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Year : 2023  |  Volume : 15  |  Issue : 1  |  Page : 16-21

Association between low back pain, pelvic floor dysfunction, and diastasis rectus abdominis in postnatal delivery women

Department of Orthopaedic Physiotherapy, Krupanidhi College of Physiotherapy, Bengaluru, Karnataka, India

Date of Submission20-Nov-2022
Date of Acceptance20-Dec-2022
Date of Web Publication31-Mar-2023

Correspondence Address:
Sudhakar Subramanian
Krupanidhi College of Physiotherapy, Bengaluru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ajprhc.ajprhc_102_22

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Background: It is crucial to understand diastasis rectus abdominis (DRA) in postpartum women and how it affects them. DRA should be related to pelvic floor dysfunction (PFD) and low back pain (LBP). Prior researchers have contradictory findings in their studies. Objective: To estimate the prevalence of DRA and find the association between LBP, PFD, and DRA. Methodology: According to the eligibility criteria, 102 participants from Bengaluru were chosen for this study. The physical screening was performed to rule out DRA. Following informed consent, the participants have given the Oswestry Disability Index Questionnaire for LBP and Pelvic Floor Impact Questionnaire-7 for PFD. Subjects were divided into two classes: case and control. The data were analyzed using the Chi-square test and the Odds ratio using SPSS Software. Results: This analysis presents the findings of the prevalence of DRA and also the findings of rated LBP and PFD in both the groups. The degree of impact was determined to be P < 0.05. Conclusion: As an outcome, there is an association between LBP, PFD, and DRA.

Keywords: Diastasis rectus abdominis, low back pain, Oswestry Disability Index, Pelvic Floor Impact Questionnaire-7, pelvic floor dysfunction, postnatal delivery women

How to cite this article:
Rai R, Subramanian S. Association between low back pain, pelvic floor dysfunction, and diastasis rectus abdominis in postnatal delivery women. Asian J Pharm Res Health Care 2023;15:16-21

How to cite this URL:
Rai R, Subramanian S. Association between low back pain, pelvic floor dysfunction, and diastasis rectus abdominis in postnatal delivery women. Asian J Pharm Res Health Care [serial online] 2023 [cited 2023 Jun 8];15:16-21. Available from: http://www.ajprhc.com/text.asp?2023/15/1/16/373368

  Introduction Top

Low back pain (LBP) is a common clinical concern among pregnant women, accounting for 30%–78% of all cases. This condition is frequently very stressful, resulting in decreased work productivity.[1] The Fatality workgroup of the WHO has defined woman's health as “any health problem caused by and/or exacerbated by pregnancy and during delivery that has a detrimental influence on the woman's welfare.”[2] Diastasis rectus abdominis (DRA) may induce inadequate posture, spine stability, and movement patterns, resulting in poor load transfer and unpleasant symptoms such as LBP.[2],[3] Fernandes da Mota et al. discovered that women with postpartum DRA were also particularly prone to developing LBP.[4] Parker et al. discovered that women with DRA had greater abdominal or pelvic pain.[5]

Lumbar discomfort is usually stable during pregnancy, whereas pelvic pain may worsen. Pelvic discomfort symptoms delay the majority of daily activities.[6] Typically, women do not discuss pelvic floor dysfunction (PFD) often. After the 6th or 12th month after delivery, some postpartum women may suffer pelvic floor discomfort that interferes with daily activities. The spike in gut tension and decrease in collagen during labor and birth diminish pelvic floor muscles (PFMs) strength and relax PFMs, which is the latent stage of PFD.[7]

DRA is a prevalent ailment among many pregnant and postpartum women. Much research has also been conducted to examine the risk factors for DRA in women who delivered a baby more than 6 months ago. There is a lack of information in the literature regarding the effects of DRA.[8] The transmittable disease as DRA arises when the two rectus abdominal muscles are separated midline along the linea alba. Wang et al. stated that if the abdomen musculature is weak, whenever these PFMs contract, the belly muscles are helpless, resulting in weakened PFMs. Hence, factors can explain the outcome of this. DRA could be among those risk factors for PFD.[7]

Benjamin et al. discussed the evidence linking diastasis of the rectus abdominis muscle (DRAM) presence to pelvic organ prolapse (POP) and DRAM severity to poor mental well-being satisfaction with lifestyle, decreased abdominal muscle strength, and LBP intensity.[8],[9] Although DRA is not a primary cause of either suffering or discomfort, it may assist toward growth and lumbar pain or PFD.

