Diastasis Rectus Abdominis: How to use an evidence-informed approach when the evidence is still evolving

What is Diastasis rectus abdominis?

Diastasis rectus abdominis (DRA), sometimes referred to as a separation of the rectus abdominal muscles, a thinning and widening of the linea alba, or simply “mummy tummy,” is a common condition among postpartum people.

Despite being tremendously common (over half of people who have just given birth have DRA), existing research does not offer healthcare professionals a clear, uncontested management plan for the condition. Interestingly, research has shown that even with limited evidence to inform treatment of DRA, many physiotherapists report good success rates when managing the condition (Keeler et al, 2012).

How do we ensure we are adopting an evidence-informed approach to managing DRA when the evidence is slim and sometimes contradictory?

Dr. Sinéad Dufour tackles this problem head-on in her online course Pregnancy-Related Diastasis Rectus Abdominis: Bridging the Gap

We invite you to check out this online course provided by Sinead Dufour and the Canadian Physiotherapy Association by following the link below: 

Learn more with the Canadian Physiotherapy Association

In her course, Dr. Sinéad Dufour provides a rich description of DRA, including what we know, and what we don’t, about this prevalent condition. She skillfully guides us through a critical appraisal of some of the existing research and provides tangible recommendations for clinicians working with patients with DRA. She illustrates how going back to our basic treatment principles, combined with critically appraising the existing research, can provide us with evidence-informed guidance for the management of patients with DRA.

Here are some suggestions from the course to help guide your treatment of patients with DRA:

Focus on the right structures

Historically, DRA was described as an increased inter-recti distance (IRD), and it is this distance that is the predominant outcome measure in most studies on DRA. Over the years, however, many clinicians have become increasingly interested in the tissue of the linea alba itself and not only the IRD (Dufour et al, 2019). Monitoring the integrity of the linea alba is an important part of managing DRA.

Consider how the tissue responds to load, and don’t forget to progress!

We need to consider what loads are appropriate for the condition of the tissue that we are rehabilitating, by paying attention to how the tissue reacts to various loads. Keeping this principle in mind, we can move away from generic lists of exercises that must be avoided or must be prescribed for DRA, tailoring our recommendations instead to the unique condition of each patients' linea alba. Individualizing treatment includes remembering to progress exercises for patients who are showing improvement. This means that although traditionally, unsupported exercises that cause abdominal bracing have been discouraged, in someone who is managing well (i.e. not demonstrating doming or invagination at the linea alba), these exercises could be great ways of appropriately increasing load on the tissue to ensure full rehabilitation.

Keep in mind the various factors that affect the linea alba

While we don’t know all the factors involved in DRA, which could include endocrine and immune involvement, we know there are multiple aspects we can influence that have an effect on DRA. Optimizing any of the following can be a productive first step toward improving a DRA:

• The patient’s posture, breathing, and thoracic mobility – establishing appropriate length-tension relationships
• How the patient manages intra-abdominal pressure during lifting and ADLs
• General lifestyle management, and specifically the patient’s level of physical activity.
  
  

Finally, remember that we are managing a person with DRA, not just a diastasis

A patient can perform all the right exercises, but if they aren’t sleeping or eating nutritiously, they aren’t going to be achieving optimal rehabilitation. Keeping in mind the patient’s lifestyle and individual goals is key to ensuring their rehabilitation program is targeted and meaningful to them.

3 Reasons to Sign up for Dr. Sinead Dufour's online course

• Reason 1: Learn current up to date perspectives regarding pregnancy-related DRA
• Reason 2: Enhance your confidence working with women in the perinatal care period.
• Reason 3: Gain some related clinical pearls regarding caring for women pre and post-natally.

Upon completion of this online course participants will be able to:

• Discuss the epidemiology of diastasis rectus abdominis (DRA) throughout the different phases of pregnancy and the relationship between linea alba (LA) and other structures forming the abdominal manometric system such as the pelvic floor muscles (PFM).
• Identify scientific updates on evidence (both evidence-based and practice-based inquiry) pertaining to the management of pregnancy-related DRA, including points of congruence and incongruence and review considerations related to appraising different forms of scientific evidence and literature.
• Provide current evidence-informed and integrative conservative care principles for pregnancy-related DRA from a primary health care perspective, with an emphasis on the roles of physiotherapists.    

Diastasis Rectus Abdominis is just one example of a condition in which the current evidence is limited and at times contradictory. As we strive to best serve our patients through evidence-informed practice, finding areas where the evidence is slim gives us an opportunity to combine our basic guiding principles with a critical appraisal of existing research to develop a solid management approach. Here’s to bridging that gap!

Click Here for the Full Online Course

About The Instructor

Sinead Dufour PT, PhD

Dr. Sinéad Dufour is Assistant Clinical Professor in the Faculty of Health Science at McMaster University. She teaches and conducts research in both the Schools of Medicine and Rehabilitation Science. She completed her MScPT at McMaster University (2003), her PhD in Health and Rehabilitation Science at Western (2011), and returned to McMaster to complete a post-doctoral fellowship (2013). Her current research interests include: conservative approaches to manage pelvic floor dysfunction, pregnancy-related pelvic-girdle pain, and interprofessional collaborative practice models of service provision to enhance pelvic health. Sinéad stays currently clinically through her work as the Director of Pelvic Health Services at The World of my Baby (the WOMB) in Milton, Ontario.

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Blog Writer: Linnea Thacker, MScPT Student