Diastasis recti

Diastasis recti
Diastasis recti in an infant
Classification and external resources
Specialty	Pediatrics
ICD-10	M62.0
ICD-9-CM	728.84
MedlinePlus	001602

Diastasis recti (also known as abdominal separation) is commonly defined as a gap of roughly 2.7 cm or greater between the two sides of the rectus abdominis muscle.^[1] This condition has no associated morbidity or mortality.^[2]

The distance between the right and left rectus abdominis muscles is created by the stretching of the linea alba, a connective collagen sheath created by the aponeurosis insertions of the transverse abdominis, internal oblique, and external oblique.^[3]

Diastasis of this muscle occurs principally in two populations: newborns and pregnant women. It is also known to occur in men.

• In the newborn, the rectus abdominis is not fully developed and may not be sealed together at midline. Diastasis recti is more common in premature and black newborns.
• In pregnant or postpartum women, the condition is caused by the stretching of the rectus abdominis by the growing uterus. It is more common in multiparous women due to repeated episodes of stretching. When the defect occurs during pregnancy, the uterus can sometimes be seen bulging through the abdominal wall beneath the skin.
• Women are more susceptible to develop diastasis recti when over the age of 35, high birth weight of child, multiple birth pregnancy, and multiple pregnancies. Additional causes can be attributed to excessive abdominal exercises after the first trimester of pregnancy.^[4]

Presentation

A diastasis recti may appear as a ridge running down the midline of the abdomen, anywhere from the xiphoid process to the umbilicus. It becomes more prominent with straining and may disappear when the abdominal muscles are relaxed. The medial borders of the right and left halves of the muscle may be palpated during contraction of the rectus abdominis.^[5] The condition can be diagnosed by physical exam, and must be differentiated from an epigastric hernia or incisional hernia, if the patient has had abdominal surgery.^[2] Hernias may be ruled out using ultrasound.

In infants, they typically result from a minor defect of the linea alba between the rectus abdominis muscles. This allows tissue from inside the abdomen to herniate anteriorly. On infants, this may manifest as an apparent 'bubble' under the skin of the belly between the umbilicus and xiphisternum (bottom of the breastbone).

Examination is performed with the subject lying on their back, knees bent at 90° with feet flat, head slightly lifted placing chin on chest. With muscles tense, examiners then place fingers in the ridge that is presented. Measurement of the width of separation is determined by the number of fingertips that can fit within the space between the left and right rectus abdominis muscles. Separation consisting of a width of 2 fingertips (approximately 1 1/2 centimeters) or more is the determining factor for diagnosing diastasis recti.^[6]

Treatment

No treatment is necessary for women while they are still pregnant. In children, complications include development of an umbilical or ventral hernia, which is rare and can be corrected with surgery.^[7]

Alerting a medical professional is important when an infant displays signs of vomiting, redness or pain in the abdominal area.

Typically the separation of the abdominal muscles will lessen within the first 8 weeks after childbirth, however the connective tissue remains stretched for many postpartum women. The weakening of the abdominal muscles and the reduced force transmission from the stretched linea alba may also make it difficult to lift objects, and cause lower back pain. Additional complications can manifest in weakened pelvic alignment and altered posture.^[6]

Physiotherapy

A Systematic Review of the evidence found that exercise may or may not reduce the size of the gap in pregnant or postpartum women. The authors looked at 8 studies totaling 336 women and concluded, “Due to the low number and quality of included articles, there is insufficient evidence to recommend that exercise may help to prevent or reduce DRAM.”^[1]

Exercises

Nevertheless, the following exercises are often recommended to help build abdominal strength, which may or may not help reduce the size of diastasis recti^[8]

