Can we talk about diastasis research?

Dear Diastasis Community-Can we talk about diastasis research? 

Recently, I returned to school to pursue my DPT (a clinical doctorate in physical therapy). My middle schooler and high schooler have assured me that it can’t possibly be as hard as what they are studying, so I am not allowed any whining. Which sucks because Pharmacology is officially kicking my butt.  Though I am not here to whine, I am here to share the eye opening results of a recent assignment. I was asked to develop a question one might ask within my area of interest and develop a variety of online scientific research search strategies to locate relevant articles. I chose to look at the diastasis research.

My question: How effective are exercise programs for diastasis recti recovery?

No matter how I manipulated the search strategies I came up with only about 17-18 diastasis research articles with quite a bit of overlap between searches. Of those, only about 8-10 articles actually addressed the question in one way or another. The not as relevant articles that kept popping up included a few on the surgical procedures for diastasis. One I reviewed actually noted:

“..there was insufficient evidence to recommend exercise or physiotherapy

programs as a means of preventing or treating rectus diastasis.”¹

Say What?

Before we get our knickers in a twist about their bias towards surgery over exercise based programs, the reality is that statement is accurate. In a systematic review by Benjamin et al (2014) published in a very pro-therapeutic exercise journal called Physiotherapy, they parsed the available literature down to 8 studies.  They indicated it was hard to draw conclusions from them because of the low quality of the studies, and the differences in measurement tools, what they measured, the specificity of the exercise program, etc. So much so their conclusion was:

 “Due to the poor quality of the current literature, current evidence suggests that non-specific exercise may or may not help to prevent or reduce DRAM during the ante- and postnatal periods.”²

Wow. “May or may not” is not a huge vote of confidence.

Now for those of us who have been at this for a while, this isn’t actually surprising. I mean the language is a little in your face when they put it that way, but we know that these kinds of needs are under-represented in the literature. In working toward my doctorate and heading in a new direction, I hope to be a female researcher asking questions about and for females to help fill some of those huge blind spots in the literature. However, we are a long way off.

Wait, What?

But here is the truly eye-opening part, that reveals a different kind of blind spot. Just for funsies, I googled diastasis AND exercise. I got over 950,000 results.

via GIPHY

That should stop you in your tracks. Helping women recover from pregnancy is now a big business, and loads of folks are jumping on the bandwagon. I am not here to point fingers or cast doubt. But that number is so out of proportion with the amount of research we have. It is staggering and a bit disconcerting actually.

I have written about misrepresentations of research before (100% of Women Have Diastasis?.…please read beyond the abstract folks) and concepts that have become urban legend and perpetuated by gurus and newbies alike ( Can We Talk About Planks? they are NOT a no-no for everyone, no matter who tells you that they are. To Brace or Not to Brace….they are NOT a yes-yes for everyone, no matter who tells you that they are. Don’t Make Me Come In There….just don’t). Please take care before you post, folks (or make an online course/product). Consider a full read of the literature (it won’t take long…it’s just 8 articles) before you tell folks how YOU recovered or how you taught your wife or a couple of friends to recover from diastasis as a blueprint for everyone else’s recovery. That’s not how this works.

Now What?

In my search there was a ray of sunshine. Recent diastasis research and clinical momentum is moving us away from measurements of the gap between the sides of the abdomen (the inter-recti distance-IRD) and towards an understanding of the role of the fascia that binds the two sides together (called the Linea Alba-LA) as our metric for successful rehab³. The ability to create tension again over the fascia helps the sides of the abdomen communicate with one another to coordinate their ability to control the trunk and pelvis during function and fitness. This return of tension can also help reduce the IRD, but the gap doesn’t always return to baseline measures. Our focus clinically now is to recreate coordinated function in the abdominal wall (through integrated relationships with Diaphragm and Pelvic Floor), tension in the fascia, and integrated control of the center in function and fitness as measures of success. The key is how well your abdomen is functioning as a part of the whole picture versus just how wide is your gap (More on that here).

But we don’t have much diastasis research into the function of the abdominal wall with DRA within activities to help us build better programs. Until now! Cue the sunshine!! In a study by Hills et al (2018) they looked at abdominal wall function for women with and without DRA one year after their first delivery⁴. They used the standards set by Beer et al to set their line in the sand for who had a “diastasis” and who did not⁵. Women with a gap larger than 2.2 cm at two measurement points (immediately above the navel and one other point) were considered positive for DRA. The mean values for those with DRA ranged around 2.2-2.7 cm, while the non-DRA group had gaps in the range of 1.3-1.6 cm. These are not big DRAs, nor a big difference between groups, in fact both groups fall into the range found by Beer et al that exists in women that have never had children. Nonetheless they did find a significant difference in the ability of the women with DRA to generate trunk rotational torque and to perform a sit-up test.

I see rotational deficits for a strong majority of my postpartum female athletes (and those that have never had kids), so this result didn’t surprise me. However, one caveat, the non-DRA group spent 39% more time on weekly exercise than the DRA group, but the types of exercises they did weren’t specified. The authors did some statistical analysis on this time-spent-exercising variable and noted that, though there was a big difference, it didn’t impact their result statistically. However, I’d like to know more about the exercise activities the non-DRA group did to determine if it prepared them better for the rotational testing or sit ups. If everyone tested were runners, and the non-DRA group just ran for a longer time than the other group each week, then I get how that wouldn’t impact the result. But if part of what they did in their exercising was a lot of sit ups, or rotational work for 39% more time, they would have scored better on the tests.

This doesn’t necessarily negate the result. Answering that question would help us understand better what the results mean and how to apply them. Understanding what type of activity that the women in the non-DRA group engaged in will help us know if it threw off the result. OR to put a positive spin, would it show us the way towards the type of exercises that improve both DRA measures AND the function of the abdominal wall?  At the end of the day they had better FUNCTION. If we believe that exercise is part of creating that, don’t you want to know what they were doing? 

Lots to chew on, but a ray of sunshine nonetheless. Thank you Hills et al!  We are starting to ask the right types of diastasis research questions, that is the key. The deeper we dig the closer we get to understanding how best to build programs!

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1. Nahabedian, Maurice. “Management Strategies for Diastasis Recti.” Seminars in Plastic Surgery, vol. 32, no. 03, 2018, pp. 147–154., doi:10.1055/s-0038-1661380.
2. Effects of Exercise on Diastasis of the Rectus Abdominis Muscle in the Antenatal and Postnatal Periods: a Systematic Review.” Physiotherapy, vol. 100, no. 1, 2014, pp. 1–8., doi:10.1016/j.physio.2013.08.005
3. Lee D, Hodges PW. Behavior of the Linea Alba During a Curl-up Task in Diastasis Rectus Abdominis: An Observational Study. J Orthop Sports Phys Ther. 2016; 46(7):580-9.
4. Hills, Nicole F, et al. “Comparison of Trunk Muscle Function Between Women With and Without Diastasis Recti Abdominis at 1 Year Postpartum.” Physical Therapy, vol. 98, no. 10, 2018, pp. 891–901., doi:10.1093/ptj/pzy083.
5. Beer, Gertrude M., et al. “The Normal Width of the Linea Alba in Nulliparous Women.” Clinical Anatomy, vol. 22, no. 6, 2009, pp. 706–711., doi:10.1002/ca.20836