Managing Diastasis Recti
Diastasis recti abdominis (DRA) is a common clinical condition that affects the anterior abdominal walls. A characteristic of DRA is weakened linea alba that leads to an abdominal lump . Linea alba is weakened by intra-abdominal changes and pressure such as pregnancy (from the associated hormonal changes, enlargement of the uterus, and orientation of the frontal pelvis), abdominal surgery, several pregnancies, fetal macrosomia, genetic-linked flaws in collagen structure, and obesity (Michalska et al., 2018; Akram & Matzen, 2014). Nahabedian (2018), associates DRA with a negative body image, rheumatological pain, and urogynecological issues, making the condition noteworthy.
Although diastasis recti abdominis is mostly identified among women following pregnancy, DRA can be found in both genders, at any given age (2018). Risk factors for DRA among men include aging, weight fluxes, weight-lifting, complete sit-ups, and genetically weak abdominal muscles. In males, diastasis recti abdominis (DRA) primarily appear above the umbilicus while in females, it is positioned at the umbilicus level. In females, however, the abdominal lump can spread and cover the supraumbilical and infra umbilical areas, especially during postpartum (Michalska et al., 2018). As a self-diagnosed sufferer of DRA, the writer did some research on management/treatment strategies for diastasis recti; the current article outlines a number of strategies that can be used after consulting with a primary care provider.
There are several management strategies for diastasis recti abdominis. The most common include physiotherapy, prolotherapy, use of abdominal supporting contraptions, and the more progressive surgical corrections such as abdominoplasty, plication of the linea alba and anterior rectus, and Laparoscopic/Endoscopic surgery (Nahabedian, 2018; Michalska et al., 2018; Mota et al., 2015). The choice of strategy to use for DRA depends on the symptoms and physical results. Some patients have severe impairments that are aggravated by physical movement and constriction of the rectus abdominis muscles. According to Bellido Luque et al. (2015), DRA is sometimes accompanied by an umbilical hernia. When this occurs, the rectification of the umbilical hernia can only endure after correcting the DRA.
Physiotherapy
According to Jessen et al. (2019), physiotherapy involves conventional interventions such as physical and aerobic exercises and postural training. It is the primary recommended treatment for diastasis recti. Physiotherapy is both a preventive and corrective measure. Preventive exercise technique comprises strengthening the core abdominal muscles while corrective exercises include core strengthening, aerobic exercise, and neuromuscular retraining (Nahabedian, 2018). Although physiotherapy has been considered to potentially rectify diastasis recti, there is no generally determined protocol formulated for the process.
The commonly used physiotherapy procedures for the treatment of diastasis recti include abdominal exercises aimed at strengthening transversus abdominis muscles or rectus abdominis muscles. Postural, mobility, and functional training/education to strengthen transversus abdominis muscles is another option. Some people find improvement in condition following exercise programs that reinforce rectus abdominis muscles. Myofascial and soft tissue therapy, abdominal stimulation, and use of bandages and corsets have been used with varying degrees of efficacy (Michalska et al., 2018). According to Gitta et al. (2016), strengthening of the pelvic floor, the gluteus maximus, and the outer and deep back muscles should also be stressed.
Individuals with diastasis recti abdominis are taught how to properly sit, stand, get up, lift, and lactate. According to Gitta et al. (2016), physiotherapy should strictly observe the principle of progressive overload by using a recumbent exercising position and coordinating actions with breathing. To stimulate the transverse abdominis, the patients should inhale, and pull in their abdominal wall towards their spine as they exhale. Rectification of the abdominal lump can be achieved after three months of therapeutic interventions. Physiotherapy also relieves the effects of diastasis recti such as low back pain (Gitta et al., 2016). Additionally, neuromuscular electrical stimulation combined with physiotherapy (Nahabedian, 2018), has proved beneficial to some individuals.
Abdominal supporting contraptions
Abdominal support belts, binders, adaptable canular bandages/girdles, and corsets are used in diastasis recti management. The support contraptions can potentially reduce abdominal circumference, strain abdominal muscles, and ligaments, lessen low back pain, and offer support in diastasis recti(Mota et al., 2015). Patwardhan et al. (2021) notes that a combined intervention of abdominal contraptions and physiotherapy designed to strengthen the core muscles not only reduces abdominal circumference but also the inter-recti distance.
Prolotherapy
Prolotherapy involves controlled injections of an irritant solution into the rectus abdominis muscle. “Dextrose, phenol-glycerol-glucose (P2G), and combinations of polidocanol, manganese, zinc, human growth hormone, pumice, ozone, glycerin, or phenol” is one such solution (Michalska et al., 2018). According to Strauchman and Morningstar (2016), prolotherapy aims at stimulating tissue regeneration factors and moderating central and low back pain. The treatment has the potential to reduce the inter-recti distance from 2.7 centimeters to 0.5 centimeters after seven prolotherapy sessions administered within 14 weeks (Strauchman & Morningstar, 2016). Prolotherapy may be a preferable option for recurring diastasis recti and umbilical hernias.
