Diastasis recti, also known as DRAM or DRA and commonly known as abdominal separation, occurs when the two halves of the rectus abdominis muscle (the "six-pack" muscles) stretch apart. This condition is most often seen in women after pregnancy, but it can also affect men and non-pregnant women. We are going to focus on the research surrounding women because there is barely any research on men and Diastasis recti. During pregnancy, the growing uterus places pressure on the Linea alba. This is the facial tissue to which all of your abdominal muscles attach to and this can cause the linea alba to stretch and separate the rectus abdominis muscles.
Possible factors that increase your risk of Diastasis Recti are:
1. Internal oblique aponeurosis insertion absent in rectus sheath (1) This basically means that your internal oblique (one of your abdominal muscles) doesn't attach in the same way as other people's, and this could potentially mean you are more susceptible to abdominal seperation.
2. Less type 1 & type 3 collagen in the linea alba (So could potentially affect those that are hypermobile more) (2)
3. More pregnancies
4. Higher BMI (3)
5. Diabetes (3)
6. Possibly lower abdominal strength? (6)
7. An increase in intra-abdominal pressure, i.e., higher BMI, pregnancy, etc.
There is a lot of fearmongering around DRA, so here is a quick summary that may bust a few myths along the way.
Women with diastasis DO NOT have more: (4)
1. Pelvic floor dysfunction
2. Urinary or fecal incontinence
3. Pelvic organ prolapse
4. They also don’t have more pelvic or back pain
Women with Diastasis Recti can have: (5),(7)
1. More abdominal discomfort and bloating
2. Weaker abdominal muscles
3. Body image issues
4. Reduced functional movement
Did you also know?
Women with diastasis have lower vaginal pressure and less pelvic organ prolapse (POP). So maybe diastasis is a positive adaptation to reduce POP. Although this is just a hypothesis (11)
Women who exercise during pregnancy have less risk of diastasis. (12)
There is no single agreed definition for Diastasis Recti. (13)
We don’t know the normal width of the linea alba because all the studies used different measuring tools and variables. So, whilst we know it’s certainly a frequent condition, we don’t actually know its prevalence. Unfortunately, most of the studies done on DRA have used fingers to measure the distance, which is obviously inaccurate due to people having different-sized fingers. (14)
57% of women with Diastasis Recti don’t have pain, so is it a pathology? (15)
The Inter recti distance (the distance between the 2 halves of your 6 pack muscles and how diastasis recti is diagnosed depending on how many fingers you can fit in the gap...) 3cm above the umbilicus may be considered normal up to 34mm. It means that maybe it's normal and you always had this separation before pregnancy. The study referenced here called for the definition of DRA to be revised to avoid over-treatment. (16)
Contraction of the pelvic floor, transverse abdominis (Often shortened to TVA and is your deepest abdominal muscle) and the diaphragm also increase intra abdominal pressure, which puts more pressure on the linea alba, widening the Diastasis Recti. And yet exercises for these muscles are often recommended with the assumption that they narrow Diastasis Recti. I’m not saying you shouldn’t strengthen the above; instead, I'm just pointing out that doing specific exercises for diastasis may not have been having the effect you thought it might have. (17)
There’s weak evidence that pre natal abdominal strengthening reduces diastasis postpartum by 35%. (21)
There’s some low-quality evidence that TVA strengthening and curl-ups postpartum reduce diastasis. (22)
Using fingers to measure Inter recti distance
Qu: I’ve been told to avoid curl-ups and instead activate my TVA and pelvic floor (PF) to improve my diastasis and prevent it from getting worse.
1. We lack evidence to support this, so seek a second opinion from someone who knows the latest research. We can recommend a few women’s health physios.
2. The TVA actually stretches the Linea alba further apart. This is not necessarily a bad thing because the load is needed to strengthen tissue; it’s just not what many people thought they were doing when they engaged their TVA. (8)
3. Like TVA, Pelvic floor contraction also widens diastasis (9)
4. Curl-ups engage the Rectus abdominis, reducing the diastasis recti gap (the inter recti distance). This is very controversial in the Pilates industry but not in the research. (10)
5. There is not a single study that finds ab curls increase the risk of diastasis
Qu: I get a lot of doming/coning. Is this okay?
Doming is where the intra-abdominal pressure exceeds the resting tension of the linea alba. Therefore, pushing the linea alba away from the pressure creates a bulge between your abs when doing things like ab curls.
Despite the many strong opinions on doming, there is no research on it—none! So we can’t recommend much, and health professionals should avoid creating fear around doming, considering it’s based on no evidence.
