromuscular or metabolic
condition that could affect muscle
contractility or lumbopelvic function;
(6) respiratory dysfunction; (7) a lower
limb pathology (eg, fracture, surgery,
October 2018

neoplasm); (8) low back pain prior
to pregnancy (defined as a history of
lumbopelvic, hip, or thigh pain that
was severe enough to interfere with
work or recreation or required medical
attention) in order to study only pain
that arose over the course of or after
pregnancy; or (9) DRA prior to preg-
nancy.
Eligible participants completed a series
of online questionnaires prior to their
physical testing. The Roland-Morris Disa-
bility Questionnaire (RDQ)28 is scored
out of 24, where 0 indicates no disability
and a score of 24 indicates severe disa-
bility. The RDQ has been shown to have
high construct validity when compared
to pain rating scores,29 is easily under-
stood by patients,30 and has been found
to be a reproducible28,31 and respon-
sive questionnaire.31 The RDQ is an
appropriate questionnaire to use when
investigating populations with mild-
to-moderate disability due to low back
pain.32 Four numerical pain rating scales
(NRS) were also used.33 The NRS asked
the participants to rate their worst pain
in the past 24 hours separately for the
abdomen, low back, upper-mid back,
and pelvis or hips on a 0 to 100 scale
(0 indicated no pain; 100 indicated worst
pain imaginable). The NRS is valid, reli-
able,33 and has demonstrated superior
responsiveness and ease of use when
compared to a visual analog scale.34
Participants also completed the Inter-
national Consultation on Incontinence
Questionnaires (ICIQ) for vaginal symp-
toms (ICIQ-VS) and urinary tract symp-
toms (ICIQ-FLUTS).35 Demographic
information (ie, age, delivery mode,
baby’s birth weight, breastfeeding status,
education level, work status, and weekly
minutes of moderate-to-vigorous phys-
ical activity) was obtained using self-­
report, and standard procedures were
used to measure height, weight, and hip
and waist circumference.
Procedure
A physical therapist who was blinded
to the participant’s DRA status at the
time of testing performed the physical
testing. To investigate the function of
their abdominal muscles, participants
performed 3 trials of strength, endur-
ance, and functional tasks in the order
described below.
October 2018
First, isometric trunk flexion then exten-
sion torque were tested using a custom
portable dynamometer (IFLEXD);
maximum peak torque efforts were
captured during each 5-second trial.
The IFLEXD has excellent test-retest
reliability (ICC [3,1] > 0.973) and
concurrent validity (R  >  0.829) rela-
tive to a Biodex dynamometer.36 The
IFLEXD force output signal was condi-
tioned with an amplifier (Model 9243,
Burster, Germany) and then sampled at
100Hz using a 12-bit Analog to Digital
Conversion Card (USB-201, Measure-
ment Computing Corporation, Norton,
Massachusetts). Using a custom Labview
2013 program (National Instruments,
Austin, Texas), raw data were saved to a
personal computer.
Right and left trunk rotation torques
were then measured using 2 Mark-10
Series 5 digital force gauges (Mark-10
Corporation, Copiague, New York).
Resistance was provided at a stand-
ardized position on the forearm of the
participant’s outstretched arms (45 cm
from the acromion) and the contralat-
eral thigh (35 cm from the greater
trochanter). Each 5-second contraction
effort was ramped to the participant’s
maximum effort. Peak torque was
calculated as peak force obtained multi-
plied by the perpendicular distance of
the point of application of the force to
the center of rotation at the acromion,
which was kept consistent between
trials and participants at 0.45 m.
Participants demonstrated no signifi-
cant difference between left and right
rotation, and therefore, an average of
the 6 measures of peak torque was
calculated (3 trials of left rotation and
3 trials of right rotation) and retained
for statistical analysis. Prior to initiating
this study, it was important to assess
the intrarater reliability of this meas-
urement. Intrarater test-retest reliability
was computed using a convenience
sample of 10 women, and the intra-
class correlation coefficient (ICC [3,1])
was 0.985 or excellent.
Next, participants performed the
Sit-Up Test,37 which was scored on
a scale from 0 to 3. A score of 0 indi-
cated the participant was unable to
perform a sit-up; a score of 1 indicated
Volume 98  Number 10  Physical Therapy    893
Diastasis Recti Abdominis
the participant could perform a sit-up
with their lower extremities straight
(long lying position), with their ankles
secured to the plinth, and with their
arms held at their sides (Task 1); a score
of 2 indicated the participant could
perform a sit-up in Task 1 and addi-
tionally with their hands held behind
their head (Task 2); a score of 3 indi-
cated the participant could perform a
sit-up with their hands behind their
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head, hips and knees flexed, and the
soles of their feet on the plinth (hook
lying position; Task 3)37 while their
lower extremities were not restrained
in any way. A sit-up was considered
complete if the participant was, after
rising from the dependent position and
in a controlled manner, able to achieve
a position in which their head, shoul-
ders, and upper torso were in line and
at a 40-degree angle from horizontal,37
