Rachel Kilgore, DPT, OCS, COMT, PRPC, PPCES graduated from Central Washington University with a Bachelor of Science (BS) in exercise science and a minor in nutrition in 2004 and completed her Doctor of Physical Therapy (DPT) at the University of Washington in 2007. Rachel practices in Seattle at Flow Rehab in the Freemont Neighborhood with Holly Tanner and focuses her patient care on orthopedics, female athletes, and women’s health conditions for bladder & bowel dysfunctions, pelvic, pain, pregnancy, and post-partum issues.
I have always been very particular about the precision of words. I have been known to ruminate about the origin, evolution, and application of words. As my husband always kindly says, I am an overthinker. This leads me to our nomenclature analysis for today, Diastasis.
When teaching pregnancy and post-partum courses we always have healthy discussions about Diastasis Rectus Abdominus (DRA) as this is an important topic in the peripartum world. One question that always comes up is what is the difference between a hernia and DRA? If DRA is not a condition you deal with often in the clinic, it can be a bit confusing. According to the Merriam-Webster Dictionary diastasis means “an abnormal separation of parts normally joined together,” so DRA is often defined as a separation of the Rectus Abdominus muscles. I think the word separation is what causes the confusion. This word may lead some people to think there is an actual disruption of the abdominal tissue which is not the case. The rectus abdominus halves remain joined together by the linea alba. The linea alba is the tendinous raphe formed by interdigitating fascia of external/internal obliques and Transversus Abdominis. A DRA is an increase in the distance between the right and left Rectus Abdominus halves. If you stretch connective tissues (increase the distance between two ends), they may become thinner, lengthened, or weakened. A DRA is an increased distance between the right and left Rectus Abdominus halves that may result in lengthened, thinner, weaker tissue. In contrast, a hernia is an actual defect in the connective tissue. DRA and hernias are not the same thing; however, they can exist together.
Let’s contrast these two conditions. Hernias can occur anywhere in the abdominal wall, whereas DRA is only at the midline. Hernia can strangulate intestines, but DRA does not as there is no hole or defect in the connective tissues. The only way to truly diagnose a hernia is by ultrasound. The only definitive treatment of a hernia involves surgery with closure of the hole, sometimes supported by mesh. Patients may elect to not have surgery if the hernia is small, is not painful, or if other conditions make surgery too risky. For diastasis, treatment rarely involves surgery. Hernias are disrupted fascia. Diastasis is lengthened, thinning, or weakened fascia.
Diastasis Rectus Abdominus occurs commonly towards the end of pregnancy, with 66-100% of women having DRA by the end of the third trimester (Boissonnault & Blaschak, 1988; Mota et al, 2015). Mota et al. 2018 measured the distance between the two rectus halves in 84 primiparous women in the third trimester 2 cm below the umbilicus and found the average to be 49-79 mm. In contrast, a study of 150 nulliparous women (Beer et al.) showed the inter recti distance at that same point (2 cm below umbilicus) to be 16mm. However, DRA is not exclusive to the pregnant or postpartum person, they can exist in children and men as well.
Another example of the word diastasis, where separation does not mean disruption, is with pubic symphysis diastasis. The words may be confusing. When a patient hears the word diastasis and is told it means separation, they may conclude they have a disrupted pubic joint. I think the definition of it from Stolarczyk et al. is much more descriptive and less likely to cause angst in a patient. “A pubic symphysis diastasis (PSD, diastasis symphysis pubis) is defined as excessive widening of the system of anatomical structures that make up the pubic symphysis (above the physiological norm of 10 mm), occurring during pregnancy or postpartum.”
This is another instance where the word separation may imply disruption when it just means increased distance.
Let’s return our thoughts to the title of this blog. I hope we are thinking about how the words we choose make our patients feel. Many of our patients receive a diagnosis and turn to the internet, where they may find confusing and even scary descriptions of their condition. If you were told that your abdominals had separated, doesn’t that sound scary? Would you feel nervous that your organs may fall out from your separated abdominals? I would have so many questions and fears! How will they get back together, what activities should I refrain from, can I even move? Wouldn’t the term separated make you feel scared to do anything? Think about the term separated shoulder, we hear it all the time in sports, we know it is a torn AC joint. There is an actual disruption of tissue, but DRA is not. As health care providers it is important that we use safe and encouraging words with our patients. Our role should be to educate them on their condition and make sure they understand the anatomy, physiology, and functional implications. We need to empower. The more a patient knows about their condition, the better choices they make regarding activity and lifestyle. Words are powerful.
References:
- Boissonnault, J. S., & Blaschak, M. J. (1988). Incidence of diastasis recti abdominis during the childbearing year. Physical Therapy, 68(7), 1082-1086.
- Mota, P., Pascoal, A. G., Carita, A. I., & Bø, K. (2018). Normal width of the inter-recti distance in pregnant and postpartum primiparous women. Musculoskeletal Science and Practice, 35, 34-37.
- Beer, G. M., Schuster, A., Seifert, B., Manestar, M., Mihic‐Probst, D., & Weber, S. A. (2009). The normal width of the linea alba in nulliparous women. Clinical anatomy, 22(6), 706-711.
- Stolarczyk, A., Stępiński, P., Sasinowski, Ł., Czarnocki, T., Dębiński, M., & Maciąg, B. (2021). Peripartum Pubic Symphysis Diastasis—Practical Guidelines. Journal of clinical medicine, 10(11), 2443.