Updated: Mar 29, 2019
So many women are concerned with the appearance, and functionality, of their abdominals post pregnancy.Known as "Diastasis Recti" or a separation of the medial borders of the Rectus Abdomis muscle of over 2 CM, it can wreck havoc on our self-confidence, aesthetic perception and sometimes hit deep into the realms of postpartum depression. But, is it really necessary to try and reduce this separation? Or, should we just "mind the gap:)
In this review I'm pointing out how performing curl-up can improve this very common (and not just for women!) condition-
Article review: Immediate Effect of Active Abdominal Contraction on Inter-recti Distance
The muscular dysfunction known as “Diastasis Recti” is a widely discussed topic among medical professionals, fitness trainers and populations groups that are affected by it. Defined as the “linear distance between the medial aspects of the rectus abdominis, which spans the Linea Alba” (LA)”.[i] This condition is mostly diagnosed among porous women and prevails postpartum. It can be visible by a “bulging” midline and poses a potential risk for lower back pain, functional and cosmetic impairment and lumbo pelvic dysfunctions. To this date, there has not been support for the claim that RD is related to ventral hernias or intestines strangulation.
The word “Diastasis” actually pertains to more than the Rectus abdominis bellies separated as mentioned above; it can be a mere non-fracture separation of (a) bone- for example, of the pubic symphysis bone, a condition which occurs more with children and can be familial in nature[ii]. The occurrence of DR (Diastasis Recti) is especially prevalent among parous women and has been studied widely focusing on two factors: location and condition, or how far from the reference point of the umbilicus and by what degree the distance of the DR is. Having gone through the bearing of multiple children, I have a personal interest in this topic as I too have been diagnosed with DR right after my first pregnancy, and ever since. The article reviewed here attempts to measure the distance, or degree, of the DR at rest (supine) and during active muscle test (a curl-up exercise was used).
The debate over the diagnosis and evaluation of DR is almost as wide as the DR itself. A meta-analysis of recent literature[iii] brings up multiple studies presenting various approaches in how to diagnose, where the reference points are (mainly superior and inferior to the umbilicus) and what treatment approach is the most beneficial; for instance, strengthening the abdominal wall (“Abdominal capsule”) as a whole, rather than directing efforts on narrowing the DR has been suggested as a long-term approach in rehabilitation protocols[iv]. A widely accepted diagnostic (and therapeutic) standard is the rest vs. effort presence of DR, or placing the individual in supine resting position (passive muscle test) and consequently cueing a partial curl-up (halting spinal flexion while inferior angle of the scapula rises off the table). The article in review applied these to examine DR in cross-reference to two locations- 4.5 CM above and below the midpoint of the umbilicus. The researches hypothesized that DR will narrow at curl-up and widen at rest. Although the hypothesis itself does not necessarily suggest applying the curl-up as a treatment, or even a prevention method, it does explore the important tensile forces sustained by the abdominal wall and the pelvic floor muscles as well (Levator ani, Coccyges[v]). In the case the intra-abdominal pressure becomes greater than the ability of the abdominal wall and pelvic floor muscles can bear, few risks are associated – from reoccurrence to urinal incontinence and postural dysfunctions[vi].
The diagnosis tool used for this research was Ultrasound. The decision to use USI was made after the same researches previously compared ultrasound to calipers when measuring DR[vii], and concluded that ultrasound was more precise (caliper has also been proved reliable, however limited to measuring above the umbilicus only, due perhaps to anatomical variations occurring along the Linea alba below the umbilicus). This method has been proved reliable and is preferred when available[viii] (mostly for the superior location). Palpation and caliper, or ruler, are still widely used, likely due their availability, simplicity of use and lack of expertise that is required.
The study spanned over almost two years, with a co-ed sample size of fifty six adults. The biometric data of both genders gathered included (in metric values). At this point it should be note that gender. And age, have their own predisposition for DR; a study done on cadavers by the same researcher asserted this, using a regression analysis[ix].