The primary objective of this research work is to establish the prevalence of DRA as determined by physical examination. The secondary goal has been to look at this correlation between low back discomfort and DRA, the connection between PFD and DRA. The assumption is that there is a link between postnatal delivery women's LBP, PFD, and DRA.

  Methodology Top

Ethical clearance was acquired from the Institutional Ethical Committee from Krupanidhi College of Physiotherapy, Bengaluru (Ref. No: EC-MPT/21/PHY/004). The study was a case–control research, and a convenient sampling technique was performed in and around Bengaluru South. A straightforward sampling procedure determined the overall number of participants during the research. This investigation was conducted thoroughly in Bengaluru in hospitals, nursing homes, and other settings for 8 months from January 2021 to August 2021.

The eligibility guidelines were used to ascertain inclusion: women who have had a C-section or an episiotomy give birth,[2] postpartum time of more than 6 months/<3 years,[9] gravida 2, parity 1, maximum of 2,[10] and age between 25 and 35 years old.[2] Exclusion criteria were as follows: over 35, prolapsed intervertebral disc, spondylitis/spondylosis, prenatal exercise regime, polycystic ovarian syndrome, acute discogenic pain, and low back ache. Written consent had been received through them at their leisure. In this probe, 110 individuals were evaluated as per [Figure 1]. Based on the inclusion requirements, 102 postnatal delivery women were recruited for the following study via hospitals, care homes, and other feasible approaches. There were 102 participants (54 in Group 1 and 48 in Group 2).
Figure 1: Flowchart for the study

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Palpation was used to corroborate the initial screening of individuals. Initially, DRA was declared when the examiner observed an abnormal abdomen protruding from 2 cm widths or greater throughout an abdominal curl-up.

The standard physical examination is as follows:

Step1: Lie on your back with your knees bent and your feet hip width apart. Shoulders are relaxed, and the spine is in a relaxed state.

Step 2: Directly over your navel, place your index and third fingers (belly button). Your fingers should be parallel and pointing in the direction of your feet.

Step 3: Raise your head and shoulders away from the supporting surface and exhale (don't hold your breath as this will increase intra-abdominal pressure, creating additional diastasis). Feel for any gaps or dip under your fingers.

Step4: Return the top spine to its original position.

Remember, it is not only about the space but also about the tension beneath it. These have, as earlier noted, different degrees of abdominal separation.


  1. Normal separation = 1 finger spacing separation or less and very firm linea alba/fascia between the gap
  2. Functional diastasis = 1–2 finger space or less firm linea alba/fascia between the gap. Can maintain abdominal tension without excessive coning or bulging when exercising and breathing properly
  3. Diastasis recti means a separation or gap of 2.1/2 finger spacing or 25 mm between the rectus abdominis muscles (<1 inch). This indicates that the tissues connecting the rectus abdominis muscles have either strained or split apart.

The standard outcome

A patient-completed questionnaire that provides a subjective percentage score of level of function (disability) in daily life activities in persons recovering from LBP. The questionnaire investigates the perceived level of disability in ten daily living tasks. The six statements are scored from 0 to 5, with the first statement scoring 0 and the last statement scoring 5. For example, take the highest score if more than one box is marked in any section. The Oswestry Disability Index (ODI) score is computed as follows:

For example, if all ten portions are completed, the following score is calculated: If (16) out of 50 (total possible score) × 100 = 32%. If one section is skipped (or is not applicable), the following score is calculated: If 16 (total points scored)/45 (total possible score) × 100 = 35.5%, standard interpretation follows.[4]