and the participant was able to hold
the position for 5 seconds. A controlled
manner was defined as a motion where
accessory muscles, compensatory move­
ments, and momentum were not used
to achieve the position. The partici-
pants had 3 attempts at a task before
the test was either terminated (unsuc-
cessful after 3 attempts) or progressed
(successful completion of the task).
­Although this task has been used in the
literature,37 the reliability of the task has
not been tested. Therefore, our research
group tested the intra- and interrater
reliability of scoring this task on a
sample of 10 women prior to initiating
this study. Our results suggested that
intrarater reliability (ICC [3,1] = 0.938)
and interrater reliability (ICC [3,2] =
0.832) were both excellent.
The Sitting-Rising Test (SRT)38 then
measured the participants’ ability to sit
down and then rise up from the floor
using as little support as possible.
Participants were asked to begin by
standing in bare feet and with a com­
fortable base of support. They were
then asked to lower themselves to a
seated position on the floor without
leaning on anything or using their
hands for assistance. Once on the
floor, they were asked to stand back
up, trying not to use support from
their hands, knees, forearms, or sides
of their legs. A score out of 5 was
given for the sitting phase, and another
Diastasis Recti Abdominis
(A)
Figure 1.
Plots of test scores that were significantly different between groups. (A) Correlation between mean interrectus distance (IRD) recorded at
rest and mean trunk rotation torque in women with DRA (red) and without DRA (black) with best fit regression. (B) Boxplots for mean IRD
recorded at rest vs Sit-Up Test scores. DRA = diastasis recti abdominis.
score out of 5 was given for the rising
phase. One point was subtracted
from the possible total of 5 for each
phase each time a support was used
and/or if the evaluator observed an
unsteady execution of the task or a
loss of balance.38 An overall SRT score
(0 to 10) was calculated by adding the
sitting and rising scores together.38
The participants were given 3 attempts
at the task, and their best score was
recorded. The SRT has been found to
be reliable and reproducible between
days and raters on a small sample of
men and women.39
Finally, trunk endurance was assessed
using 5 different tasks (flexion, exten-
sion, bilateral side planks, and a front
plank) (Fig. 2). Electromagnetic sensors
(Ascension Technologies, Burlington,
Vermont) were adhered to the partic-
ipants’ thorax at the T2, T6, T12, and
S1 vertebral levels, and the data were
used to calculate the amount of time (in
seconds) that each position was held.
Using the motion sensor data, the time
during which the participant held the
test position in a steady state without any
sensors moving more than 2 standard
deviations away from their original
steady-state position was deemed the
endurance time for that task.
894    Physical Therapy  Volume 98  Number 10
(B)
Trunk flexor endurance was measured
as the amount of time a participant could
hold a sit-up position with their trunk
angled at 60 degrees from the horizontal
while keeping their knees and hips
flexed to 90 degrees and with their feet
secured to the table by strapping.40
Back extensor endurance was tested
using the Biering-Sorensen position.41
The participant’s hips were aligned
with the edge of the table, and their
pelvis, hips, and knees were secured to
the table. Participants held their arms
across their chest with their hands on
opposite shoulders and were instructed
to hold their body straight and parallel
to the floor.41
Right- and left-side plank endurance
were tested by having the participant lie
on their side with their hips and knees
extended and their feet placed one on
top of the other. Participants were asked
to lift their hips off the table using their
forearm and dependent foot as points
of support. Their top arm (uninvolved
arm) was held across the chest with the
hand placed on the opposite shoulder.40
For the front plank task, the partici-
pants were asked to lie prone and to lift
their body off of the table and attempt
to keep their torso and legs in a straight
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line, using their forearms and the balls
of their feet as points of support. The
lateral flexion, flexion, and extension
trunk endurance tests have been found
to have high inter- and intrarater relia-
bility (ICC [3,1] > 0.82).42
To prevent fatigue, a 2-minute rest
was given between trials of maximum
effort trunk flexion, extension, and
rotation torque and between trials of
the 2 functional tasks, the Sit-Up Test
and the Sitting-Rising Test. A 5-minute
rest was given between endurance task
trials to limit the influence of fatigue
on the test outcomes.40
Ultrasound Imaging
The ultrasound assessment was
performed after the physical testing
had been completed, to ensure the
investigator was blinded to each
participant’s DRA status at the time of
the physical assessment, where such
knowledge may have biased testing
outcomes. The ultrasound assessment
was performed by a physical therapist
with formal postgraduate training in
musculoskeletal ultrasound imaging
(USI) and more than 100 hours of clin-
ical and research experience using USI
to evaluate the abdominal musculature.
A General Electric Voluson-i ultrasound
October 2018
 Diastasis Recti Abdominis

