Diastasis Rectus – Navigating the Ins & Outs: Part 2 – The Causes

This blog was adapted from its original post on https://drlaurenkeller.com by the author.

Now that we know what Diastasis rectus abdominis (DRA) is, we can look at the causes of DRA. It’s important to note that there is not one cause of DRA, so there is not one solution to fix it either. However, knowing the causes may help lower the incidences.
1. Hormones
According to Rett, “During pregnancy, hormonal changes caused by relaxin, progesterone and estrogen combined with uterine growth may cause stretching of the abdominal muscles (3), affecting mainly the rectus abdominis muscles.”
What does this mean to you and me? Well, in part one we learned that 100% of women have a diastasis in the third trimester and this highlights that it is NOT 100% avoidable. In fact, the hormones that our body naturally produces during pregnancy, labor, and postpartum naturally lead to increased stretching.
2. Posture
Rett also stated that “during pregnancy, it is common to have anterior pelvic tilt with or without lumbar hyperlordosis (3,12,5,13). These postural changes can affect the insertion angle of pelvic and abdominal muscles, influencing postural biomechanics.”
Basically, as a woman’s belly grows in order to make room for baby, so does her posture. It’s common for women to go into anterior pelvic tilt. Anterior pelvic tilt is best described as a basin or cup in your pelvis that during pregnancy rocks forward. Just as your cup will lose water with increased tipping, your body naturally loses its stability and support with this movement. Furthermore, due to the increased muscle stretch, the abdominal muscles may actually decrease in contractile strength.
3. Non-ideal development in childhood / Insufficient postural function of the diaphragm
Did you know that every baby is born with a diastasis? It naturally closes starting around 4.5 months when optimal childhood development includes a synergistic contraction of the diaphragm, abdominal muscles and pelvic floor muscles and the oblique chains start to be utilized (14,15). This includes the integration of the diaphragm to act as both a respiratory and postural muscle. “According to Kolar, intra-abdominal pressure (IAP) regulation & the integrated spinal stabilizing system (ISSS) can be disrupted by insufficient postural function of the diaphragm” (16,17).
If, during normal childhood development, we don’t develop adequate diaphragm activity, our body will compensate with faulty movement patterns, including rib flare or elevation of the ribs. This can cause excessive use of low back muscles and is often seen with “inadequate lateral rib cage expansion or resistance of the abdominal wall against IAP changes” (15). This means as we inhale our body is not able to maintain appropriate intra-abdominal pressure and this is often seen in chest breathing or when someone only belly breaths and does not breathe into all aspects of their abdomen. You see, IAP is not inherently bad. In fact, in order to breathe you MUST create IAP. Therefore, it is not IAP that makes a diastasis worse, it is the body’s inability to appropriately manage changes in IAP that can cause or worsen DRA. Intra-abdominal pressure is best managed when we develop the synergistic contraction of the diaphragm, abdominal muscles, and pelvic floor muscles.Note: For more information on the causes of dysfunctional breathing, check out Dysfunctional Breathing: The Whys (https://drlaurenkeller.com/dysfunctional-breathing-whys/) . For more information on IAP, check out For the love of all things good, stop sucking in. (https://drlaurenkeller.com/for-the-love-of-all-things-good-stop-sucking-in/)
4. Multiple Pregnancies, Twins & Age
It is believed that women who have given birth (whether vaginally or cesarean), are more likely to have a DRA. Furthermore, there is increased DRA below the umbilicus in women who have given birth multiple times.5 While there are limited studies, the one study we do have indicates that there is a higher prevalence of DRA among women over the age of 50. The reason for this is due to cumulative mechanical stress on the connective tissue of the abdominal wall, the linea alba.
5. Not exercising
In a study released in 2005 by Chiarello, et al, it was observed that “90% of non-exercising pregnant women exhibited DRA while only 12.5% of exercising women had the condition.” Furthermore, the study showed that the DRA was more severe in all three locations of testing in the women that did not exercise (18).
6. Ineffective Exercise
Not all exercises are created equal.
Ineffective exercise can be exercises that are done wrong or exercises that are less than ideal for pregnancy. As always, each person is unique but general exercises that are ineffective include:
  • Sit-ups, crunches and curls (including oblique sit-ups and sit-ups on exercise balls, incline sit-ups, roll ups)
    Reverse crunches
    Triangle pose

    Like most movements, this can be a great exercise but it needs to be done correctly. Specifically, we don’t want to arch the low back during this movement or collapse on the sides. If you think of the set up for functional progression 2, it is important to maintain neutral spine in order to effectively perform this exercise; it is equally important for triangle pose.

    V-ups & V-sits
    Double leg raises
    Bicycle legs
    Planks
    Hanging knee raises
    Pilates exercise “The Hundred” or “roll up”
    ANY movement that creates abdominal wall bulging, coning or tenting.