Pelvic Floor Impact Questionnaire-7

It is used to assess PFD in women. Barber (2007).[11] designed something to save effort in achieving accomplishment in the laboratory, and therapeutic settings The Urinary Impact Questionnaire 7, the POP Impact Questionnaire-7, and the Colorectal-Anal IQ-7 were all included. The Pelvic floor IQ-7 (PFIQ-7) is composed of seven queries, each one of which should be addressed in 3 magnitudes, relating illnesses of the bladder or urine, vagina or pelvis, and bowel or rectum. The question's choices range from “not at all” (0) to “quite a little” (3). Grade rankings are calculated using the overall sum of every assessment scale. All three categories are measured independently, and the result is multiplied by 100 and split by three. The scale scores are then combined to yield the PFIQ-7 total score, ranging from 0 to 300. A lower score indicates less of an impact on quality of life (QoL).[8]

Data analysis

SPSS was used to analyze the data Version 20.0 for Windows (IBM SPSS Inc., Chicago, USA). Based on the collected demographic data, the frequency, percentage and mean of the variables were calculated. The Chi-square test was employed to analyze the association between cases and controls. The odds ratio and relative risk (RR) were analyzed in groups to find the risk factor.

The level of significance was chosen at 5% (P ≤ 05) with a 95% confidence interval.

  Results Top

This study includes 102 female participants. [Table 1] displays the current baseline data, including mean and standard deviation of age, Oswestry disability score, and (PFIQ-7) for women who have and do not have DRA.
Table 1: Mean and standard deviation of age, Oswestry Disability Index % score, and Pelvic Floor Impact Questionnaire-7 score in years in both the groups

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The mean age of participants in Group A is 30.44 years, while the mean age of participants in Group B is 31.33 years.

The ODI percentage score in Group A (case) was 63.7593, while it was 22.8194 in Group B (control). The case group had a higher score than the control group. Comparatively to the control, the percentage of women experiencing low back discomfort was higher. The PFIQ-7 score in Group A (case) was 174.4989, while it was 76.6990 in Group B (control). The score in the case group seemed to be larger than that in the control group. The percentage of the woman going through PFD was higher.

Delivery women, who have a 61.1% chance of having diastasis recti abdominis that extends beyond three fingers, 37% of having diastasis recti abdominis that is between 2.5 and3 fingerbreadths, and 1.9% of having < 2%, have DRA. As a result, this study found a 98.1% increased prevalence of DRA [Figure 2].
Figure 2: X-axis - Diastasis recti gap score, Y-axis - Percentage.

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[Table 2] shows that the accompanying table's χ2 = 98.254, P = 0.001 (P ≤ 0.05) value reveals that the Diastasis recti gap score is statistically significant. However, the ODI percentage score is statistically significant at χ2 = 58.933, P = 0.021, (P ≤ 0.05), and the PFIQ-7 score is statistically significant (P ≤ 0.05) at χ2 = 54.418. It signifies that the alternate hypothesis for LBP, PFD, and DRA is accepted, and the null hypothesis is rejected. As a result, it suggests that LBP, PFD and DRA are linked.
Table 2: Chi-square test for case and control group of Oswestry Disability Index score, Pelvic Floor Impact Questionnaire-7, and diastasis rectus gap

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[Table 3] shows the risk among subjects (”exposed” subjects) is 48/54 = 0.89, compared to a risk of 27/48 = 0.56 among “unexposed” subjects. The RR was thus 0.89/0.56 = 1.58, showing that patients exposed to LBP were approximately 58% more inclined toward developing LBP than those not exposed to LBP. A similar calculation using odds yields an odds ratio (OR) of 6.22, which is more than the RR. It demonstrates that the variable is significant, with P < 0.05.
Table 3: The proportion of cases and control exposure among LBP and PFD

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The risk among participants exposed to factors was 51/54 = 0.94, compared to an 'unexposed' risk of 26/48 = 0.54. As a result, the RR was 0.94/0.54 = 1.74, indicating that people exposed to PFD were approximately 74% more likely to develop PFD than subjects in the unexposed group with less PFD. A similar calculation using odds yields an OR of 14.38, which is more than the RR. It demonstrates that the variable was significant, with P < 0.05. It signifies that the alternate hypothesis for varying PFD has been accepted.