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Figure 2.
Scatter plot of trunk muscle endurance (in seconds) vs mean IRD (cm) recorded at rest and trunk muscle torque versus mean IRD (cm)
recorded at rest in women with DRA (red) and without DRA (black) with best fit regression. DRA = diastasis recti abdominis; IRD = interrectus
distance.

October 2018 Volume 98  Number 10  Physical Therapy    895

Diastasis Recti Abdominis
system (GE Healthcare, Mississauga,
Ontario, Canada) was used, and static
2-dimensional images were recorded in
B-Mode using a 10-Megahertz linear
transducer with a 53 mm width (Model
9L-RS). Images were captured with
the transducer centered between the
rectus abdominal heads, along the LA,
and at 3 specific spots on the ante-
rior abdominal wall: at the superior
border of the umbilicus, 3 cm above
the umbilicus, and 5 cm above the
umbilicus.43 Images of the LA were
taken at levels above the umbilicus, as
previous research has found USI meas-
urements to be reliable43,44 and valid45
at these locations and less reliable43,44
and valid45 below the umbilicus.
Three images were captured at rest at
each location with the participant in
a standardized supine position with
knees and hips flexed and arms posi-
tioned at their sides.46
Classification of DRA
IRDs were measured offline using
Image J v1.46r software (National
Institutes of Health, Bethesda, Mary-
land, USA). IRD, the linear distance
between the most posterior-medial
hypoechoic borders of each rectus
abdominis (RA) head at the end of
tidal expiration,20 was measured at
each measurement site. Because no
diagnostic cut-off for DRA exists in
the literature, we identified women
as having DRA based on norma-
tive values presented by Beer and
colleagues;47 women were deemed to
have DRA if the mean of the 3 IRD
measures at 3 cm above the umbilicus
was greater than the 90th percentile
of the normative values reported for
nulliparous women (>2.2 cm).47 For a
participant to be allocated to the DRA
cohort, they had to meet the following
criteria: (1) an IRD greater than 2.2 cm
at the site 3 cm above the umbilicus as
well as, at a minimum, at least 1 other
measurement site; and (2) the mean
IRD (calculated as an average of the
3 measures taken at each of the 3 loca-
tions) greater than 2.0 cm.
Data Analysis and Statistics
Isometric flexion, extension outcomes
were recorded as the mean of the
peak torque values determined from
the 3 trials of each task performed.
896    Physical Therapy  Volume 98  Number 10
Trunk rotation torque was recorded
as the mean from 6 trials: 3 from left
rotation and 3 from right rotation. The
mean endurance time recorded across
the 3 trials of each endurance task was
also determined.
Data analysis was completed using
SPSS version 24 (Chicago, Illinois, USA).
Data were first tested for normality
using the Shapiro-Wilks tests. All data
were normally distributed except for
trunk extension peak torque and trunk
extension endurance. Women with and
without DRA were compared using
independent-sample t  tests (normal
data), Kruskal-Wallis H tests (nonnormal
data), and chi-square (Fisher exact test;
nominal distribution), as appropriate.
Associations between mean IRD and
variables in which significant differences
were found between cohorts were
determined using Pearson product-mo-
ment correlation coefficients (normal
data), and Spearman rank correlation
coefficients (nonnormal data). In all
statistical tests, alpha was set to .05.
Role of the Funding Source
This research was supported by the
OrthoCanada Research Grant and
administered by the Physiotherapy