Some fitness professionals may ask you to avoid hard doming, as it suggests more pressure. However, this is just a cautious preference, as there is no evidence to say soft doming is better than hard doming. We tend to base it on client preference, concerns and fitness levels. If you want to learn more about this, please get in touch.
What the research concludes:
“There is not currently a gold standard method of treating diastasis recti abdominis. However, abdominal exercises during pregnancy reduce the risk of this condition postpartum.” (26)
“There is currently very low quality scientific evidence to recommend specific exercise programs in the treatment of DRA postpartum.” (27)
“An exercise program containing curl -ups for women with DR did not worsen IRD or change the severity of pelvic floor disorders or low back, pelvic girdle or abdominal pain, but it did increase abdominal muscle strength and thickness.” (29)
Despite the above conclusions, you will find many highly complex & specific exercise programs. (28)
How to help?
Women with Diastasis recti say that they want help with body image, abdominal discomfort, bloating and functional ability, i.e., any activities they want to do. (23) They might also have weaker abdominal muscles. (24). So how can we help?
1. Studies have shown that women with more social support have a better body image (19).
At HKore, you can improve your body image by strengthening your abdominals and the whole body alongside amazing social support from our community of like-minded women who have been or are currently in similar situations.
2. Exercise reduces bloating and abdominal discomfort. (20) Anything from heading out for a walk, strength training to dancing in the kitchen can make you feel better!
3. Improving abdominal and overall strength increases your confidence and ability to do functional tasks, improving quality of life and body image (18). Research recommends aiming for 2-3 weekly strength training sessions for optimal health. Don’t worry, you won’t get bulky (if that’s something you care about), but you will reap many mental and physical rewards! Improving abdominal strength means doing the abdominal curls if you're happy to! There are no exercises that are bad for DRA unless it's obviously making it worse, which is unlikely. Seek professional help if you are unsure.
4.It’s worth remembering that exercise has not been shown to eliminate diastasis, so don’t get too bogged down in an over-complicated exercise programme. (25) If it doesn’t improve after an exercise programme and it still bothers you, then surgery is something to consider.
If you need any help or advice on managing DRA, please get in touch. Our Clinical Pilates instructors can coach you through moving fearlessly and help you manage symptoms.
References:
1. Lacking Internal oblique insertion. Cavalli, M., Aiolfi, A., Bruni, P., Manfredini, L., Lombardo, F., Bonfanti, M., . . . Campanelli, G. (2021). Prevalence and risk factors for diastasis recti abdominis: a review and proposal of a new anatomical variation. Hernia, 1 -8.
2. Women with less collagen in their connective tissue. Blotta, R. M., Costa, S. d. S., Trindade, E. N., Meurer, L., & MacielTrindade, M. R. (2018). Collagen I and III in women with diastasis recti. Clinics, 73.
3. Higher BMI and Diabetes - Cavalli, M., Aiolfi, A., Bruni, P., Manfredini, L., Lombardo, F., Bonfanti, M., . . . Campanelli, G. (2021). Prevalence and risk factors for diastasis recti abdominis: a review and proposal of a new anatomical variation. Hernia, 1- 8.
4. Women with DR do not have more: Pelvic floor dysfunction, Urinary or fecal incontinence, Pelvic organ prolapse, more pelvic or back pain.
L. F., Rejano-Campo, M., Donnelly, G. M., & VicenteCampos, V. (2020). Self-reported symptoms in women with diastasis rectus abdominis: A systematic review. Journal of Gynecology Obstetrics and Human Reproduction, 101995- 101995.
da Mota, P. G. F., Pascoal, A. G. B. A., Carita, A. I. A. D., & Bø, K. (2015). Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Manual Therapy, 1(20), 200-205.
Bø, K., Hilde, G., Tennfjord, M. K., Sperstad, J. B., & Engh, M. E. (2017). Pelvic floor muscle function, pelvic floor dysfunction and diastasis recti abdominis: Prospective cohort study. Neurourology and urodynamics, 36(3), 716-721
Aparicio, L. F., Rejano-Campo, M., Donnelly, G. M., & Vicente-Campos, V. (2020). Self-reported symptoms in women with diastasis rectus abdominis: A systematic review. Journal of Gynecology Obstetrics and Human Reproduction, 101995-101995.
Gluppe, S., Engh, M. E., & Kari, B. (2021). Women with diastasis recti abdominis might have weaker abdominal muscles and more abdominal pain, but no higher prevalence of pelvic floor disorders, low back and pelvic girdle pain than women without diastasis recti abdominis. Physiotherapy.
5. Women with DR can have more abdominal discomfort and bloating: Gluppe, S., Engh, M. E., & Kari, B. (2021). Women with diastasis recti abdominis might have weaker abdominal muscles and more abdominal pain, but no higher prevalence of pelvic floor disorders, low back and pelvic girdle pain than women without diastasis recti abdominis. Physiotherapy.