  Discussion Top

These abdomen musculatures extend during pregnancy to make room for the developing fetus inside the uterus. As a result, the abdominal muscles are known as the “rectus abdominis” or “six-pack” partially or separately. Diastasis recti, or abdominal separation, are an uncomfortable sickness that commonly affects pregnant women and new mothers. This is a common symptom, with 50% of mums still reporting DRA after giving birth and 80% of women experiencing it throughout the third trimester. The initial objective is to determine how common DRA is among postpartum mothers.

Postpartum back pain is an issue that typically lasts 6 months, but can last up to a decade. The type of birth, such as vaginal, surgical, or cesarean section, may also have a bearing on postpartum back pain (C-section).

This may be expected that half of all pregnant women may feel low back (LB) discomfort. The second goal is establishing a link between diastasis recti abdominis and LB problems.

Urinary incontinence (UI), constipation, and discomfort during sex in the lower back, pelvic area, genitals, or rectum can occur when the PFMs are either excessively tight (high tone) or insufficiently loose (low tone). In patients with DRA, the prevalence of PFD was 82.8%. As a result, the final purpose of this research is to establish a relationship between DRA and PFD.

Prevalence of diastasis rectus abdominis

It represents an initial investigation. To relate LBP, PFD, and diastasis recti abdominis in postnatal delivery women using all end variables. According to this data, 98.1% of people have a diastasis recti abdominis that extends from 2.5 to 3 fingerbreadths or more, whereas 1.9% have a gap of <1 fingerbreadth. Adkitte et al.[12] studied the prevalence of DRA muscle work shortly after childbirth in women living in rural and urban locations. Diastasis was discovered in 68% of immediate postpartum women. A total of 100 women aged between 20 and 35 years were studied. The study found that metropolitan women possessed multipara women had a higher prevalence than primipara women, and mean diastasis beyond the umbilical cord was greater than below the umbilicus.

The difference in low back pain and pelvic floor dysfunction with diastasis rectus abdominis

The Chi-square analysis demonstrates that the previous table's P = 0.001 (P ≤ 0.05) value indicates that DRA is significantly present, but the value of LB discomfort was P = 0.021 (P ≤ 0.05). In this scenario of PFD, however, P = 0.051 indicates that the null hypothesis is rejected and the alternate hypothesis is accepted. This equates to statistically significant in both the case and control Groups for DRA; however, that is simply none. Statistically, there is a strong relationship between the lower spine and pelvic floor problem in either group.[8] A thorough research was conducted by Benjamin et al.[8] According to the research, there is no link between DRAM and lumbopelvic discomfort or incontinence. The ages of such 2242 individuals, either men or female, range from 25 to 60. According to the study, DRAM was linked to POP, lower QoL, abdominal muscular weakness, and the degree of LB discomfort. According to Sperstad et al.,[13] women who reported 20 times per week of hard lifting had a greater risk of DRA.

Fei et al.[14] discovered no disparity in the occurrence of UI and POP between women who had and did not have DRA.

Association of low back pain and pelvic floor dysfunction with diastasis rectus abdominis

This strategy differs from past research in that it interprets the OR and RR as indicating that the frequency of LBP increased by 98.5% and 6.22%, respectively. Similarly, the subjects were 14.3 times more likely and 98.26% more likely to have PFD. DRA is associated with LBP and malfunction of the vaginal wall in a statistically meaningful way. Null hypothesis is rejected and Alternate hypothesis is accepted, as there is association between low back pain, pelvic floor dysfunction and Diastasis rectus abdominis in postnatal delivery women (p < 0.05).

