Diastasis Rectus Abdominis

Diastasis rectus abdominis (DRA) is a separation of the left and right sides of the outermost abdominal muscle. It is caused by excessive forces that stretch the connective tissue called the linea alba. This condition most often occurs in pregnancy but may also occur in infants, older women, and men. Physical therapists help -adults with DRA manage their symptoms, improve their strength and stamina, and safely return to their regular activities. Diastasis recti is fairly common in infancy and any follow-up care should be deferred to the pediatrician.

What is Diastasis Rectus Abdominis?

The most common cause of DRA is pregnancy. As the fetus grows, the uterus expands and increases pressure against the abdominal wall. This pressure causes the connective tissue (linea alba) to widen, increasing space between the right and left sides of the muscle. It may be noticed during or after pregnancy. Typically, DRA develops during the second or third trimester when the fetus grows most rapidly. DRA often resolves on its own during the first three months after the birth (postpartum).Other potential causes for DRA include frequent or rapid changes in weight, abdominal obesity, genetics, and poor training technique or overloading the abdominal wall during heavy lifting activities. Infants commonly are born with a DRA that resolves over time without treatment. Pediatric physicians may monitor for progression to an umbilical hernia.

There are several factors that may make a people more prone to developing DRA. These include age, being pregnant with multiple children, and having had many pregnancies. The abdominal muscles have many important functions within the body. These muscles aid in postural support, movement, breathing, and protection of the internal organs. For other people, a DRA may persist after pregnancy, alter the appearance of the abdominal muscles, and result in reduced muscle strength. For a person juggling the normal stresses of a new baby, discomfort, weakness, and changes to postural control, the added muscle weakness from a DRA may impact quality of life.

How Does it Feel?

Separated abdominal muscles are usually painless and often have no symptoms. Some people, however, report problems that may be related to DRA that can include:

• Appearance.
• Discomfort.
• Difficulty doing certain activities.

A person with DRA may experience any of the following symptoms:

• A separation of the rectus abdominis muscle that is visible and felt by touching the stomach.
• Feelings of “flabbiness” in the abdominal muscles.
• Low back, pelvic, or hip pain.
• Poor trunk posture.
• Feeling weak through the midsection.

Doming or tenting of the abdominal midline. This can occur during activities such as lifting, rolling over in bed, or certain exercises.

How Is It Diagnosed?

Your physical therapist will review your medical history and conduct a thorough interview. For women, this may include specific questions about your:

• Pregnancies
• Labor and delivery history.
• Type of delivery (cesarean or vaginal)
• Pain
• Activities that make your symptoms better or worse.
• History of abdominal organ illness or surgeries.
• Types and level of physical demands at work, home and sport.

Your physical therapist also will ask you when your symptoms began, and how they impact your daily life.

To diagnose DRA, your physical therapist will gently feel and press on your abdominal muscle (palpate) to find if it has separated. Your physical therapist will also assess factors that can influence your strength, mobility and endurance. These factors can include your:

• Posture.
• Breathing.
• Flexibility.
• Overall muscle strength.
• Movement patterns during certain activities.

How Can a Physical Therapist Help?

Physical therapy is a very effective way to manage the symptoms of DRA. It can improve your strength and stamina so you can return to normal activities. Your physical therapist may help you with:

Education. Your physical therapist can help you understand which movements or activities to modify or avoid as you recover. They will help you safely progress your activities as you heal. Your physical therapist will teach you safe and effective ways to regain your full function so you can return to the activities you enjoy.

Postural Training. Learning how to engage the deep core muscles through posture and breathing is one of the most important parts of treatment for people with DRA. This involves posture training and breathing to activate your deep core muscles as a unit. Postural training will focus on the:

• Transverse abdominis muscles.
• Low back muscles.
• Pelvic floor muscles.

Your physical therapist will show you techniques to manage daily activities, such as lifting and carrying a baby or other objects. These methods will help to strengthen and reduce pressure on your abdominal muscles

Exercise Training. There are four layers of abdominal muscles, and all are important in DRA rehabilitation. These muscles are the:

• Transverse abdominis.
• Internal and external obliques.
• Rectus abdominis.