Stay tuned for part 3 of this blog series!

Dr. Lauren Keller, DC, DABCA


BIRTHFIT Chicago: Western Suburbs
IG: @birthfit_chicago_western_burbs
FB: @birthfitchicago
Website: https://chicagowestern.birthfit.com
References:
Mota P, Pascoal AG, Carita AI, et al. Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Man Ther 2015;20:200–5.
Reliability of the inter-rectus distance measured by palpation. Comparison of palpation and ultrasound measurements. Mota, Patrícia et al. Manual Therapy , Volume 18 , Issue 4 , 294 – 298
Corrêa MC, Corrêa MD. Puerpério. In: Corrêa MD, editor. Noções práticas de obstetrícia. 12ª ed. Rio de Janeiro: Medisi; 1999. p. 95-104.
Gilleard WL, Brown JM. Structure and function of the abdominal muscles in primigravid subjects during pregnancy and the immediate postbirth period. Phys Ther. 1996;76(7):750-62.
Spitznagle TM, Leong FC, Van Dillen LR. Prevalence of diastasis recti abdominis in a urogynecological patient population. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18(3):321-8.
Rett, MT, Braga, MD, Bernardes, NO, & Andrade, SC. (2009). Prevalence of diastasis of the rectus abdominis muscles immediately postpartum: comparison between primiparae and multiparae. Brazilian Journal of Physical Therapy, 13(4), 275-280. Epub August 21, 2009.https://dx.doi.org/10.1590/S1413-35552009005000037
Sperstad JB, et al. Br J Sports Med 2016;0:1–6. doi:10.1136/bjsports-2016-096065
Boissonnault JS, Kotarinos KR. Diastasis recti I. In: Wilder E. ed. Obstetric andgynecologic physical therapy. New York: Churchill Livingstone, 1988:63–81.
Boissonnault JS, Blaschak MJ. Incidence of diastasis recti abdominis during the childbearing year. Phys Ther 1988;68:1082–6.
Rath, A.M., Attali, P., Dumas, J.L., et al., 1996. The abdominal linea alba: an anatomo-radiologic and biomechanical study. Surgical Radiologic Anatomy 18, 281–288.
Coldron, Y., Stokes, M.J., Newham, D.J., Cook, K., 2007. Postpartum characteristics of rectus abdominis on ultrasound imaging. Manual Therapy. Epub.
Whiteford B, Polden M. Seu Corpo antes e depois do parto. In: Whiteford B, Polden M, editores. Exercícios pós-natais: Um programa de seis meses para a boa forma da mãe e do bebê. São Paulo: Maltese-Norma; 1992. p. 10-23.
Artal R, O’Toole M, White S. Guidelines of the American College of Obstetricians and Gynecologists for exercise during pregnancy and the postpartum period. Br J Sports Med. 2003;37(1):6-12
Sapsford R. Rehabilitation of pelvic floor muscles utilizing trunk stabilization. Man Ther. 2004;9(1):3-12.
Frank C, Kobesova A, Kolar P. DYNAMIC NEUROMUSCULAR STABILIZATION & SPORTS REHABILITATION. International Journal of Sports Physical Therapy. 2013;8(1):62-73.
KolarP,SulcJ,KynclM,SandaJ,CakrtO,AndelR, Kumagai K, Kobesova A. Postural function of the diaphragm in persons with and without chronic low back pain. J Orthop Sports Phys Ther. 2012;42(4):352-62.
Kolar P, Sulc J, Kyncl M, et al. Stabilizing function of the diaphragm: dynamic MRI and synchronized spirometric assessment. J Appl Physiol. 2010;109:1064-1071.
Chiarello, Cynthia & A. Falzone, Laura & E. McCaslin, Kristin & N. Patel, Mita & R. Ulery, Kristen. (2005). The Effects of an Exercise Program on Diastasis Recti Abdominis in Pregnant Women. Journal of Women’s Health Physical Therapy. 29. 11–16. 10.1097/01274882-200529010-00003.
*Disclaimer:
The information by Dr. Lauren Keller of Elemental Chiropractic, Inc. and BIRTHFIT is provided for general information only and should in no way be considered as a substitute for medical advice or information about any particular condition. While every effort has been made to ensure that the information is accurate, Dr. Lauren Keller nor Elemental Chiropractic, Inc. and BIRTHFIT make no warranties or representations as to its accuracy and accept no responsibility and cannot guarantee the consequences if individuals choose to rely upon these contents as their sole source of information about a condition and its rehabilitation. If you have any specific questions about any medical matter or think you may be suffering from any medical conditions, you should consult your doctor or other professional healthcare provider. You should never delay seeking medical advice, disregard medical advice, or discontinue medical treatment because of information on this website.

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