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Interrater Reliability of Diastasis Recti Abdominis
Measurement
S Gail Bursch
PHYS THER. 1987; 67:1077-1079.
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Interrater Reliability of Diastasis Recti
Abdominis Measurement
S. GAIL BURSCH
Diastasis recti abdominis, or midline separation of the abdominal musculature,
has not been investigated scientifically. The purposes of this study were to
provide data on the incidence and degree of diastasis recti abdominis, to describe
the measurement system used, and to determine the interrater reliability of the
measurements performed. Forty subjects less than four days postpartum were
tested by four raters. All subjects were measured in a supine, flexed-knee position
at a standard point of palpation above the umbilicus. During palpation, each
subject performed a partial sit-up, and the rater determined the number of finger
widths filling the separation. An analysis of variance for repeated measures
revealed a highly significant difference between the measurement scores of the
four raters. This measurement system, therefore, was found to be unreliable. All
subjects had some degree of diastasis recti abdominis; over 60% had separations
significant enough to warrant protective exercises. The author proposes that the
incidence and degree of diastasis recti abdominis may be underestimated, that
selected components of exercise prescriptions may be contraindicated, and that
a reliable instrument for measuring the degree of separation is needed.
Key Words: Abdominal wall, Physical therapy, Postpartum period.
Diastasis recti abdominis is the "separation of the rectus
muscles of the abdominal wall, sometimes occurring during
pregnancy."1 Although usually detected by palpation, diastasis
recti abdominis may be visible as a midline bulge on exertion
(Fig. 1). The greatest point of fascial stretching is usually at
the umbilicus, but may extend the entire length of the linea
alba.2 In cases of marked separation, only the peritoneum,
attenuated fascia, subcutaneous fat, and skin comprise the
abdominal wall.3
Noble states that "most women after childbirth do have
some degree of muscle separation."4 The separation occurs
frequently during pregnancy, either gradually or suddenly, as
a result of exertion imposed on weak musculature. Conjecture
regarding the causes of the condition suggests hormonal
changes and mechanical stress. Other predisposing factors
include obesity, multiple-birth pregnancy, a large baby, excess
uterinefluid,and a lax abdominal wall from former pregnancies.4
The incidence, duration, short- and long-term complications, and treatment of diastasis recti abdominis have not
been investigated. The purposes of this study were to 1)
provide data on the incidence and degree of diastasis recti
abdominis less than four days postpartum, 2) describe the
measurement system used, and 3) determine the interrater
reliability of the measurements performed. The incidence of
diastasis recti abdominis during the early postpartum period
was expected to be high. Because of the subjectivity of current
assessment methods, discrepancies among the methods, and
Ms. Bursch is Director of Rehabilitation, Park View Medical Center, 230
25th Ave N, Nashville, TN 37203. Address correspondence to 902 Woodmont
Blvd, Nashville, TN 37204 (USA).
This study was completed in partial fulfillment of the requirements for Ms.
Bursch's master's degree, University of Kentucky.
This article was submitted July 3, 1985; was with the author for revision 43
weeks; and was accepted September 4, 1986. Potential Conflict of Interest: 4.
variations in raters'fingerwidths, measurements of diastasis
recti abdominis probably would be unreliable.
METHOD
Subjects
Forty subjects, aged 16 to 31 years, who were less than four
days postpartum, participated with informed consent approved by the Human Investigations and Studies Committee
at the University of Kentucky Medical Center. Subjects having a cesarean section or a tubal ligation after delivery were
excluded from the study. The subjects did not exercise after
delivery until they were tested.
Instrumentation
Construction of a Polyform®* device standardized diastasis
recti abdominis measurement by guiding palpation of the
abdominal wall. The device is inserted into the center of the
umbilicus and extends 4.5 cm superiorly on the abdominal
surface (Fig. 2).
Procedure
Four physical therapists consecutively measured each subject in a supine,flexed-kneeposition on a flat hospital bed.
After positioning the Polyform® device, the rater inserted the
second, third, and fourth fingers of her right hand into the
subject's abdomen, the volar surface of thefingersjust touching the superior rim of the device (Fig. 3). Insertion to the
depth of the rater's proximal interphalangeal joints occurred
most frequently because of the yielding laxity of the abdomen
(Fig. 4).
* Polyform Products Inc, 9420 W Byron St, Schiller Park, IL 60176.
Volume 67 / Number 7, July 1987
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1077
Fig. 1. Diastasis recti abdominis visible as a midline bulge on
exertion.
Fig. 2. Polyform® device used to standardize diastasis recti abdominis measurement inserted into center of umbilicus.
Fig. 4. Rater inserts fingers into patient's abdomen to the depth of
proximal interphalangeal joints.
