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Diastasis Recti Rehabilitation
Introduction
Diastasis recti is an increased distance between the rectus abdominis muscles at the midline caused by weakness in the anterior abdominal wall.[1] Most experts agree that there is a weakness, thinning, and widening of the linea alba and weakness of the associated abdominal musculature. Signs and symptoms caused by diastasis recti are common patient complaints to healthcare providers in many different fields, including emergency medicine, plastic surgery, general surgery, family medicine, and obstetrics and gynecology. Patients may notice an overall feeling of instability and/or a bulge in the midline of the anterior abdominal wall, which worsens with increased abdominal pressure, such as with the movement of an abdominal crunch. Diastasis recti has been shown to contribute to urinary stress incontinence and back pain.
While diagnosis and treatment options should focus on patient perception of the bulge or other symptoms, several studies have been performed to look at normal versus widened distance between the rectus muscles. While it is accepted that the supraumbilical distance of the rectus muscles is usually higher than the infraumbilical distance, most authorities consider separation more than two centimeters to be abnormal, although less or more may be present with or without bothersome symptoms.
Diastasis recti can be confused with a ventral hernia; however, there is no fascial defect in diastasis recti. Diastasis recti is associated with conditions in which there is an increase in intraabdominal pressure, including pregnancy and obesity, as well as diseases that result in weakness of the connective tissues. The treatment of diastasis recti is somewhat controversial and ranges from conservative management with lifestyle modifications and exercises to surgical repair with mesh recommendations.[2][3]
Anatomy and Physiology
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Anatomy and Physiology
Rectus abdominis diastasis physiology directly relates to the anatomy of the abdominal wall.[4] The layers of the abdominal wall from superficial to deep are the skin, subcutaneous fat, including Scarpa's fascia, anterior rectus abdominis fascia, rectus abdominis musculature, preperitoneal fat, and then the parietal peritoneum. The midline of the superficial abdominal musculature is the linea alba which separates the rectus abdominis musculature.[5]
The rectus abdominis muscles are a pair of bilateral muscles that run along the anterior midline of the abdomen from the costal cartilages of the fifth through seventh ribs to the pubic symphysis.[6] The linea alba is an extension of the rectus abdominis fascia, which is made from the aponeuroses of the external oblique, internal oblique, and transversalis muscles. The blood supply for the anterior abdominal wall is mainly via the inferior epigastric artery, which is a branch of the external iliac artery. There are musculocutaneous perforating vessels arising from the inferior epigastric artery that supply the more superficial tissues of the abdominal wall, including the skin.[7]
There is debate about the exact pathophysiology of rectus abdominis diastasis. However, it appears to relate to the weakness of both the linea alba itself and the anterior abdominal musculature as a whole.[8][9] Diastasis can be acquired, such as with weight gain, or it can be congenital, such as in cases with a genetic basis.[10] An individual patient's anatomy can be evaluated using a simple physical exam and, if further evaluation is indicated, can be evaluated with other imaging modalities such as ultrasound, computed tomography, or magnetic resonance imaging if needed to rule out other pathologies.[11]
Indications
Patients with diastasis recti commonly present with a midline bulge with or without other symptoms. The indication for treatment of diastasis recti is based on patient perspective and complaint. These patients should be provided reassurance that there is not a true hernia or risk of complications. However, for patients who complain of bothersome symptoms and/or concerns about cosmesis, treatments should be offered and discussed, ranging from conservative management with exercises to surgery. Experts have a range of specific distances, which constitute diastasis recti. A generalization can be that a distance greater than 2 cm between the rectus abdominis muscles at the midline is considered abnormal.[8]
Some experts measure different distances along the midline - for example, superior to the level of the umbilicus, at the level of the umbilicus, and inferior to the level of the umbilicus. Typically, there is a larger distance between the muscles superior to the umbilicus compared to inferior to the umbilicus, even in patients without diastasis recti. Overall, it may be recommended to focus on the patient's perspective of bothersome symptoms versus exact distances. These measurements can, however, be used to help monitor progress during and after treatment. To reiterate, treatment success is typically determined by patient satisfaction and improvement of symptoms rather than by a specific decrease in the distance.[1][4]
Contraindications
A fascial defect causing a ventral or umbilical hernia must be excluded in patients complaining of diastasis recti symptoms. Sometimes, a fascial defect can be ruled out by a physical exam alone. However, clinicians may choose to perform imaging of the abdomen to definitively rule out hernia if there is any question in the diagnosis. A hernia would have a different set of risks and a different treatment regimen than diastasis recti alone. It should be noted that diastasis recti and hernias can occur concurrently. It is important to identify patients with true abdominal wall hernias as they are at risk for bowel obstruction, ischemia, incarceration, and strangulation.[12]