Foundation of Canada. The funders
played no role in the design, conduct,
or reporting of this study.
Results
Forty primiparous women (mean [SD],
31.5 [4.1] years) were recruited and
participated in this study. Complete
datasets were acquired from all 40
women. The participants’ demographic
characteristics are presented in Table 1.
Baby’s weight at birth was the only
demographic variable that was signifi-
cantly different between the 2 cohorts:
women with DRA at 1 year postpartum
had delivered heavier babies (P = .009)
than those without DRA. The DRA group
had a mean IRD of 2.5 (0.4) cm, and
the non-DRA group had a mean IRD of
1.4 (0.4) cm. IRD values are reported in
Table 2.
The results for the muscle torque and
endurance tests are summarized in
Table 3. Trunk rotation torque was the
only test that was found to be statisti-
cally different between the 2 cohorts
of women. Women with DRA demon-
strated lower trunk muscle rotation
torque when compared to women
without DRA (P = .004) (Fig. 1).
The results for the functional tests
and perceived pain are summa-
rized in Table  4. Women with DRA
achieved lower scores on the Sit-Up
Test compared to women without
DRA (P  =  .024). Self-­ reported low
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back, pelvis, and abdominal pain and
self-reported dysfunction due to low
back pain did not significantly differ
between women with and without DRA.
Yet, self-reported upper-mid back pain
approached significance (P  =  .066),
with women with DRA trending toward
reporting more pain than women
without DRA.
The correlation analyses of significant
variables revealed that IRD was
positively associated with the weight of
the baby at birth (r = 0.466, P = .002)
and that IRD was negatively associated
with trunk rotation torque (r = –0.367,
P = .02) and ability to perform a sit-up
(r = –0.514, P = .0007); larger IRDs were
associated with worse performance on
both tasks.
Discussion
To our knowledge, the present study is
the first to investigate the impact of DRA
on trunk muscle strength and endur-
ance in primiparous women at 1 year
postpartum. The women who presented
with DRA had a lower capacity to
generate trunk rotation torque than
women without DRA. Further, the
women with DRA performed worse
on the Sit-Up Test when compared to
women without DRA. Concurrently,
we found significant, moderate, and
negative correlations between IRD and
trunk rotation peak torque-generating
capacity, and between IRD and Sit-Up
Test scores.
Consistent with other recent reports,19,20
no difference in urinary tract (inconti-
nence) or vaginal symptoms (prolapse)
was found between the women with
and without DRA. Based on our ques-
tionnaire data, there appears to be a
large (39%) difference between groups
in terms of activity level; however,
this difference was not statistically
October 2018
 Diastasis Recti Abdominis

Table 1. between IRD and trunk rotation

Demographic Characteristics of Primiparous Women With (n = 18) and Without (n = 22) strength persists at the end of the first
Diastasis Recti Abdominisa postpartum year. Our findings are
similar to those reported by Liaw and
Variable DRA (n = 18) No DRA (n = 22)
colleagues,21 who found IRD to have a
Age (y) 31.9 (3.6) 31.2 (4.5)
moderate and negative correlation with
Height (cm) 165.5 (6.3) 166.1 (6.1) trunk rotation strength in women at
Weight (kg) 68.4 (14.6) 66.7 (12.5) 6 months postpartum.21 However, the
BMI (kg/m2) 25.1 (5.6) 24.1 (3.9)
methods used to assess trunk muscle
rotation strength in the present study are
Waist-to-hip ratio 0.81 (0.1) 0.79 (0.1)
significantly different from those used