· Umbilicus circumference
· Distance of DR (at the umbilicus level)
A consequential division of the group by: location (supra and infra umbilical) and parity followed. The position in which DR was measured included supine rest and partial curl-up (spinal flexion held till spine of scapula cleared the table). The correlation between the variables and the group can be viewed in the following table-
DR change from rest to contraction
Nulliparous women: Increase
Parous women: Reduction
Although each group is highly unique in its characteristics, a correlation exists between and among the groups, in the distance of DR and its changes with rest/effort.
Review of results & conclusions
The study adopted the common definition of 2 CM distance of DR and kept its overall adherence to reliable details by distinguishing between the locations (supra and infra umbilical) of RD measured; with both locations, only the parous women group presented a small, yet significant change in the measurement of DR between rest and curling up. Based on the values, researchers concluded that the curl-up does not negatively (widens the distance) affect RD. In light of the short term nature of the testing, this study has provided an initial base for a long term hypothesis of the possible benefits of incorporating curl-up exercises in rehabilitation / corrective exercise program to improve the condition of DR. The researchers do recommend a prior measurement of DR before applying curl up as a corrective tool, since it may, in fact, increase as reported above among the nulliparous women.
The obvious application would be an application of a curl-up as a tool to improve, or narrow for this respect, DR; however, recent literature challenges this approach by addressing DR through holistic, overall strengthening of the abdominal wall[x]. Since the connection between DR and functionality is still being studied, perhaps focusing on the muscular (morphological) changes occurring pre-DR can contribute to the improvement of the condition- with the definition of “improvement” tested in cardiovascular capabilities (for example. VO2 Max testing pre and postpartum) or functional exercise where the abdominals are synergists and stabilizers (single leg dead lifts).
As a personal note, from my perspective as an older, parous endurance athlete, such approach might also contribute to the psychological aspect of rehabilitation by improving self-confidence and maybe even benefit treatment protocols of postpartum depression. After reading this and other studies by the same researcher, I have reached out to her in person as I am fascinated by these efforts to define, address and improve the lives of people suffering from DR.
[i] CHIARELLO, C. M., MCAULEY, J. A., & HARTIGAN, E. H. (2016). Immediate Effect of Active Abdominal Contraction on Inter-recti Distance. Journal of Orthopaedic & Sports Physical Therapy, 46(3), 177–183.
[ii] Mathews, R., Gearhart, J., Bhatnagar, R., Sponseller, P. (2006). Staged Pelvic Closure of Extreme Pubic Diastasis in the Exstrophy-Epispadias Complex. Journal of Urology, Pediatric Urology, Vol. issue 5, P. 2196-2198
[iii] Werner, Laura A.; Dayan, Marcy (2019). Diastasis Recti Abdominis-diagnosis, Risk Factors, Effect on Musculoskeletal Function, Framework for Treatment and Implications for the Pelvic Floor
Current Women's Health Reviews, Volume 15, Number 2, 2019, pp. 86-101(16)
[iv] LEE, D., & HODGES, P. W. (2016). Behavior of the Linea Alba During a Curl-up Task in Diastasis Rectus Abdominis: An Observational Study. Journal of Orthopaedic & Sports Physical Therapy, 46(7), 580–589
[v] Biel, Andrew. (1997) Trail guide to the body :how to locate muscles, bones and more Boulder, CO : Andrew Biel, P. 300
[vii] CHIARELLO, C. M., & MACAULEY, J. A. (2013). Concurrent Validity of Calipers and Ultrasound Imaging to Measure Interrecti Distance. Journal of Orthopaedic & Sports Physical Therapy, 43(7), 495–503
[viii] Mendes, Denise de Almeida, Nahas, Fábio Xerfan, Veiga, Daniela Francescato, Mendes, Fernando Vilela, Figueiras, Ricardo Góes, Gomes, Heitor Carvalho, Ely, Pedro Bins, Novo, Neil Ferreira, & Ferreira, Lydia Masako. (2007). Ultrasonography for measuring rectus abdominis muscles diastasis. Acta Cirurgica Brasileira, 22(3), 182-186
[ix] Chiarello, Cynthia M.; Zellers, Jennifer A.; Sage-King, Francine M. (2012). Predictors of Inter-recti Distance in Cadavers. Journal of Women's Health Physical Therapy: September/December 2012 - Volume 36 - Issue 3 - p 125–130
[x] Lee D, Hodges PW. Behaviour 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.