Aparicio, L. F., Rejano-Campo, M., Donnelly, G. M., & Vicente-Campos, V. (2020). Self-reported symptoms in women with diastasis rectus abdominis: A systematic review. Journal of Gynecology Obstetrics and Human Reproduction, 101995-101995.
6. Can have weaker abdominals - Gluppe, S., Engh, M. E., & Kari, B. (2021). Women with diastasis recti abdominis might have weaker abdominal muscles and more abdominal pain, but no higher prevalence of pelvic floor disorders, low back and pelvic girdle pain than women without diastasis recti abdominis. Physiotherapy.
7. Women with DR want help with body image, physical function and discomfort. Aparicio, L. F., Rejano-Campo, M., Donnelly, G. M., & VicenteCampos, V. (2020). Self-reported symptoms in women with diastasis rectus abdominis: A systematic review. Journal of Gynecology Obstetrics and Human Reproduction, 101995- 101995.
8. The TVA widens diastasis - Werner, L. A., & Dayan, M. (2019). Diastasis Recti Abdominis-diagnosis, Risk Factors, Effect on Musculoskeletal Function, Framework for Treatment and Implications for the Pelvic Floor. Current Women's Health Reviews, 15(2), 86-101.
9. Pelvic floor contraction also widens diastasis - Theodorsen, N., Strand, L., & Bø, K. (2019). Effect of pelvic floor and transversus abdominis muscle contraction on inter-rectus distance in postpartum women: a cross-sectional experimental study. Physiotherapy, 105(3), 315-320.
10. Head lifts, curl ups and diagonal curl ups decreased the inter recti distance - Theodorsen, N.-M., Moe-Nilssen, R., Bø, K., & Haukenes, I. (2023). Effect of exercise on the inter-rectus distance in pregnant women with diastasis recti abdominis: an experimental longitudinal study. Physiotherapy.
Chiarello, C. M., McAuley, J. A., & Hartigan, E. H. (2016). Immediate effect of active abdominal contraction on inter-recti distance. Journal of Orthopaedic & Sports Physical Therapy, 46(3), 177-183.
Gluppe, S. B., Engh, M. E., & Bø, K. (2020). Immediate effect of abdominal and pelvic floor muscle exercises on interrecti distance in women with diastasis recti abdominis who were parous. Physical therapy, 100(8), 1372-1383.
11. Women who have Diastasis have less POP - . Bø, K., Hilde, G., Tennfjord, M. K., Sperstad, J. B., & Engh, M. E. (2017). Pelvic floor muscle function, pelvic floor dysfunction and diastasis recti abdominis: prospective cohort study. Neurourology and urodynamics, 36(3), 716- 721
12. Women who exercise during pregnancy have less risk of diastasis - . Chiarello, C. M., Falzone, L. A., McCaslin, K. E., Patel, M. N., & Ulery, K. R. (2005). The effects of an exercise program on diastasis recti abdominis in pregnant women. Journal of Women’s Health Physical Therapy, 29(1), 11-16.
13. No single agreed definition of DR - van de Water, A., & Benjamin, D. (2016). Measurement methods to assess diastasis of the rectus abdominis muscle (DRAM): A systematic review of their measurement properties and metaanalytic reliability generalisation. Manual Therapy(21), 41- 53.
Cavalli, M., Aiolfi, A., Bruni, P., Manfredini, L., Lombardo, F., Bonfanti, M., . . . Campanelli, G. (2021). Prevalence and risk factors for diastasis recti abdominis: a review and proposal of a new anatomical variation. Hernia, 1-8.
14. The different measurement methods used - van de Water, A., & Benjamin, D. (2016). Measurement methods to assess diastasis of the rectus abdominis muscle (DRAM): A systematic review of their measurement properties and meta-analytic reliability generalisation. Manual Therapy(21), 41-53
Gluppe, S., Engh, M. E., & Bø, K. (2021). What is the evidence for abdominal and pelvic floor muscle training to treat diastasis recti abdominis postpartum? A systematic review with meta-analysis. Brazilian Journal of Physical Therapy
15. 57% pain free women have diastasis. Kaufmann, R., Reiner, C., Dietz, U., Clavien, P., Vonlanthen, R., & Käser, S. (2022). Normal width of the linea alba, prevalence, and risk factors for diastasis recti abdominis in adults, a cross-sectional study. Hernia, 26(2), 609-618.
16. IRD of 34mm considered normal - Kaufmann, R., Reiner, C., Dietz, U., Clavien, P., Vonlanthen, R., & Käser, S. (2022). Normal width of the linea alba, prevalence, and risk factors for diastasis recti abdominis in adults, a cross-sectional study. Hernia, 26(2), 609-618.