Surgical intervention
Surgical interventions are often used when the efficacy of physiotherapy and prolotherapy in the management of diastasis recti abdominis is absent. These include abdominoplasty (commonly called tummy tuck), plication of the linea alba and anterior rectus, and endoscopic and laparoscopic surgery. Surgical interventions involve abdominal incisions and the use of retro-muscular mesh and/or absorbable or non-absorbable suture materials. Because surgical repairs are controversial, they should be considered when the inter-recti distance is more than three centimeters (Michalska et al. 2018). The decision to use surgical procedures should also be dependent on protrusion evaluation instead of diastasis.
The commonly used option among individuals with mild to severe diastasis recti abdominis is abdominoplasty. This surgical intervention aims to further recover the abdominal curve, especially where DRA is a result of pregnancy (Nahabedian, 2018). Abdominoplasty involves an incision to the anterior rectus sheath and detachment of adipose-cutaneous tissues to “preserve the loose areolar layer.” The incision can be protracted alongside the frontal iliac apexes to expose the linea alba and rectus muscles (Jessen et al., 2019). The repair also encompasses mild stretching of the patient’s hip, removal of excess skin, and reduction of rectus abdominis muscles (Michalska et al., 2018). After the operative process, tamper-proof pressure drains are occasionally used and the incision is closed with absorbable intradermal suture material.
Another surgical intervention utilized is the plication of the linea alba and anterior rectus. Plication is considered in minor to moderate diastasis recti. The procedure involves demarcation of the weakened linea alba after which a single or a double layer plication of the absorbable or non-absorbable suture is applied (Nahabedian, 2018). Plication can be performed with or without a supportive mesh. The use of a mesh depends on the absence or presence of a hernia. A triangular suture to integrate the adjacent fascia edges and the midline of the posterior rectus sheath is often used. In situations where the anterior rectus sheath displays substantial laxity, then a lateral plication is done on both sides to accelerate recovery and constrict the abdominal curve. According to Nahabedian (2018), this twofold lateral plication is accomplished with an absorbable intermittent suture and a successive continuous suture for extra support.
Laparoscopic/endoscopic surgery is a minimally invasive way of correcting diastasis recti. Laparoscopic surgery can be performed when DRA co-occur with an umbilical hernia. The procedure can also be used to rectify diastasis recti exclusively. According to Jessen et al. (2019), laparoscopic surgery is highly effective even in the clinically complex individual with both diastasis recti and hernia. Laparoscopic surgery focuses on anterior abdominal wall strengthening. For patients who have previously undergone a plication of the linea alba and anterior rectus sheath, Nahabedian (2018) suggests the placement of an intraperitoneal mesh rather than an on-lay mesh during a laparoscopic procedure.
Endoscopy is considered when the individual has never undergone laparotomy or hernia repair before and has a midline or umbilical hernia longer than two centimeters. The procedure generally involves inserting a trocar into the supra-aponeurotic zone and divulging the linea alba and the anterior rectus sheath (Nahabedian, 2018). This allows for the plication of the sheath and site strengthening with an artificial mesh. Non-absorbable suture drains and soft supportive bandages are often used in the process.
Surgical treatments for diastasis recti generally have low relapse and complication rates. According to Jessen et al. (2019), surgical interventions have substantially demonstrated efficacy in the repair of abdominal rectus, and umbilical hernia and impeding low back pain. The complexity of diastasis recti, when it co-occurs with umbilical hernia, has resulted in the development of supplementary procedures for surgical corrections. These include endoscopic mini or less open sub-lay repair and laparoscopic intracorporeal rectus apo-neuroplasty (Gómez-Menchero et al., 2018; Schwarz et al., 2017). These new surgical developments show potential in the management of diastasis recti. However, the literature on the efficacy of the two surgical practices is currently limited.
Takeaway Message
The choice of management strategy for diastasis recti abdominis depends on the severity of the diastasis recti, size of inter-recti distance, weakness of the anterior abdominal wall, co-existence of DRA with an umbilical hernia, and previous abdominal surgeries. The various management options have demonstrated efficacy in correcting diastasis recti at the individual level. Generally, physiotherapy, especially regular exercises, substantially reduce the risk and severity of diastasis recti. Physiotherapy is even more effective when combined with the use of abdominal supporting contraptions. And although prolotherapy may be the preferred option for recurring diastasis recti and umbilical hernias, surgical interventions have proved to be more effective for moderate to severe cases.
