PT Blog • September, 2018
Engage your core. – Every physical therapist [to every patient. Ever.]
Engage your core. Engage your core. If you have ever graced the hallowed halls of your neighborhood physical therapy clinic, you have undoubtedly heard those immortal words, as if on a repeating loop – endlessly, mind-numbingly reverberating into infinity. Core is more. Another iteration of the ever-present rehab instruction, morphing slowly into more and more of a hypnotic life-motto with each passing breath. You begin to feel encouraged – nay, empowered – to not only overcome your current physical pain and dysfunction, but to defeat all of life’s problems one core contraction at a time. You are, only momentarily, distracted by one recurring thought: What in the world is my core? How do I “engage” it? My core is so big, there can’t possibly be MORE to it.” The above anecdote is obviously hyperbole; it is meant to illustrate the ubiquity and enigmatic cloud surrounding “the core” and core training. One specific diagnosis that is commonly overlooked and misunderstood will be the focus of today’s post: Diastasis Recti Abdominus.
What is Diastasis Recti Abdominus (DRA)?
DRA is medically defined as
“a separation of the medial edge of the rectus abdominus muscle bellies in the midline of the abdomen at the linea alba.” 1
Diastasis means “separation” and recti refers to the “rectus abdominus” (superficial abdominal muscle). The condition can affect newborn babies, men who participate in extreme dieting plans or poorly programmed weightlifting protocols, but most commonly, DRA is seen in pregnant and/or post-partum females. On average, 2/3 of all pregnant females develop DRA at some point during or after pregnancy, with the highest prevalence (60.0%) occurring at 6 weeks post-partum.2 The following characteristics were once considered risk factors for developing the condition, but no connection has been established in the literature: age, height, mean weight before pregnancy, weight gain during pregnancy, baby’s birth weight, and level of abdominal/pelvic floor training.
How is it diagnosed?
The main clinically relevant examination finding is the presence on palpation of an ‘abnormal’ inter-rectus distance (IRD). Normative data for the width of the linea alba is inconclusive, but work done by Beer and colleagues suggests that “in nulliparous women (women who have not given birth), the normal width of the linea alba should be <1.5 cm at the xiphoid level, <2.2 cm at 3 cm above the umbilicus, and <1.6 cm at 2 cm below the umbilicus.3 Other symptoms that could be present: low back or pelvic pain, abdominal muscle weakness, and dyspareunia.
What interventions / management strategies can help?
The physical therapy literature is scant with high-quality, randomized control trials for the treatment of diastasis recti abdominus; however, some evidence (low-to-moderate quality) does exist for several interventional strategies to reduce DRA and the associated pain and dysfunction:
- Patient Education: Patients should be instructed to avoid exercises /activity that strain the pelvic floor and increase intra-abdominal pressure.
These include rolling to the get out of bed – not “crunching” to get out or “reverse crunching” to get in; avoiding lifting older children or heavy objects; wearing an abdominal brace or belly band to avoid increased abdominal distention and promote proprioceptive feedback and muscular awareness; avoid high-intensity workouts / exercises, especially in the first 8 weeks post-partum.
- Core training: These include kegel exercises, breathing exercises, and progressive core exercises. Postural awareness activities are also indicated to avoid excessive anterior core loading and muscle imbalances. Manual therapy, including soft tissue mobilizations and relaxation techniques may be indicated prior to initiating a core-training program.4,5 Diastasis recti abdominus is a common diagnosis, especially in the post-partum population, affecting numerous individuals each year. Although the research is disparaging with regards to prevalence, risk factors, and evidence-based interventions, the patients affected can attest to its destruction and their care should be not be curtailed due to “holes in the literature.” It is the hope of this post that some light can be cast on this disorder and that as a profession, we can “close the gap” once and for all.
Contributing Author Credit: W. Evan Stringfellow, PT, DPT, CSCS, Cert. DN
Edited by: Ashley Theobald, DPT
- Sperstad JB et al. Diastasis recti abdominus during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain.” Br J Sports Med. 2016;50:1092-1096.
- Beer GM, Schuster A, Seifert B et al. The normal width of the linea alba in nulliparous women. Clinical anatomy. 2009 Sep 1;22(6):706-711.
- Walton LM, Costa A, LaVanture D, McIlrath S and Stebbins B. The effects of a 6 week dynamic core stability plank exercise program compared to a traditional supine core stability strengthening program on diastasis recti abdominus closure, pain, oswestry disability index (ODI) and pelvic floor disability index scores (PFDI). Phys Ther Rehabil. 2016; 3:3. http://dx.doi.org/10.7243/2055-2386-3-3
- Acharry N, Kutty RK. Abdominal exercise with bracing, a therapeutic efficacy in reducing diastasis-recti among postpartal females. Int J Physiother Res. 2015;3(2):999-1005.