17. Theodorsen, N., Strand, L., & Bø, K. (2019). Effect of pelvic floor and transversus abdominis muscle contraction on inter-rectus distance in postpartum women: a cross-sectional experimental study. Physiotherapy, 105(3), 315-320.
Gluppe, S. B., Engh, M. E., & Bø, K. (2020). Immediate effect of abdominal and pelvic floor muscle exercises on interrecti distance in women with diastasis recti abdominis who were parous. Physical therapy, 100(8), 1372-1383.
18. Aparicio, L. F., Rejano-Campo, M., Donnelly, G. M., & Vicente-Campos, V. (2020). Self-reported Gynecology Obstetrics and Human Reproduction, 101995 symptoms in women with diastasis rectus abdominis: A systematic review. Journal of -101995
19. Izydorczyk, B., Walenista, W., Kamionka, A., Lizińczyk, S., & Ptak, M. (2021). Connections Between Perceived Social Support and the Body Image in the Group of Women With Diastasis Recti Abdominis. Frontiers in psychology, 3182.
20. Saglam, H. Y., & Orsal, O. (2020). Effect of exercise on premenstrual symptoms: A systematic review. Complementary Therapies in Medicine, 48, 102272.
21. Benjamin, D., Van de Water, A., & Peiris, C. (2014). Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy, 100(1), 1-8.
22. Gluppe, S., Engh, M. E., & Bø, K. (2021). What is the evidence for abdominal and pelvic floor muscle training to treat diastasis recti abdominis postpartum? A systematic review with meta-analysis. Brazilian Journal of Physical Therapy
Gluppe, S., Engh, M. E., & Bø, K. (2021). What is the evidence for abdominal and pelvic floor muscle training to treat diastasis recti abdominis postpartum? A systematic review with meta-analysis. Brazilian Journal of Physical Therapy.
23. Women with DR have more abdominal discomfort and bloating. And want help with. Gluppe, S., Engh, M. E., & Kari, B. (2021). Women with diastasis recti abdominis might have weaker abdominal muscles and more abdominal pain, but no higher prevalence of pelvic floor disorders, low back and pelvic girdle pain than women without diastasis recti abdominis. Physiotherapy.
Aparicio, L. F., Rejano-Campo, M., Donnelly, G. M., & Vicente-Campos, V. (2020). Self-reported symptoms in women with diastasis rectus abdominis: A systematic review. Journal of Gynecology Obstetrics and Human Reproduction, 101995-101995.
24. Women with DR might have weaker abdominal muscles. Gluppe, S., Engh, M. E., & Kari, B. (2021). Women with diastasis recti abdominis might have weaker abdominal muscles and more abdominal pain, but no higher prevalence of pelvic floor disorders, low back and pelvic girdle pain than women without diastasis recti abdominis. Physiotherapy.
25. Don’t get bogged down in an overly complicated exercise programme, they haven’t been shown to work. Dufour, S., Bernard, S., Murray-Davis, B., & Graham, N. (2019). Establishing expert-based recommendations for the conservative management of pregnancy-related diastasis rectus abdominis: a Delphi consensus study. Journal of Women’s Health Physical Therapy, 43(2), 73-81.
Mommers, E. H. H., Ponten, J. E. H., Al Omar, A. K., de Vries Reilingh, T. S., Bouvy, N. D., & Nienhuijs, S. W. (2017). The general surgeon’s perspective of rectus diastasis. A systematic review of treatment options. Surgical Endoscopy, 31(12), 4934 -4949. doi:10.1007/s00464 - 017 -5607 -9.
26. Gruszczy ńska, D., & Truszczy ńska -Baszak, A. (2018). Exercises for pregnant and postpartum women with diastasis recti abdominis – literature review. Advances in Rehabilitation, 32(3), 27 -35.
27. Gluppe, S., Engh, M. E., & Bø, K. (2021). What is the evidence for abdominal and pelvic floor muscle training to treat diastasis recti abdominis postpartum? A systematic review with meta -analysis. Brazilian Journal of Physical Therapy.
28. Gluppe, S., Engh, M. E., & Bø, K. (2021). What is the evidence for abdominal and pelvic floor muscle training to treat diastasis recti abdominis postpartum? A systematic review with meta -analysis. Brazilian Journal of Physical Therapy
29. Gluppe, S. B., Engh, M. E., & Bø, K. (2023). Curl -up exercises improve abdominal muscle strength without worsening inter -recti distance in women with diastasis recti abdominis postpartum: a randomised controlled trial. Journal of physiotherapy
30.
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