DRA was found in 39% of the females at 6 months postpartum, according to Patricia Fernandes da Mota et al. (2015).[4] No risk indications for the existence of DRA were detected during the current investigation.[15] Lumbopelvic discomfort was not more frequently reported by DRA patients than by non-DRA individuals.[16]

DRA separation, or abdominal wall separation, is typically caused by the growing fetus straining the abdominal wall. The physiology behind this is that when our abdominal muscles are weakened due to diastasis recti, our back muscles bear the brunt of lifting. DRA may result from various causes, such as increasing abdominal cavity capacity and hormonal changes during pregnancy. The coordination of lumbopelvic and abdominal muscles and fascia is vital for incontinence, breathing, and musculoskeletal function, including postural stabilization.

The structure of abdominal muscles changes during pregnancy when preserving their function. The enlarging uterus changes the abdomen's form and the lumbar spine's overall altitude (deepening of the lumbar lordosis). Studies carried out by Sperstad et al.,[13] Fernandes da Mota et al.,[4] and Parker et al.,[5] found no differences in the proportion of overall lumbar spine distress between female who has and does not have DRA. Women with DRA had neither poorer PFM nor greater PFD than women without DRA, according to a Norwegian study.[6] Recti muscles women have their abdominal muscles work in concert with their PFM's, or incontinence of urine. The PFM's work with the deep core muscles, lumbar muscles, and respiratory diaphragm as a component of the core. We may deduce that there is some form of relationship between these three disorders based on the pathophysiology of the condition, even though each is over-related because it all comes down to stabilising the pelvic, abdominal, and lumbar muscles. As a result, our data indicate a connection between lumbar spine discomfort, PFD, and DRA.

The small sample size was the study's limitation. Another limitation was there were no home programme given, as well as only few participants were screened for DRA.

  Conclusion Top

There is some connection among lower lumbar discomfort, PFD and DRA, which has been proved in this study because postnatal delivery women are at risk of getting LBP, PFD, and diastasis recti abdominis. However, during our analysis, we identified a connection between them.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Hutson MA. Back Pain Recognition and Management. London, England: Butterworth, Heinemann; 1993.  Back to cited text no. 2
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Fernandes da Mota PG, Pascoal AG, Carita AI, Bø K. Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Man Ther 2015;20:200-5.  Back to cited text no. 4
Parker MA, Millar LA, Dugan SA. Diastasis rectus abdominis and lumbo-pelvic pain and dysfunction-are they related? J Womens Health Phys Ther 2009;33:15-22.  Back to cited text no. 5
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Wang Q, Yu X, Chen G, Sun X, Wang J. Does diastasis recti abdominis weaken pelvic floor function? A cross-sectional study. Int Urogynecol J 2020;31:277-83.  Back to cited text no. 7
Benjamin DR, Frawley HC, Shields N, van de Water AT, Taylor NF. Relationship between diastasis of the rectus abdominis muscle (DRAM) and musculoskeletal dysfunctions, pain and quality of life: A systematic review. Physiotherapy 2019;105:24-34.  Back to cited text no. 8
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Barber MD. Questionnaires for women with pelvic floor disorders. Int Urogynecol J Pelvic Floor Dysfunct 2007;18:461-5.  Back to cited text no. 11
Adkitte RG, Yeole U, Gawali P, Gharote GM. Prevalence of diastasis of rectus abdominis muscle in immediate post-partum women of urban and rural areas. Eur J Pharm Med Res 2016;3:460-2.  Back to cited text no. 12
Sperstad JB, Tennfjord MK, Hilde G, Ellström-Engh M, Bø K. Diastasis recti abdominis during pregnancy and 12 months after childbirth: Prevalence, risk factors and report of lumbopelvic pain. Br J Sports Med 2016;50:1092-6.  Back to cited text no. 13
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Misra UK, Kalita J. Clinical Neurophysiology: Nerve Conduction, Electromyography, Evoked Potentials. UK: Elsevier Health Sciences; 2019.  Back to cited text no. 15
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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3]


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