The overall health of each patient and the risks and benefits of each treatment and/or procedure should be discussed and individualized for each scenario. As surgical treatment of diastasis recti is typically considered an elective procedure, the patient's overall health should be optimized before the procedure.[13]
Equipment
Surgical treatments for rectus abdominis diastasis are performed in an operating suite with appropriate surgical instrumentation for the planned procedure. Special equipment is not typically required for surgical treatment of RAD.[1]
Technique or Treatment
While rectus abdominis diastasis can spontaneously resolve, mostly in infants, which is typically congenital rather than acquired, it often persists and may warrant further treatment options for patients.[14][15][11] While the optimal treatment of diastasis recti has not been determined, most sources recommend conservative management with lifestyle modifications, weight loss, and physiotherapy as the first-line treatment for bothersome diastasis recti. There are many different exercise treatment regimens and physical therapy programs targeted for the treatment of diastasis recti. Studies show that physiotherapy may be more helpful for functional improvement than cosmetic improvement. There are several exercise treatment programs geared towards the prevention of diastasis recti during pregnancy, as well as improvement in symptoms postpartum.[16][17] These programs may also be combined with exercises for pelvic floor strengthening for prevention and/or treatment of urinary incontinence.
If a patient fails conservative treatment, surgery can be considered. There is literature available discussing different surgical treatment approaches for diastasis, including rectus plication to reconstruct the linea alba and restore the anatomy, modified hernia repair techniques, and combined hernia repair and plication techniques.[18][19] Some procedures can be performed open, often combined with another procedure such as abdominoplasty or hernia repair, laparoscopically, or robotically, and with or without mesh.[20]
Laparoscopy should only be performed if the patient has not had a prior hernia or laparotomy and does not desire an abdominoplasty. There is a study to support decreased risk of complications with laparoscopic repair compared to open repair.[21] With an abdominoplasty, extra skin and subcutaneous fat can be removed at the same time as a rectus abdominis diastasis is repaired.[22][23][24][25] Plication alone can be considered for mild or moderate diastasis recti. However, the exact definition is controversial. Most surgeons appear to use a permanent or slowly absorbable suture for these techniques.[26]
Many sources also recommend considering surgery if there is a concomitant ventral or umbilical hernia that requires surgical treatment or if the patient is having difficulties with the function of the abdominal wall.[27] Most sources do not recommend surgical intervention for diastasis recti if future pregnancy is anticipated. Diastasis recti repair procedures are sometimes combined with abdominoplasty in cases where patients have both diastasis recti and laxity of the skin of the abdominal wall.[2][3][16]
Complications
Complications from physiotherapy and other conservative treatments for diastasis recti are rare; however, patients may complete treatment regimens and be dissatisfied with the results obtained.[28] Complications from surgical repairs for diastasis recti include lack of satisfaction in surgical repair or improvement in appearance or symptoms, recurrence of diastasis, hematoma, especially of the rectus sheath, wound complications, infection, damage to surrounding structures, scarring from the incision, and mesh-related complications if a mesh is used.[29][21][30] If a ventral or umbilical hernia is mistaken for diastasis recti, serious complications can occur, including bowel obstruction and/or strangulation within the hernia.[31]
Clinical Significance
Patients with diastasis recti may present with concerns about underlying hernia or other pathology. Some patients may be satisfied with reassurance that there are no risks of complications with untreated diastasis recti. Other patients may desire intervention, and clinicians need to explain the treatment options. As far as long-term or systemic considerations for patients with diastasis recti, the aneurysmal disease has been associated with diastasis recti, most likely due to a linked cause of the weakness of the tissues. However, at this time, there are no guidelines indicating additional screening for abdominal aortic aneurysms or other aneurysms in patients with diastasis recti.[32][33]
Enhancing Healthcare Team Outcomes
Abdominal diastasis recti and the treatment options for management are relevant topics for obstetricians, gynecologists, nurse midwives, general surgeons, family practitioners, physical therapists, and many other healthcare team members. Recognizing abdominal diastasis recti is important in order to prevent unnecessary interventions or alarms and provide evidence-based treatment options to patients with symptoms of diastasis recti. Over the course of evaluation and treatment, the patient may benefit from care and insight from many different healthcare team members.
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