• Core contraction - In a seated position, place both hands on abdominal muscles. Take small controlled breaths. Slowly contract the abdominal muscles, pulling them straight back towards the spine. Hold the contraction for 30 seconds, while maintaining the controlled breathing. Complete 10 repetitions.^[8]
• Seated squeeze - Again in a seated position, place one hand above the belly button, and the other below the belly button. With controlled breaths, with a mid-way starting point, pull the abdominals back toward the spine, hold for 2 seconds and return to the mid-way point. Complete 100 repetitions.^[8]
• Head lift - In a lying down position, knees bent at 90° angle, feet flat, slowly lift the head, chin toward your chest, (concentrate on isolation of the abdominals to prevent hip-flexors from being engaged),^[6] slowly contract abdominals toward floor, hold for two seconds, lower head to starting position for 2 seconds. Complete 10 repetitions.^[8]
• Upright push-up - A standup pushup against the wall, with feet together arms-length away from wall, place hands flat against the wall, contract abdominal muscles toward spine, lean body towards wall, with elbows bent downward close to body, pull abdominal muscles in further, with controlled breathing. Release muscles as you push back to starting position. Complete 20 repetitions.^[8]
• Squat against the wall - Also known as a seated squat, stand with back against the wall, feet out in front of body, slowly lower body to a seated position so knees are bent at a 90° angle, contracting abs toward spine as you raise body back to standing position. Optionally, this exercise can also be done using an exercise ball placed against the wall and your lower back. Complete 20 Repetitions.^[8]
• Squat with squeeze - A variation to the "Squat against the wall" is to place a small resistance ball between the knees, and squeeze the ball as you lower your body to the seated position. Complete 20 repetitions.^[8]

It is also noted that incorrect exercises, including crunches can actually increase the distasis recti separation. All corrective exercises should be in the form of pulling in of the abdominal muscles rather than a pushing of them outwards. Consultation of a professional physiotherapist is recommended for correct exercise routines.^[8]

In addition to the above exercises, the Touro College study concluded the "quadruped" position yielded the most effective results.^[6] A quadruped position is defined as "a human whose body weight is supported by both arms as well as both legs".^[9] In this position, the subject would start with a flat back, then slowly tilt the head down, and arch the back, contracting the abdominal muscles towards the spine, holding this position for 5 seconds, then releasing back to starting position. Complete 2 sets of 10 repetitions.^[6]

Surgical

In extreme cases, diastasis recti is corrected during the cosmetic surgery procedure known as an abdominoplasty by creating a plication or folding of the linea alba and suturing together. This creates a tighter abdominal wall.

In adult females, a laparoscopic Venetian blind technique can be used for plication of the recti.^[10]

References

1. Benjamin, D.R.; Van de Water, A.T.M; Peiris, C.L. (March 2014). "Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review". Physiotherapy 100 (1): 1–8. doi:10.1016/j.physio.2013.08.005. PMID 24268942.
2. Norton, Jeffrey A. (2003). Essential practice of surgery: basic science and clinical evidence. Berlin: Springer. p. 350. ISBN 0-387-95510-0.
3. Brauman, Daniel (November 2008). "Diastasis Recti: Clinical Anatomy". Plastic and Reconstructive Surgery 122 (5): 1564–1569. doi:10.1097/prs.0b013e3181882493.
4. Harms, M.D., Roger W. "Why do abdominal muscles sometimes separate during pregnancy?". Why do abdominal muscles sometimes separate during pregnancy?.
5. University of Pennsylvania Health System Encyclopedia: Diastasis Recti
6. Engelhardt, Laura (1988). "Comparison of two abdominal exercises on the reduction of the diastasis recti abdominis of postpartum women". ProQuest Dissertations and Theses. UMI Dissertations Publishing. Retrieved 10 June 2013.
7. MedlinePlus Medical Encyclopedia: Diastasis Recti
8. Liao, Sharon (February 2012). "15 minutes and you're done: crunch-free abs". Real Simple (Time Inc.) 13 (2). ISSN 1528-1701.
9. Saunders (2007). "Definition of quadruped". Dorland's Medical Dictionary for Health Consumers. Elsevier, Inc. Retrieved 11 June 2013.
10. Laparoscopic repair of diastasis recti using the 'Venetian blinds' technique of plication with prosthetic reinforcement: a retrospective study Authors:C Palanivelu, M Rangarajan, P Jategaonkar, V Amar, K Gokul, B Srikanth; HERNIA June 2009