A physical therapist can teach you the right type and intensity of exercises for your specific condition and goals. They can help you progress through them as you get stronger. Your physical therapist can address muscle imbalances and show you stretches and diaphragm releases to help restore normal breathing patterns.

Bracing. Taping or braces for the abdominal region can provide external support for some women with DRA during pregnancy. Your physical therapist also may recommend the use of support for people in the early phases of rehabilitation. Support garments put the abdominal muscles in a more normal position. The tape or brace may help remind you to safely use your core muscles during activities that increase  pressure on the abdomen. A brace or tape does not make your muscles weaker. Physical therapists treating pregnant women can make sure a support brace or garment is made for pregnancy.

Electrical Muscle Stimulation. This treatment may be used by a physical therapist to reduce DRA after pregnancy or in other adult populations. Gently activating the rectus abdominis muscle has been shown to improve function and reduce the amount of separation.

Can this Injury or Condition be Prevented?

DRA is a natural consequence of pregnancy. In most cases it  resolves on its own and does not impair function. Studies show that starting a core and pelvic-floor muscle stabilization program in early pregnancy is highly effective. It can improve function and help you manage the abdominal pressure that may worsen a DRA during and after pregnancy. Working with a physical therapist during pregnancy helps women learn safe and effective exercise strategies to improve their:

• Pregnancy.
• Labor.
• Delivery.
• Postpartum experience.

If you do develop DRA, the earlier you see a physical therapist, the faster you will be able to return to the activities you love.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to identify diastasis rectus abdominis. However, you may want to consider:

• A physical therapist who has experience working with people who have diastasis rectus abdominis. Some physical therapists have a practice with a women’s health physical therapy focus.
• A physical therapist who is a board-certified clinical specialist, has completed advanced education in obstetrics physical therapy offered through the Academy of Pelvic Health  (CAPP-OB), or who completed a residency or fellowship in women’s health physical therapy. These therapists have advanced knowledge, experience, and skills in pregnancy and postpartum rehabilitation.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you’re looking for a physical therapist (or any other health care provider):

• Get recommendations from family and friends or from other health care providers.
• When you contact a physical therapy clinic for an appointment, ask about the physical therapists’ experience helping people with diastasis rectus abdominis.
• During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible.

Authors

• Karen Litos, PT, DPT, Board-certified Women’s Health Physical Therapist
• Sandi Gallagher, PT, DPT, Board-certified Women’s Health Physical Therapist

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions, and also prepare them for a visit with their health care provider.

The following articles provide some of the best scientific evidence related to physical therapy treatment of diastasis rectus abdominis. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

Benjamin DR, van de Water AT, Peiris CL. Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy. 2014;100(1): 1–8. Free Article.

Sharma G, Lobo T, Keller L. Postnatal exercise can reverse diastasis recti. Obstet Gynecol. 2014;123 Suppl 1:171S. Article Summary on PubMed.

Barbosa S, de Sa RA, Coca Velarde LG. Diastasis of rectus abdominis in the immediate puerperium: correlation between imaging diagnosis and clinical examination. Arch Gynecol Obstet. 2013;288(2):299–303. Article Summary on PubMed.

Thabet, A. A., & Alshehri, M. A. (2019). Efficacy of deep core stability exercise program in postpartum women with diastasis recti abdominis: a randomised controlled trial. Journal of musculoskeletal & neuronal interactions, 19(1), 62.  Free article

Hills, N. F., Graham, R. B., & McLean, L. (2018). Comparison of trunk muscle function between women with and without diastasis recti abdominis at 1 year postpartum. Physical therapy, 98(10), 891-901.

Keshwani, N., Mathur, S., & McLean, L. (2018). Relationship between interrectus distance and symptom severity in women with diastasis recti abdominis in the early postpartum period. Physical Therapy, 98(3), 182-190.

Kamel, D. M., & Yousif, A. M. (2017). Neuromuscular electrical stimulation and strength recovery of postnatal diastasis recti abdominis muscles. Annals of rehabilitation medicine, 41(3), 465.  Free article: https://www-ncbi-nlm-nih-gov.liboff.ohsu.edu/pmc/articles/PMC5532353/

Additional resources can be found at ChoosePT.com