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Baby’s birth weight (kg)
Delivery mode
 Vaginal
 C-section
Weeks since delivery
Currently breastfeeding
 Yes
 No
Education level
  High school diploma
  College diploma
  University bachelor’s degree
  University master’s degree or higher
Work status
  Not working
 Part-time
 Full-time
Minutes of moderate to vigorous physical activity per week
ICIQ-VS vaginal symptoms score (max = 53)
ICIQ-VS sexual matters score (max = 56)
ICIQ-FLUTS filling symptoms score (max = 15)
ICIQ-FLUTS voiding symptoms score (max = 12)
ICIQ-FLUTS incontinence symptoms score (max = 20)
aData are mean (SD) or numbers with percentages (%). Independent t test (P < .05), Kruskal-Wallis H
tests, and chi-square Fisher exact test were performed on all variables as appropriate, with significant
differences between cohorts indicated by an asterisk. BMI = body mass index; DRA = diastasis recti
abdominis; ICIQ-FLUTS = International Consultation on Incontinence Questionnaire–Female Lower
Urinary Tract Symptoms; ICIQ-VS = International Consultation on Incontinence Questionnaire–Vaginal
Symptoms; max = maximum.
significant (t  =  3.098; P  =  .154). It is
possible, and even likely, that women
who perform more physical activity
would have greater trunk strength and
endurance, and that group differences
in physical activity level may indeed
underpin findings of higher trunk
strength and endurance in the women
without DRA. To investigate whether
group differences found in trunk rota-
tion strength were attributable to
different levels of fitness between our
groups, we included physical activity
3.6 (0.4) 3.2 (0.5)* by Liaw and colleagues,21 which makes
a closer comparison between these
14 (77.8%) 17 (77.3%) 2 studies difficult. Liaw and colleagues21
used a manual muscle testing tech-
4 (22.2%) 5 (22.7%)
nique to quantify trunk strength and,
56 (4) 55 (4.5) although this measurement is used clin-
ically,21 this assessment of strength is
9 (50.0%) 9 (40.9%) subjective and imprecise. Therefore, the
approach used to measure trunk rota-
9 (50.0%) 13 (59.1%)
tion torque in the present study may
have achieved more precise results.
1 (5.6%) 1 (4.6%)
4 (22.2%) 6 (27.3%) A woman’s ability to perform a sit-up
6 (33.3%) 10 (45.5%) also appears to be impacted by whether
or not she has DRA and by the extent
7 (38.9%) 5 (22.6%)
of the IRD. A reduced capacity to
perform a sit-up has also been reported
4 (22.2%) 9 (40.9%) among women during pregnancy and
4 (22.2%) 4 (18.2%) at 8 weeks postpartum.1 Interestingly,
despite this finding, we did not find a
10 (55.6%) 9 (40.9%)
significant effect of DRA on isometric
101.3 (79.0) 151.1 (125.9) trunk flexion torque-generating capacity
6 (4) 5 (4) when measured using the IFLEXD. The
12 (15) 8 (15) IFLEXD tests trunk flexion strength in
3 (3) 2 (2)
isolation; that is, the lumbopelvis is
stabilized by the sitting position and
1 (1) 1 (1)
strapping, and thus participants did not
2 (2) 2 (2) need to use synergists to stabilize their
lumbopelvis during the task. The Sit-Up
Test likely required more stabilization
of the lumbopelvic region than what
was required to generate flexion torque
using the IFLEXD. If a larger IRD reflects
poor transfer of forces generated by the
muscles of the lateral abdominal wall
as a covariate in our ANOVA for trunk across the midline, it is possible that
rotation; this analysis confirmed that DRA would have a greater impact when
physical activity levels did not signifi- trunk flexion force requires concur-
cantly influence our results (F = 0.194, rent effort to stabilize the spine and
P = .662). pelvis (eg, a sit-up) than when trunk
flexor force is measured with minimal
Trunk Muscle Strength, influence of gravitational loading
Endurance, and Functional and with the pelvis stabilized (eg, on
the IFLEXD). This would support our
Task Performance
finding that women with larger IRDs
The results of this study build on the
performed more poorly on the Sit-Up
limited research exploring the influence
Test despite not demonstrating a signif-
of DRA on impairment and function in
icant association between trunk flexion
women and show that an a­ssociation