Fig. 3. Palpation of abdomen for diastasis recti abdominis using
Polyform® device.
The patient performed a partial sit-up with arms extended
toward the knees (Fig. 5) three times during palpation by the
rater. Standard execution of the sit-up, with scapulae elevated
above the bed, was ensured by palpating the inferior angle of
the right scapula with the rater's left index finger. To avoid
fatigue, each subject rested at least three minutes between
trials. The number offingersfillingthe diastasis was recorded
for each trial and averaged. Discussion of findings among
raters was prohibited.
Noble classifies the slight gap, one or two finger widths, as
tissue slackness that will tighten independently within a week
after childbirth. A diastasis of three or more finger widths
requires a special exercise to restore tissue integrity. Crossing
the hands over the abdomen and pulling the bands of muscle
toward the midline during a partial sit-up is her recommended
modification.4 If a subject's diastasis recti abdominis was
greater than two finger widths, the last rater demonstrated
Noble's exercise modification.
Fig. 5. Subject demonstrates partial sit-up used during palpation by
rater.
scores recorded by the most experienced rater. Experienced
raters in diastasis recti abdominis measurement were compared by Pearson product-moment correlations with inexperienced raters who received instruction in the method. The
experienced raters also were compared with each other as
were the inexperienced raters. Assessment of interrater intraclass reliability of this measurement system used an analysis
of variance (ANOVA) for repeated measures.
Data Analysis
RESULTS
The incidence and degree of diastasis recti abdominis were
evaluated through a frequency distribution of measurement
All subjects had some degree of diastasis recti abdominis
(Tab. 1). A frequency distribution shows 25 women (62.5%)
1078
PHYSICAL THERAPY
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TABLE 1
Means and Standard Deviations of the Four Raters (N = 40)
Ratera
s
a
E1
E2
N1
N2
3.03
1.27
2.99
1.15
2.43
1.12
2.94
1.01
E = experienced; N = not experienced.
TABLE 2
Frequency Distribution on One Measure
Finger-Width
Separation
1
2
3
4
5
TOTAL
Frequency
Percentage
6
9
11
7
7
40
15.0
22.5
27.5
17.5
17.5
100.0
TABLE 3
Correlations Between the Four Raters
a
b
Ratera
E1
E2
E1
E2
N1
N2
.75b
.69b
.51c
b
N1
estimated by health care professionals. Inadequate attention
is given to the condition, probably because a woman feels no
pain directly as a result of the separation. Nevertheless, indirect pain, such as chronic back pain, may be caused by
muscular laxity. If diastasis recti abdominis is not corrected,
a muscle imbalance persists, and the abdominal wall may
remain weakened.4
The majority of the subjects had an abdominal separation
of greater than two finger widths. Such a degree of separation
requires a modified exercise program according to Noble.4
Many women, therefore, not evaluated for diastasis recti
abdominis before a postpartum exercise prescription, may be
receiving contraindicated instruction. Extensive research is
needed concerning the condition's incidence during pregnancy and the postpartum period, duration, degree of separation, vertical length of separation, response to exercise, longterm sequelae, and correlation with gravidity and fitness level
before pregnancy.
Even though patient positioning and finger placement were
standardized, other variables such as differences in the width
of fingers and subjective interpretation of pressure compromise the test. Because palpation is not a reliable tool for
measurement, an instrument that is reliable, inexpensive, and
convenient is needed. An accurate measurement instrument
would provide objective data for diagnosis and rehabilitation.
N2
CONCLUSION
.66
.60b
.40d
E = experienced; N = not experienced.
p < .0001.
p < .001.
d
p < .05.
c
with a separation greater than two finger widths (Tab. 2).
Correlation results between the four raters (r = .84) showed
a definite linear relationship in the testing procedure. The two
experienced raters demonstrated the highest correlation of
measurements (Tab. 3). The ANOVA revealed a highly significant difference between raters' measurement scores (F =
6.30; df = 3,117; p < .0005). The traditional measurement
system for diastasis recti abdominis, therefore, is unreliable
for clinical assessment.
DISCUSSION
The results indicate that the incidence of diastasis recti
abdominis in the first four days postpartum has been under-
All subjects less than four days postpartum exhibited some
degree of diastasis recti abdominis. A majority (62.5%) had a
separation greater than two finger widths, necessitating a
modified postpartum exercise program. Although the results
of testing were correlated positively between raters, statistical
analysis of their measurements indicated that diastasis recti
abdominis measurement by the finger-width method is unreliable.
Acknowledgments. I thank Eileen Dietz, Karen Ditsch,
and Kim Hurst for participating as raters.
