DR gap is primarily caused due to the separation of the connective tissue that joins the anterior abdominal muscles, primarily the Rectus Abdominis muscles, along the central line of the abdomen. The anterior abdominal wall provides a supportive brace for the back muscles. Together the back and abdominal muscles work synergistically together to protect the spine and allow for pain free and functional movements.
With DR separation it is considered within normal range to have a separation of 1-2 fingers wide in gap. The depth of the DR gap should also be considered, as well as the abdominal muscle action can be felt with ease. Real Time Ultrasound (RTUS) can also be used to show images of the DR gap,.
Complications that can develop due to a DR gap
When there is a break down in this central front wall the following may occur:
Hernia– a hernia is when an organ or part of an organ such as the intestine pushes through the gap in the anterior abdominal wall. A lump is felt just below the skins surface or can actually be seen and felt on the surface both at rest and or with movements. Umbilical “belly button” hernias are very common in pregnancy and in most cases do not require any surgical repair.
Lower back pain– is a common symptom described by clients. Clients often describe: the feeling of their “back just isn’t supported or is going to “give way”. Pain with moving in and out of bed or while sleeping, or a sudden lower back pain, whenever they go to lift their baby, car seat or pram. This may occur immediately post birth or for years after giving birth.
Pelvic Floor Dysfunctions such as: Incontinence (the leakage of urine, gas or faeces) that continues more than eight weeks postpartum. Constipation, painful intercourse, or vaginal pain at rest and or this any activity. A mummy belly that looks like a 4 month pregnancy belly, even after the mother has given birth.
Digestive changes – commonly described as either constipation and or Irritable Bowel symptoms. Increase in abdominal gas or a distended abdomen for unknown reasons. Typically mums will notice a bloated belly later in the day / evening and or with any exercises. They diet, change their diet and still their belly persists months, to years after giving birth. If mums are experiencing or noticing any of the above signs or symptoms, we would encourage them to seek a trained professional diagnosis.
Useful advise to help prevent DR from occurring
During pregnancy there are a few key considerations pregnant women needs to put in place : • Always aim to breathe rhythmically and in their natural breathing pattern. To avoid breath holding or even a minor “Valsalva” manoeuvre an action similar action to straining, when constipated. This sort of action may cause a change of pressure in the internal system, forcing pressure down on the PFMs and strain on the abdominal muscles. • In any action such as lifting stuff ,aim to always breathe well and not breathe hold and or bear down! If you think you do or may breathe hold sing whistle, hum, and chat away. You can’t breathe hold and do this at the same time!! • If you feel you are going to do this the “load” is too heavy – stop! • We do not recommend doing sit ups when pregnant, as this action may cause separation of the abdominal muscles.
Treatment options; What is Real Time Ultrasound and its benefits in Physiotherapy Real Time Ultrasound (RTUS) is a fabulous medical tool that allows clinicians to obtain clear objective images of muscles and tissues of the body. It uses sound waves that bounce of water and tissues to show a picture of the organ and or muscles allowing the clinician to view the muscle, organs in real time moving actions, gathering specific objective findings. In women’s health physiotherapy, RTUS is used to view the bladder, its shape and position, and to measure pre and post voiding amounts, and bladder dysfunction and health. RTUS allows clear noninvasive viewing of the Pelvic Floor Muscles (PFMs) and other abdominal muscles both at rest and with functional movements. Imagery is obtained between the belly button and the pubic bone and through the skin. This is great, as any incorrect movement patterns can be assessed and addressed with accuracy. Clients no longer solely rely on having a vaginal internal assessment to determine how well their muscles are functioning. RTUS allows physiotherapists to accurately measure the Diastasis Rectus (DR) separation and provide clients with measurements from which a treatment plan. When is surgery an option to close the Dr gap? In cases where the DR gap is both deep and wider than 3 fingers, it may be recommended to have a Diagnostic Ultrasound conducted with a Sonographer or trained Clinician. In cases where a tear in the connective tissue, the abdominal walls or muscles is detected and is possibly likely to hinder safe actions of the muscles, surgery may be an option. DR surgical repair is widely done with General and Plastic Surgeons here in Singapore. No surgery should ever be taken “lightly” and I believe should always be the second option to conservative management, with exercise and rehabilitation being the first action taken with a trained Physiotherapist in this area. If you decide on surgery you should always aim to strengthen your deep abdominal muscles beforehand, as doing so will help support the sutures and surgery.
Article by Danielle Barratt (senior Women’s health Physiotherapist at Physio Asia)