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Diastasis Recti Abdominis

Table 2.
Interrectus Distances (IRD) in Primiparous Women at 12 to 14 Months Postpartuma

DRAb (n = 18) Mean (SD) No DRA (n = 22) Mean (SD) P c

IRD at the superior border of the umbilicus (cm) 2.7 (0.4) 1.6 (0.5) <.001*
IRD 3 cm above the superior border of the umbilicus (cm) 2.6 (0.4) 1.4 (0.4) <.001*
IRD 5 cm above the superior border of the umbilicus (cm) 2.2 (0.6) 1.3 (0.6) <.001*
Overall average IRD (cm) 2.5 (0.4) 1.4 (0.4) <.001*
aDRA = diastasisrecti abdominis; IRD = Interrectus distance.
bWomen in the DRA cohort had: (1) an IRD greater than 2.2 cm at the site 3 cm above the umbilicus (Beer et al.)47 and at 1 other measurement site, and (2) a

mean IRD greater than 2.0 cm.

Downloaded from https://academic.oup.com/ptj/article-abstract/98/10/891/5054450 by guest on 03 June 2020

cIndependent t tests (P < . 05) were performed on all variables, with significant differences between cohorts indicated by an asterisk.

torque-generating capacity and IRD
using the IFLEXD.
Both trunk flexor endurance tasks used
in the current study were static and
required activation of the rectus abdom-
inis muscle, the lateral abdominal wall,
as well as some degree of concurrent
stabilization of the lumbopelvis. It
was somewhat surprising that we did
not detect any differences in the trunk
flexion or lateral flexion endurance task
performance between women with and
without DRA. Liaw and colleagues21
found significant negative correla-
tions between IRD and both static
(rho  =  –0.42, P  =  .020) and dynamic
(rho  =  –0.36, P  =  .049) endurance
tasks based on a curl-up position (ie,
head and scapulae lift off the plinth).
It appears that the ability to stabilize
the lumbopelvis may be particularly
impaired during the trunk curl-up
motion when the muscles of the lateral
abdominal wall must initially contract,
and less so once women approach a
full sit-up position. It also appears that
once the static position is achieved, the
endurance of the trunk muscles is not
impaired to any significant extent. As
such, the impairments seen in women
with DRA seem to be quite specific to
the position and the task. The differ-
ences in study results among recent
studies may reflect the variances in
the gravitational force vector expe-
rienced by women during the tasks.
For example, gravitational force has a
larger impact on the amount of trunk
flexion force required to move into
trunk flexion during the early phase
of a sit-up task (ie, curl-up) compared
to the later phases of the task. As such,
deficiencies in the capacity of the LA
to transmit forces generated by the
muscles of the lateral abdominal wall
may be more evident during a semi-
curl-up than during a static hold at 60
degrees of trunk flexion. The differ-
ence in the gravitational force vector
may also explain why we were able to
detect differences between women with
and without DRA using the Sit-Up Test
but not during the Sitting-Rising Test.
Future research is needed to explore
the impact of DRA on dynamic flexion,
rotation, and lateral flexion task perfor-
mance in various positions before any
firm conclusions can be drawn.
Interrectus Distance
The literature suggests that DRA is
present when IRD is greater than 2 cm
at the level of the umbilicus.48 However,
there is no known clinically meaningful
value that defines DRA based on the
IRD, or that identifies greater poten-
tial for impairment. Through using
normative cut-off values defined by
Beer and colleagues,47 the difference
in IRD between our groups (>1.1 cm)
was relatively large. This magnitude of
difference was much greater than the
minimal detectable change (MDC) for
IRD determined for repeated measure-
ments (0.29 cm to 0.31 cm) reported
by Kewshani and McLean;43 as such,
we are confident that the mean IRD
was significantly different between our
2 groups. The range of IRD values in
our sample was still low, however, and
it is imperative that future studies inves-
tigate the impact of DRA on trunk func-
tion in women with larger IRD values.
Self-Reported Pain
Researchers have hypothesized that
DRA is associated with lumbopelvic
pain,6,49–51 but this association has
not been firmly established in the
l­ iterature.9 In fact, most studies have
found no association between self-re-
ported pain and DRA.8,52 Most studies
have, however, focused on studying
women in the early postpartum period
and have focused on low back pain.8,21
The results of our study apply beyond
the postpartum year, yet still suggest
that self-reported low back, pelvis,
and abdominal pain, and self-reported
dysfunction due to low back pain, do
not differ between women with and
without DRA. Despite differences in
the approach to stratifying women, our
results are also comparable to those
recently reported by Sperstad and
colleagues,9 who found no difference
in self-reported pain between women
with and without DRA, assessed using
palpation, at 1 year postpartum.9 These
results are also in agreement with
previous studies that found no asso-
ciation between DRA and low back
or pelvic pain.8,9,52 We found a trend
toward self-reported upper-mid back
pain being higher among the women
with DRA compared to those without
DRA (P  =  .066), which may be of
interest in future work. Future research
should also explore if there is an associ-
ation between mid-back pain and trunk
rotation torque in postpartum women.
Limitations
The present study is not without limi-
tations. Because of the cross-sectional
and prospective nature of this study,
the IRDs in our DRA cohort may be
considered to be “mild” by clinical
standards.9,17 As such, the results of
this study may not be generalizable to
women who present with larger IRDs at
1 year postpartum, or to parous women
who have DRA that persists for several
years. The limited range of IRD values

