Physical Therapy Guide to Diastasis Rectus Abdominis
Diastasis rectus abdominis (DRA) is a condition in which the 2 sides of the abdominal muscle separate, as the tissue connecting them stretches. This typically happens in women during and following pregnancy due to the stretching of the abdominal wall, as the uterus expands. Physical therapy has been shown to be a highly effective approach to both the prevention and treatment of diastasis rectus abdominis.
DRA is a common condition that affects many women during the childbearing years. As a fetus grows within the uterus, the uterus expands, which places stress across the structures surrounding it, specifically the muscles. The primary abdominal muscle on the front side of the body is called the rectus abdominis. This muscle is divided into a left and right half by a thick band of connective tissue called the linea alba. You may hear people talk about "6-pack abs"; this is referring to the rectus abdominis. As the uterus expands, stretching across the rectus abdominis potentially could occur. In some cases, the weakening and stretching of the linea alba connective tissue creates a separation between the right and left sides of the muscle, or diastasis.
DRA may affect women during and after pregnancy. Typically, DRA develops in the second or third trimester. It is during this time that the fetus is growing most rapidly, and can result in the greatest increase in distance between the 2 sides of the muscle.
There are several factors that may make a woman more susceptible to developing DRA. These include age, being pregnant with multiple children (multiparity), and having many pregnancies. The abdominal muscles have many important functions within the body, including postural support, movement, breathing, and protection of the internal organs. Therefore, if their structure is affected by DRA, a woman may have difficulty controlling her posture, which may put her at an increased risk for injury. Additionally, for a woman juggling the many stresses of having a new baby, the discomfort, weakness, and changes to postural control that may result from DRA can negatively effect her quality of life.
Symptoms of DRA typically develop gradually over the course of a woman’s pregnancy, and may linger following labor and delivery. Separated abdominal muscles themselves are not always painful, but the effects of DRA can cause pain.
A woman with DRA may experience any number of the following symptoms:
- A visible and palpable (detected by touch) separation of the rectus abdominis muscle.
- Feelings of “flabbiness” in the abdominal muscles.
- Pelvic-floor muscle dysfunction that causes urinary or bowel problems (incontinence, leakage, constipation, etc).
- Low back or pelvic or hip pain.
- Poor posture.
- Feeling weak through the midsection.
- Sexual pain.
Following a cesarean section (C-section), scarring of the incision may accentuate the symptoms associated with DRA.
Your physical therapist will review your medical history and conduct a thorough interview about your condition. This may include specific questions regarding your pregnancy, labor and delivery, type of delivery (C-section or vaginal), presence of pelvic pain, and information related to your physical recovery, including your breastfeeding habits. Your physical therapist will also ask you when your symptoms began, and how they are impacting your daily life.
The primary diagnostic test for DRA is to perform a gentle abdominal examination to note the degree of separation of the abdominal muscle. Your physical therapist will also assess factors, such as your posture, back, and hip movement (range of motion), and muscle strength.
Physical therapy is a very effective way to manage symptoms and improve functional capacity when DRA is diagnosed. Your physical therapist may help you with:
Postural Training. Improving postural control is one of the most important components of treatment for women who are dealing with DRA. Your physical therapist will help you learn how to stabilize your core, without overuse of the rectus abdominis muscle. This will involve training your other core muscles, such as your transverse abdominis (a deep abdominal muscle), and your pelvic floor muscles. Your physical therapist will show you how to perform daily activities, such as lifting and carrying your baby, while using proper posture.
Stretching. When certain muscles become weak and overstretched, other muscles may become overactive and tight. Your physical therapist will help you learn which of your muscles needs to be gently stretched to improve your strength and posture.
Bracing. Sometimes taping or bracing of the low back and abdominal region can provide soothing external support for women with DRA in the early phases of rehabilitation. It can also help teach you the proper position for your midsection, as it provides support and decreases any pain you may be feeling.
Education. There are factors that you may not even know about relating to your pain or movement challenges that your physical therapist can help resolve. Your physical therapist can help you understand the movements or activities that are best to avoid, as you recover from DRA. (For example, women suffering from DRA should not perform traditional sit-ups or crunches.) Your physical therapist will be able to teach you safe and effective ways to regain your full function.
Unfortunately, DRA is not a condition that can be prevented, as it is a natural consequence of pregnancy. However, for women who are in the early stages of their pregnancies, studies have shown that starting a core and pelvic-floor muscle stabilization program is highly effective in improving function, both during and after pregnancy. Many women work with a physical therapist during their pregnancy to learn safe and effective exercise strategies that improve their pregnancy, labor, delivery, and postpartum experiences. If you do develop DRA, the earlier you see a physical therapist, the faster you will be on the road to less pain and improved function!
Katie is a 33-year-old mother who gave birth to her second daughter, Emma, 4 weeks ago. Katie’s 2 pregnancies were normal, delivered vaginally without complications. However, as she expected based on her family history, her baby girls each weighed more than 8 pounds at birth, involving more than 10 hours of labor. Her pregnancy with Emma was somewhat more difficult than her first, as she was working part-time as a paralegal, caring for 3-year-old Lucy, and moving into a bigger house. Her husband and the movers did all of the heavy lifting, but Katie was determined to paint the girls’ rooms herself!
During her third trimester, Katie struggled with some mild urinary incontinence and began developing back pain. She knew she should go see someone about it, but just didn’t have the time.
After Emma was born, Katie noticed that her abdominal muscles looked different—not just the normal stretch marks like she had with Lucy. She felt a ridge along the middle of her abdominal muscles when they contracted (tensed), and felt a divot-like separation when they relaxed. She found herself having difficulty with basic everyday tasks, like carrying laundry up the stairs, and her back really hurt. She became increasingly frustrated when she felt weak and uncomfortable, while breastfeeding Emma in their soft nursery rocker, or when lifting Lucy. One day, she told her friend about her symptoms; her friend said she had experienced the same thing after her pregnancy, and urged Katie to see a physical therapist.
Katie visited the physical therapy clinic later that week. After a detailed interview and thorough examination, her new physical therapist told her that she had a diastasis of her rectus abdominis muscle, which probably began developing during her third trimester.
During the first session, Katie's physical therapist educated her about the different positions and movements that she should avoid, and taught her how to maintain proper posture when lifting her children and when breastfeeding. She gave Katie a soft belt to wear around her midsection for use during the first several weeks of her rehabilitation program, providing a little extra support as she started getting her muscles stronger.
She taught Katie several simple exercises that she could easily do at home, while the girls were napping to "re-educate" the muscles of her abdomen and back. She encouraged Katie to commit to regular one-on-one physical therapy appointments and home exercises for the next 4 to 6 weeks.
Katie went home that day excited and hopeful that she could regain her strength and resolve her back pain, so she could return to work and regular exercise in a few weeks, and be able to care for her family without difficulty.
Two months later, Katie was amazed at how much better she felt. The separation distance of the 2 sides of her abdominal muscle had decreased, and she was able to perform all of her daily activities without pain due to her improved strength. She even started running again without back pain or incontinence. She didn’t feel nervous about reaggravating her back pain when carrying Lucy, or during long, late-night feeding sessions with Emma because of her improved posture.
Katie ran into her friend at the grocery store one morning with both girls in tow, and thanked her for sending her to physical therapy, as it had made all the difference in getting used to life as a mother of 2!
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, or who completed a residency or fellowship in women’s health physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.
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.
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. Diasatis 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.
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