Abdominal separation, also known as DRA (diastasis rectus abdominus) is a common condition that arises in late pregnancy (affecting between 66-100% of women in the third trimester) and may persist in the postnatal period (affecting 35-65% of women). For such a common condition, there is actually very little research into what constitutes normal recovery and the best way to facilitate improvement.
This is what we do know:
What is it?
DRA is a widening of the distance between the muscle bellies of the rectus abdominus (“six pack” muscle) due to a stretching of the connective tissue known as the linea alba that connects the muscle bellies together.
Image credit: Bellies Inc, 2015.
Why does it happen?
The reasons are not exactly clear but are likely related to:
- hormonal changes in the connective tissue and abdominal muscles
- increased tension in the abdomen as the uterus expands to accommodate the growing baby
- altered angle of pull of the muscles
It is not related to:
- pre-pregnancy or postpartum body weight
- The baby’s birth weight
- Abdominal circumference
What problems can it cause?
Despite common thinking, it is not directly associated with low back pain, however it may be more common in those with pelvic girdle pain (sacroiliac joint or pubic symphysis).
Can it be prevented?
There is some evidence that exercise during pregnancy (general fitness and specific abdominal exercises) can reduce the incidence and extent of the separation postnatally. (Benjamin et al 2014).
What is a normal gap?
There is quite a variation in “normal” distance between the muscle bellies and researchers disagree as what counts as a “significant” DRA.
In women who have never been pregnant it varies from 6-20mm (around one finger width) at the level of the belly button (Beer et al., 2009).
At 6 months postpartum, one group of researchers found that the gap can be considered normal up to 28mm.
In practice, we find it is how the muscles function that is important rather than the “gap” we can measure.
Think “Bridge the Gap” rather than “Close the Gap”
Recent research suggests that it is more important to use the deeper muscles to create tension across the gap rather than close it. The aim is to create a bridge like the Harbour Bridge road rather than a wobbly suspension bridge.
- Appearance with automatic head lift
- Appearance with correct activation of the deep muscles.
Image Credit: Diane Lee, Diane Lee Physio
Will it get better by itself?
For many women it will improve by itself in the early weeks after the delivery. There is disagreement in the research as to how long it may take until there is no more improvement - 8 weeks is often quoted (Coldron et al 2008) however it seems small improvements may continue until 6 months even in women who were not following any type of exercise program.
(Liaw et al 2011; Mota et al 2018)
What can help improve the DRA?
- Support garments – traditionally a binder or Tubigrip was suggested for women with DRA greater than 4 finger widths. The idea is to bring the muscle bellies closer together, however to date there is NO good quality evidence to suggest their use facilitates recovery. There is also a range of recovery support garments available. In practice, we do find that women often report use of support garments or binders help them feel more supported especially when they have the demands of managing a household or other young children in the early weeks following delivery.
- we would suggest gradually reducing the time spent wearing such support so the body does not become reliant on them.
- Exercise – again there is very little research to dictate which exercises help reduce DRA and if there are any that may worsen it. Current physiotherapy practice is based on establishing correct activation of the deeper layers of the abdominal muscles and progression of exercises to work the muscles in a functional way.
This is best achieved by an individual assessment and prescription of suitable exercises which can be progressed as function improves. It is amazing how many different ways women can activate their abdominal muscles – some are helpful and some are not. At Total Physiotherapy we use real time ultrasound to show women how the muscles are functioning.
We would suggest women with DRA avoid exercises such as sit ups and crunches until assessed by a physiotherapist with experience in women’s health.
- Posture – improvement in posture can allow the muscles to work more effectively through the day. Your physiotherapist can assist with tips and exercises to improve posture.
How late is too late to try exercises?
Again research is scarce, however clinically we see women whose children are school aged and older who show significant improvement with the correct exercises. For more information on abdominal separation or to speak with a Women's Health Physiotherapist, call us today on 02 9907 0321 or email: [email protected].