898    Physical Therapy  Volume 98  Number 10 October 2018

 Diastasis Recti Abdominis

Table 3. or tasks performed with external

Difference in Trunk Torque and Endurance Between Women With and Without Diastasis Recti stabilization to the lumbopelvis. Our
Abdominisa results suggest that once a test posi-
tion is set, the static endurance of the
DRAb (n = 18) Mean No DRA (n = 22) Mean P c
(SD) (SD) trunk muscles in that position is not
impaired to a significant extent. Based
Peak flexion torque (N·m) 67.2 (22.5) 63.7 (15.1) .56
on these findings, the impairments seen
Peak extension torque (N·m) 93.7 (53.1) 86.8 (31.2) .75 in women with DRA seem to be quite
Mean trunk rotation Torque (N·m) 37.0 (3.6) 45.3 (9.8) .004* specific to the position and the stabili-
Trunk flexion (s) 193.5 (119.3) 171.7 (93.4) .52 zation demand associated with the task.
Isometric trunk strength and endur-
Trunk extension (s) 62.6 (30.9) 62.1 (45.0) .97

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ance may not be impaired in women
Front plank (s) 44.6 (26.4) 51.9 (26.7) .39
with DRA. Moving forward, we recom-
Right-side plank (s) 33.6 (20.0) 36.9 (18.3) .59 mend incorporating (1) functional, anti-
Left-side plank (s) 39.1 (21.2) 42.2 (22.2) .66 gravity tasks that challenge the stability
aDRA = diastasis
of the lumbopelvis and (2) rotational
recti abdominis.
bWomen in the DRA cohort had: (1) an interrectus distance (IRD) >2.2 cm at the site 3 cm above the challenges. In the present study, only
umbilicus (as described by Beer et al47) and at 1 other measurement site, and (2) a mean IRD >2.0 cm. primiparous women were investigated,
cIndependent t tests were performed at the significance level of .05 on all normally distributed variables