REFERENCES
1. Dorland's Illustrated Medical Dictionary, ed 25, Philadelphia, PA, W B
Saunders Co, 1974, p 438
2. Findley P: A Treatise on the Diseases of Women. Philadelphia, PA, Lea &
Febiger, 1913, pp 59-62
3. Pritchard JA, MacDonald PC: Williams Obstetrics, ed 15. New York, NY,
Appleton-Century-Crofts, 1976, pp 147, 353
4. Noble E: Essential Exercises for the Childbearing Year, ed 2. Boston, MA,
Houghton Mifflin Co, 1982, pp 58-77
Volume 67 / Number 7, July 1987
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1079
Interrater Reliability of Diastasis Recti Abdominis
Measurement
S Gail Bursch
PHYS THER. 1987; 67:1077-1079.
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The Hip. Proceedings of the Fourteenth Open Scientific Meeting of The
Hip Society, 1986. Edited by Brand RA.
St. Louis, MO 63146, C V Mosby Co,
1987, cloth, 387 pp, illus, $65
Over the years, programs of the Hip
Society have covered virtually every
clinical and basic aspect of the hip joint.
For 1986 the program committee selected three areas for discussion: bone
formation and bone grafting, difficult
hip fractures, and noncemented hip implants. Section 1 contains papers on the
stimulus for bone formation, bone
grafting, use of allograft bone, and prevention of heterotopic bone formation.
Section 2 consists of chapters on complex acetabular fractures, fractures of the
femoral head, and metastatic tumors.
The final section addresses the advantages and disadvantages of noncemented hip implants.
Preceding the first section is an interesting chapter on early hip surgery and
characterizations of many of the early
practitioners. In addition to the main
thrust of the program, there is a section
containing three Hip Society award papers. This particular section is of little
relevance to most clinical practitioners.
One of the papers, for example, is entitled "Improvement of Femoral Head
Blood Flow in Steroid-Treated Rabbits
Using Lipid-Clearing Agent."
There is much emphasis throughout
the book on the issue of cemented versus
noncemented prostheses. There is a hiprating system and hip-score patient evaluation discussion, but rehabilitation is
mentioned only vaguely and no specific
reference is made to physical therapy.
The proceedings deal principally with
surgical technique, and the practitioner
who is seeking updated information in
that realm will find the book useful. The
chapters are well researched, and the
book is well indexed. The book's lack of
direct relevance to physical therapy,
however, will make it of limited value
to most physical therapy practitioners,
especially in view of its cost.
R. SCOTT TEETS
Common Sports Injuries in Youngsters. By Birrer RB, Brecher DB. Oradell, NJ 07649, Medical Economics
Books, 1987, paper, 144 pp, illus,
$19.95
The authors state that fewer than 25%
of high schools have continuous comprehensive medical coverage for athletes. They suggest that team physicians
should be motivated by a sincere interest
in young people and sports and should
assume major responsibility for developing a comprehensive program. The
136
Erratum
In the article "Interrater Reliability of Diastasis Recti Abdominis Measurement" (PHYSICAL
THERAPY, July 1987), on page
1077, Polyform Products Inc was
identified incorrectly as the manufacturer of Polyform®. Polyform® is the registered trademark
of Rolyan Medical Products, PO
Box 555, Menomonee Falls, WI
53051. We regret the error.
authors stress the importance of communication between the primary health
care providers and the schools, coaches,
medical support staff, athletes, parents,
and community.
The first five chapters of this monograph cover the preparticipation
evaluation, nutrition, on-field injury
management, and injuries to the head,
neck, and face. These chapters are well
organized and concisely written and
would be pertinent for primary health
care providers. Chapters 6 through 11
provide information on common injuries in athletes. Each of these chapters
contains a concise, accurate, and at
times oversimplified review of the relevant regional anatomy. The authors also
review physical examination of the low
back, shoulder, hand, hip, knee, and
ankle. Chapter 12 deals with the supervision of young athletes who have
chronic health problems or handicaps
and attempts to dispel common misconceptions about their participation in
sport. The final chapter, written by a
physical therapist, summarizes the physician-therapist relationship, physiological characteristics of children, and fundamentals of rehabilitation.
Overall, the book is well organized,
but it lacks continuity in some chapters.
Some of the illustrations are oversimplified, which detracts from their value.
The photographs depicting examination
techniques are well done. The information is not referenced specifically, but a
reading list is provided at the conclusion
of each chapter. The authors do not
identify clearly their purpose in writing
the book or their target population. The
book's title alludes to common athletic
injuries in youngsters, but the authors
describe many injuries that are, in fact,
uncommon. Early in the text, the authors list concepts of conditioning and
injury prevention as important components of a comprehensive program, but
they discuss these concepts rarely, if at
all. Their discussions of injury treatment
often consist of nothing more than defining the acronym RICE. If this book
is intended for the somewhat experi-
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