I recently took a course by Diane Lee (https://learnwithdianelee.com/) that reviewed these conditions and specifically reviewed DRA and what it means for low back and pelvic health. It was a great course to help review current best practice and how physiotherapy can help you manage these conditions. Let’s review some of this information together today!
Physiotherapy can often assist you by assessing how well your abdominal wall and pelvic floor are engaging, assess and strengthen your hips, and help ensure all muscles are working well together to help you transfer loads and support ideal postural strategies.
We know that 1 in 3 will experience incontinence in the first 3 months postpartum (Rortveit & Thom, 2010), but by 12 weeks the continence mechanism should be restored. If you are still incontinent after 12 weeks, there is a 92% chance you will still be incontinent at 5 years (Viktrup et al 2000)! We need to consider what motor control strategies, postures and/or muscle weakness may be contributing to this.
Hagen & Stark (2011), state 50% of women who have a baby have some degree of pelvic organ prolapse. Whiteside (2004) shares that 50% of women who have a surgical repair will experience a recurrence. This high recurrence rate suggests that what caused the prolapse has likely not been addressed. The anatomy may have been repaired, but without training and improving the motor strategies that caused the prolapse, you are at risk for a recurrence. Physiotherapy can help with this. When you improve your motor strategies, it means your nervous system is helping your brain and muscles talk to each other to turn on and off at the most optimal times!
The deepest layer of the abdominal wall is called transversus abdominis (TrA) and it’s fascia is blended with the fascia of the pelvic floor. One of the important jobs of TrA is to assist in supporting and lifting up the organs of the pelvic floor. You need adequate help from the abdominal wall to help off-load and assist the pelvic floor. Physiotherapy can help identify what you need to train and do it in a specific, personalized way that helps improve these motor strategies.
Another common condition you may experience after having a baby is diastasis rectus abdominis (DRA). This is when there is a wider than normal separation of the connective tissue (linea alba) that connects the rectus abdominis muscles (“six-pack” muscles) in the front of your abdomen. We do not have a gold standard to define what is ‘normal’ and what should be considered a ‘wider than normal’ distance to be classified as a DRA. One study by Mota et.al. (2014), defined the separation as wider than 1.6 cm at 2 cm below the umbilicus. Another study by Beer et.al. 2009, defined normal inter-rectus distance (IRD) as 2.2cm at 3 cm above the belly button and 1.6 cm 2 cm below the belly button.
We need more research to understand what causes DRA and why some women’s separation resolves while others do not. What we do know as shared by Mota et.al. (2014) is that there is no statistical differences between women with and without DRA (>1.6cm) at 6 months postpartum in pre-pregnancy body mass index, body mass index 6 months postpartum, weight gain, baby’s birth weight, abdominal circumference and hypermobility. We currently do not know what causes this condition, but research is looking at factors related to nutrition, collagen, genetics and the amount of type I, II, III collagen a person has. When a separation occurs it is about the ability of the person’s collagen to resist the pressure over time and we need to understand this piece better!
DRA and Low Back and Pelvic Health
What is seen with all the conditions we have discussed so far is that we have a failure to regain good strategies for transferring loads through the trunk (thorax, low back and pelvis). You will often have an impairment in your myofascia, motor control strategies and abdominal wall. There is a failure of the abdominal wall to support pelvic organs, offload the pelvic floor and help to control the joints of the pelvis, low back and thorax. This is where physiotherapy can help you regain these strategies and rebuild your tolerance to withstanding and transferring loads through your trunk well.
What we do know with retraining your abdominal wall, is that every single muscle, when it contracts, widens the gap. We do not have a muscle that closes this gap. We work with you to be able to create tension in your abdominal wall muscles and fascia. When you have optimal function of your abdominal wall, you have layers of muscle that can slide on one another and transfer force well. We want your abdominal wall and pelvic floor to have adequate motor control, and the strength and endurance you need to complete all the things you do in a day (like carry babies, push a stroller, lift and twist, etc.)!
During your assessment we check and consider all these things. Can the different layers of muscle slide, can they transfer force, do they contract and relax when they should, and is there enough strength for the tasks you need to do?
The important part is that you are able to co-activate and use all the muscles when you need to – not that you need to isolate specific muscles.
DRA and Surgery
There are times when surgery may be recommended to repair a DRA. There is not clear sub-groupings of severity of DRA but clinical experience suggests surgery is recommended when:
- you cannot regain good control of the joints of thorax, low back and or pelvis with multiple functional tasks
- you have trained the motor control of deep and superficial muscles of the abdomen well, but your optimal motor control strategies to control movement of joints still allows the joints to ‘give way’, and your trunk and low back slide to left or right with tasks – this means you cannot transfer loads well
- you have trained your deep core system well, but you still cannot generate tension in the linea alba (the central area or your abdomen where the separation occurs).
During your assessment your physiotherapist will assess the following things:
- Timing (motor control), strength and endurance of abdominal wall
- Fascial compliance/stiffness and ability to transfer forces
- Management of intra-abdominal pressure
- Anatomical integrity of the area
You and your physiotherapist will create a plan of care to outline deficits, define your goals and review the treatment plan moving forward. There are often lots of gains we can make with these conditions – and if additional interventions are needed we will help make sure you are supported every step of the way.
If you have any further questions, reach out to us at email@example.com. We will be happy to help!
Diane Lee course: Diastasis Rectus Abdominis and the Implications for Low Back and Pelvic Health. What’s the Solution? Hosted by Pelvic Health Solutions. March 2022
Beer G M, Schuster A, Seifert B 2009 The normal width of the linea alba in nulliparous women. Clinical Anat. 22(6): 706-711
Hagen S, Stark D 2011 Conservative prevention and management of pelvic organ prolapse in women, Cochrane database systematic review Issue 12 CD003882
Mota P G, Pascoal A G, Carita A I, Bø K 2014 Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Man Ther 2014
Rortveit G, Subak LL, Thom DH, Creasman JM, Vittinghoff E, Van Den Eeden SK, Brown JS. Urinary incontinence, fecal incontinence and pelvic organ prolapse in a population-based, racially diverse cohort: prevalence and risk factors. Female Pelvic Med Reconstr Surg. 2010 Sep;16(5):278-83. doi: 10.1097/SPV.0b013e3181ed3e31. PMID: 22453506; PMCID: PMC4976795.
Viktrup L, Lose G 2000 Lower urinary tract symptoms 5 years after the first delivery. Int Urogynecol J Pelvic Floor Dysfunction 11(6): 336-40
Whiteside J 2004 Risk factors for prolapse recurrence after vaginal repair. Am J Obstet Gynecol 191(5): 1533-38