The Abdominal Wall & Diastasis Rectus Abdominis

The abdominal muscles play a key role in the function of the trunk as well as the upper and lower extremity. Pregnancy and delivery can have a significant, and often long lasting, impact on both the appearance of the abdomen (form) and function of the whole body. Women with stretched/widened recti and linea alba (collectively called a diastasis rectus abdominis, DRA or DRAM) often ask whether treatment/exercise will help them or should they consider a surgical repair. Currently there are no guidelines, other than dissatisfaction with the results of training of any kind, to know which individuals with DRA are appropriate for surgery. Who to treat/train and who to refer for surgery were the initial questions in 2007 that prompted further study. At that time, it was still believed that ‘closing the gap’ between the recti was a prerequisite for improving both form and function of the abdomen.

The study published in 2016 (Lee & Hodges 2016) answered some, but not all of these questions.

We discovered that distortion of the linea alba (noted by either doming or sagging of the linea alba and measured clinically by finger depth) was more relevant than the gap, or inter-recti distance (IRD). Some women had a very large IRD: however there was minimal distortion of the linea alba and they were quite functional. Others had a smaller IRD and substantial distortion of the linea alba and were quite disabled. At this point in time, there isn’t an IRD number that suggests an individual cannot regain function without training.

Our 2016 study confirmed that TrA recruitment widens the IRD in most, but not all, women with DRA, and reduces distortion of the linea alba (mid-line doming or sagging) during loading tasks. We hypothesized that this reduction of distortion, regardless of the impact on the IRD, would facilitate improvement in both form and function of the abdominal wall. Other studies have also shown that transversus abdominis (TrA) recruitment widens the gap between the recti (increases the IRD) (Mota Pascoal Carita Bø, K 2015, Pascoal Dionisio Cordeiro Mota 2014, Sancho Pascoal Mota Bø 2015,). Some suggest that exercises specifically targeting TrA should not be recommended for women with DRA, with the belief that all training should result in ‘closure of the gap’. We (Lee & Hodges) disagree with this suggestion and feel that the focus of training should be on minimizing distortion of the linea alba, regardless of the impact of the training on the width of the IRD, such that forces can be transferred across the midline during trunk rotation tasks.

Unfortunately, “Tension of the linea alba during all exercises for all women with DRA” was the message received by some clinicians from our 2016 study. Why unfortunately? Because some have interpreted our paper to mean that any exercise which causes mid-line doming of the linea alba in a woman with DRA should be stopped. Our study did not make such a statement. When, and for whom, is mid-line doming of the LA allowed and when, and for whom, is it not? The answer is not simple; however, guidelines for exercise progressions for those with mild (2.2cm – 4cm IRD and minimal distortion), moderate (4.5cm – 7.5cm and significant distortion) and severe (>8cm and significant distortion) DRA have been updated in this edition to address this confusion. Research is ongoing, and in time, we hope that many more questions will be answered. Failure to achieve the desired form and/or function after considerable training is still the only guideline we have for referral for surgery. For now, it’s time to update the clinical guide (available on Amazon) with what we believe to be true based on the evidence, and clinical experience.

This approximately 4 hour course accompanies the e-book and includes 7 lectures of varying lengths.