By Mia Ramsey, PT, DPT
I really enjoy working with prenatal and postpartum women. It has become a passion of mine throughout my years of clinical practice. They are such a unique population, and they really come along with some interesting dysfunctions. I wanted to share a bit about a very common pathology in this demographic: Diastasis Recti Abdominis (DRA) and its association with pregnancy.
What is it exactly?
In technical speak, it is the separation of the linea alba fascia that connects the right and left rectus abdominis muscles. This occurs during pregnancy as the belly grows. The occurrence of DRA pre and postnatally has been reported to be as high as 60% (Sperstad, 2016). This can cause problems as the abdominal wall has important functions in posture, trunk and pelvic stability, respiration, trunk movement and support of the abdominal viscera.
Why does it happen?
Risk factors for DRA include pregnancy and the resulting hormonal changes, the increased size of the uterus, anterior pelvic tilt with or without lumbar hyperlordosis, the increased intraabdominal pressure, cesarean section, multiple pregnancies, fetal macrosomia, as well as genetically-conditioned defects in collagen structure (including congenital disproportion of the collagen III/I ratio), considerable body mass losses occurring spontaneously or after bariatric surgeries, and abdominal surgical procedures (Michalska, 2018). Mota et al (2015) and Sperstad et al (2016) reported no association between DRA and the pre-pregnancy body mass index, weight gain, a baby’s birth weight or abdominal circumference, heavy lifting, lifting and carrying children, and regular exercise.
How is it diagnosed?
The separation of the rectus abdominis can be measured with ultrasound, calipers, or most commonly in practice, finger widths. It is typically measured 4.0-4.5 cm above the umbilicus, at the umbilicus, and 4.0-4.5 cm below the umbilicus. A separation of 2.5 cm or more is considered clinically significant and may contribute to other issues such as back pain. A larger diastasis can be more challenging to manage as it is more likely to cause secondary issues such as pelvic pain or lower back pain.
How can we help?
Physical therapy treatment of DRA can be effective at not only reducing the separation, but also in reducing pain and improving function. It is certainly a preferable place to start before considering surgical options.
What about using Functional Dry Needling (FDN)?
FDN as a reset to the rectus abdominis is a great start to treating this diagnosis, in the postpartum period. I like to think of the needle as being like a reset button on an outlet. And the rectus abdominis is your hairdryer. (Come on guys, just go with it!) You push the button and all of a sudden your hairdryer works! Of course, as most clinicians who have been needling for a while know, this is only the beginning. You still need to tweak the temperature and airflow on the hairdryer to make it work just right.
A typical needling treatment for this type of diagnosis may include 2-3 needles in rectus abdominis bilaterally, and then using electrical stimulation to facilitate a motor response. It is not at all uncommon to see an arrhythmic contraction in the muscle when it has not been firing well. If this doesn’t correct within a minute or so, I will commonly leave the electrical stimulation on the indwelling needles for 5-10 minutes. I usually use a higher frequency (10-15 hz) in this case (if that is comfortable for the patient), with the goal of attaining better neuromuscular recruitment.
Other regions to assess and possibly needle for their contribution to DRA, and the fall-out from it, are the T/L junction (because of its biomechanical contribution as well as its innervation of rectus abdominis), the pelvic floor, along with the obliques, transverse abdominis and sometimes the hip flexors.
Is dry needling dangerous in these areas?
Keep in mind, it is not safe to needle the abdominals at any time during pregnancy. And it is not advisable to needle during the first trimester simply because spontaneous miscarriages most often occur during the first trimester. If treating for DRA during pregnancy, I do not needle iliacus because of its location on the medial ilium, but it is safe to needle the iliopsoas attachment through the femoral triangle. Needling multifidus can be extremely helpful with SI joint dysfunction and lower back pain during pregnancy but T/L junction and sacral multifidus should be approached cautiously due to the afferent and efferent innervation of the uterus from these regions.
Positioning when needling multifidus on a pregnant woman must be a consideration as well. This can be done with a pregnancy pillow, two “Boppy’s” (C shaped nursing pillows) positioned to make a hole for the belly with a prone patient, or possibly in a seated position on a stool with the patient leaning forward and resting her head on a treatment table. (When using alternate positions with needling, be sure to keep your 3D anatomy in mind to keep your needle angles correct.)
What about other treatment ideas?
As with most diagnoses, FDN is not a magic bullet and needs to be combined with other treatments that reinforce corrected movement patterns and strengthen what is weak/dysfunctional. When treating DRA, I often prescribe a corrective “crunch” (Neville, 2008) that manually closes the diastasis (with the patient’s own hands or a sheet, see photos), transverse abdominis exercises, as well as posterior chain strengthening. Posterior chain exercises often include a bridge (with a manual correction to the rectus abdominis), or quadruped exercises such as hip extension with a neutral spine and transverse abdominis engaged. Abdominal exercises are progressed very carefully so as not to separate the rectus abdominis further. Manual palpation is encouraged while the patient is progressing abdominal exercises to ensure the rectus abdominis is not separating.
In addition to FDN and prescriptive exercise, I find taping, using a myofascial correction in a herringbone pattern over the abdomen, is helpful biofeedback for those who tolerate that much tape on their abdomen.
Patient education focuses on postural control/ergonomics with picking up baby, nursing postures, correct breathing with exercise and lifting (not bearing down), and avoiding exercises that further separate the diastasis.
Diastasis recti abdominis can significantly impact a woman’s ability to return to her pre-pregnancy level of function, although it is something that is often undertreated. Women will frequently seek out high level “core” classes to achieve their pre-baby body and function without being aware of the damage they can do if a DRA is present. Providing these mamas with education and close monitoring of abdominal strength progression are key elements to a successful return to function.
Mia Ramsey, DPT is a physical therapist in Colorado. She is a lead instructor with KinetaCore, teaching the Level One and Level Two courses. She has found a passion for teaching dry needling and enjoys sharing her passion with colleagues all over the states and Canada. Clinically, she has a specialization in treating prenatal and postpartum women, but also enjoys seeing a variety of primarily orthopedic patients with diagnoses from TMD to ankle sprains. Mia’s Doctorate in Physical Therapy was earned from Northern Arizona University (2002). She lives in beautiful Fort Collins with her ever-patient husband, two incredible daughters and two boisterous dogs. Together they enjoy skiing, hiking and all the outdoor music they can find in the summers.
Neville, C. Physical Therapy for Pelvic Girdle Pain in Pregnancy and Postpartum. Course Rehabilitation Institute of Chicago, Sept 12-13, 2008
Sperstad, JB, et al. Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. Br J Sports Med 2016;50:1092–1096. doi:10.1136/bjsports-2016-096065
Michalska, A, et al. Diastasis recti abdominis— a review of treatment methods. Ginekologia Polska 2018, vol. 89, no. 2
Mota PG, 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(1): 200–205, doi: 10.1016/j.math.2014.09.002, indexed in Pubmed: 25282439.