and significant differences between cohorts indicated by an asterisk. Kruskal-Wallis H tests were per-
formed at the significance level of .05 on nonnormally distributed variables.
Table 4.
Functional Test, Self-Reported Pain, and Dysfunction Scores Compared Between Women
With and Without Diastasis Recti Abdominis
DRAa (n = 18) No DRAa (n = 22) P b
Sitting to Rising Test 9.5 (8–10) 9 (8–10) .55
Sit-Up Test 2 (1–2) 3 (2–3) .02
Roland-Morris Disability Questionnaire Score 1 (1–2) 0 (0–1) .22
Worst abdominal pain in past 24 hours 0 (0–6) 0 (0–1) .35
Worst upper-mid back pain in past 24 hours 8 (0–18) 0 (0–5) .07
Worst low back pain in past 24 hours 6 (0–11) 7 (0–26) .90
Worst pelvis and hip pain in past 24 hours 0 (0–4) 0 (0–11) .44
aMedian scores with interquartile ranges. Women in the DRA cohort had: (1) an interrectus distance
(IRD) >2.2 cm at the site 3 cm above the umbilicus (as described by Beer et al47) and at 1 other
measurement site, and (2) a mean IRD >2.0 cm. DRA = diastasis recti abdominis.
bMann-Whitney U-Test was performed at the significance level of .05; bold indicates significant
differences between cohorts.
and the relatively low BMIs the women breadths (or 3 cm) could help capture
presented with in this study may have a greater range of IRDs without biasing
been the result of self-selection bias. the sample toward women with
Potential participants interested and complaints of pain or dysfunction.
willing to participate in a study looking
at trunk muscle function after preg- Second, the selection of tasks included
nancy may be more physically active in this study may have been too limited
than their peers. In the interest of inves- to capture impairments that are associ-
tigating women with larger IRDs, future ated with DRA. Because there is limited
studies should consider recruiting research that investigates the functional
multiparous women or women with limitations associated with DRA, we
long-standing DRA who seek physical decided to explore a broad range of
therapy with primary complaints of tasks. Based on our findings, it appears
DRA. Recruiting potential participants that tasks that require dynamic move-
through partnerships with local obste- ments against gravity (the sit-up task)
tricians, midwives, and family doctors may provide more meaningful infor-
who would be able to screen women mation than those tasks that require
who have IRD larger than 2.5  finger a participant to hold a static ­ position
and the women with DRA would be
considered mild (mean IRD of 2.6 cm)
by most clinical standards. It is possible
that demands on the obliques and trans-
versus abdominis muscles to provide
stability during tasks such as front
or side planks would be impaired in
women with more moderate or severe
DRA. Moving forward, we recommend
incorporating functional, antigravity
tasks that challenge trunk rotational
stability and evaluating the impact of
IRD on task performance in women
who present with larger IRDs.
Finally, researchers have theorized that
IRD may not be the best measure when
characterizing the changes that occur to
abdominal musculature after pregnancy
and that other measures that reflect the
capacity of the LA to transmit forces
generated by the muscles of the lateral
abdominal wall may be more appro-
priate.46 Based on the findings of this
study, such measures warrant develop-
ment to better assess the biomechan-
ical function of the linea alba. Future
studies should explore tasks that chal-
lenge lumbopelvic stability and involve
movement through a larger range of
trunk flexion and rotation.
Conclusion
The presence of mild DRA in primip-
arous women at 1 year postpartum
appears to be associated with trunk
rotation torque-generating capacity and
the ability to perform a sit-up. However,
these impairments do not seem to be
associated with self-­ reported pain or

October 2018 Volume 98  Number 10  Physical Therapy    899

Diastasis Recti Abdominis
dysfunction when measured using
self-report questionnaires. Future
research should continue to build on
the results of the present study by
exploring the relationship between
abdominal strength, endurance, and
pain in women (both primiparous and
multiparous) with moderate, severe, or
long-standing DRA.
Author Contributions
Concept/idea/research design: L. McLean,
N.F. Hills, R.B. Graham
Writing: N.F. Hills, R.B. Graham, L. McLean
Data collection: N.F. Hills, L. McLean
Data analysis: N.F. Hills, L. McLean
Project management: L. McLean
Fund procurement: N.F. Hills, L. McLean
Providing facilities/equipment: L. McLean,
R.B. Graham
Providing institutional liaisons: L. McLean
Consultation (including review of manu-
script before submitting): L. McLean
Ethics Approval
The study protocol was approved by the
Queen’s University Health Sciences Research
Ethics Board (REH-636–15). All volunteers
provided written informed consent before
participating.
Funding
The authors acknowledge that this
­research was supported by the OrthoCan-
ada ­Research Grant and administered by
the Physiotherapy Foundation of Canada.
L. McLean reports an operating grant and
equipment purchased through funding
provided through the Natural Sciences and
Engineering Research Council (NSERC) of
Canada.
Disclosures and Presentations
The authors completed the ICJME Form for
Disclosure of Potential Conflicts of Interest.
No conflicts of interest were reported.
An abstract of this work was presented
as a poster at the International Society for
the Study of the Lumbar Spine in Athens,
Greece, in May 2017.
DOI: 10.1093/ptj/pzy083
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