Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain

Mota PGF, Pascoal AGBA, Carita AIAD, Bø K. Manual Therapy 2015; 20, 200-205
Pelvic Distance Journal Club November 2015

Trisha Jenkyns PT, DPT, WCS

Study Objective/Purpose

The aim of this study was to investigate the prevalence of DRA at gestational week 35 and three time-points postpartum, possible risk factors, and the relationship between DRA and lumbo-pelvic pain. 

Brief Background: Authors note that there are no high quality clinical studies to support theories about DRA causing long term sequelae  like lumbo-pelvic pain and abnormal posture

Study Design: Longitudinal observational study following first time pregnant women from gestational week 35 till 6 months postpartum.

Target Population 

Participants: Various professionals in the community referred women attending prenatal courses in the Lisbon, Portugal area to the study 

·   Inclusion criteria: Primaparas, had to agree to participate in 4 testing sessions

·   Exclusion criteria: Any conditions affecting the ability to perform ADL, any symptoms that required medical attention (i.e., high-risk pregnancy, delivery before gestational week 37, previous spinal or abdominal surgery, and neuromuscular diseases) and if any of the 4 testing sessions were missed

123 women agreed to participate in this study, and 84 completed all 4 testing sessions

women agreed to participate in this study, and 84 completed all 4 testing sessions

Methods

Instrumentation & Procedures

US images were recorded with 12-MHz linear transducer. Physical therapist performed all measurements.  PT had 10 years experience, special US training, 3 years of experience assessing IRD and was blinded to the identification of women and to previous IRD measurements.

·         Definition & cut-off value for DRA was determined by Beer et al. (2009) which was an IRD >16 mm at 2 cm below the umbilicus. 

o   US measurements of 150 healthy nulliparous, age 20-45, BMI <30kg span="">

·         The IRD was measured at 4 time points: Gestational weeks 35-41, 6-8 weeks postpartum, 12-14 weeks postpartum, 24 -26 weeks postpartum

·         Possible risk factors related to DRA that were Identified were based on former published studies and included: Age, BMI before preg, BMI at 6 months preg, weight gain during preg, Baby birth weight, height, abdominal circumference in late preg (2 cm below umbilicus), hypermobility (positive = or > 4 out of 9 on Beighton Scale), vaginal birth, regular exercise training (> or = 3X week) before preg, during preg & 6 months postpartum

Joint Mobility tests for the The Beighton score is calculated as follows:

1. One point if while standing forward bending you can place palms on the ground with legs straight
2. One point for each elbow that bends backwards
3. One point for each knee that bends backwards
4. One point for each thumb that touches the forearm when bent backwards
5. One point for each little finger that bends backwards beyond 90 degrees

The scoring system has an ICC of 0.75 for intra-observer and 0.78 for inter-observer reliability

Low back pain: defined as localized pain in the L2-L5 area with and without radiation to the lower limb.

Pelvic girdle pain: defined as pain located at the sacroiliac joints, unilaterally or bilaterally and at the pubic symphysis

Pain was defined as moderate or severe (0,1,2) and needed to be in at least one location.  Location of pain was established by having the subjects point to the painful body area, then it was classified into 5 categories:

1)      Localized low back pain

2)      Low back pain with radiation

3)      Pain in the pubic symphysis

4)      Unilateral sacroiliac joint pain

5)      Bilateral sacroiliac joint pain

Statistical Analysis: “Independent sample t-test and binary logistic regression was used to assess differences and risk factors in women with and without DRA and women with and without lumbo-pelvic pain. P < 0.05 was considered statistically significant.” Mota et al.

Results

Table 1: There were no statistically significant differences between groups in terms of possible risk factors (stated above) and background variables

·   84 of 123 concluded the longitudinal study

o   22 women excluded before 1st measurement: 11 because of preg complications

o   Mean age was 32.1 years (range 25-37)

o   81% of the women had university education

o   They gave birth at mean gestational week 38.8 (range 37-41)

o   61.9% had vaginal delivery and 38.1% had cesarean sections

o   Mean birth weight was 3130g (6.9 lb), range 2300-4000g (5.07–8.8 lb)

·   At gestational week 35 the mean IRD was 64.6 mm (SD 19.0) and ranged from 22.1 mm to 126.0 mm at rest on measurement 2 cm below the umbilicus; prevalence of DRA 100%.

·   At 6-8 weeks postpartum, the mean IRD at rest was 18.8 mm (SD 10.7); prevalence 52.4%

·   At 12-14 postpartum weeks the mean IRD at rest was 17.2 mm (SD 8.9); prevalence 53.6%

·   At 6 months postpartum the mean IRD decreased to 15.3 mm (SD 8.4); prevalence  39.3%

Table 2: shows the binary logistic analysis to predict possible risk factors associated with the presence of DRA at 6 months post- partum. No significant factors were found in the logistic regression models for DRA at 6 months postpartum.

Table 3: There were no significant differences in prevalence of lumbo-pelvic pain between women with and without DRA

Discussion & Conclusions

·         Participants were classified as either with or without lumbo-pelvic pain at 6 months postpartum

·         They did not find any significant risk factors with the presence of DRA at 6 months postpartum with respect to any of the reported risk factors

·         Prevalence of lumbo-pelvic pain was similar for women with (27.3%) and without (27.5%) DRA.

·         Women with DRA were not more likely to report lumbo-pelvic pain than women without DRA (p > 0.05). The Odds Ratio observed were approximately 1 (OR _ 0.991), showing that women with DRA have the same chances to having lumbo-pelvic pain than those without DRA. This is in line with the other results in the literature.

Limitations

·         Data went only until 6 months postpartum

·         The IRD cut-off value of 1.6 cm for categorizing DRA was established for nulliparous women and needs to be further observed as it is rather narrow, especially for multips

·         A larger sample size is needed and may reveal more of a relationship between DRA and lumbo-pelvic pain

·         No pain hx was taken or clinical assessment was made to evaluate the condition

Strengths

·         First study of it’s kind; longitudinal study following the cohort with US assessment of IRD from late pregnancy to 6 months postpartum

·         Investigator was blinded

Conclusions: The aim of this study was to investigate the prevalence of DRA at gestational week 35 and three time-points postpartum, possible risk factors, and the relationship between DRA and lumbo-pelvic pain. 

·         Prevalence of DRA decreased from 100% during pregnancy to 52.4% at 4-6 weeks after childbirth and then to 39% at 6 months postpartum, suggesting that recovery is still in progress and was in line with other studies

·         No significant risk factors were identified that could predict DRA; all were inconsequential in this study: “age, BMI before pregnancy and at 6 months postpartum, weight gain during pregnancy, Beighton's hypermobility score, baby weight at birth, abdominal circumference at gestational week 35 or exercise training level before during and after pregnancy”.

·         No relationship between DRA and lumbo-pelvic pain was determined

 Applicability

Are these results comparable with your clinical practice?