HOW TO MANAGE DIASTASIS RECTI
by Alison Brunson, PT, DPT, CSCS, PCES
In an earlier blog, I explained what Diastasis Recti is and how to do a quick self-test at home. Check out that blog here.
Quick Summary of Understanding Diastasis Recti:
DR is a separation of the rectus abdominis muscle, think: “six pack abs” due to thinning of the linea alba. The linea alba is a band of connective tissue that runs between your “six pack” vertically; it functions to stabilize and control the abdominal muscles. It is flexible and is meant to stretch to accommodate pressure within your body. Some natural stretching and DR formation during pregnancy is normal!
I want to be clear: it is extremely normal to have separation of your abdominals, and the vast majority of women will have DR by the third trimester of pregnancy. Your body is designed to expand in order for your baby to have room to grow.
There is a lot of negative talk surrounding DR online. Hopefully, this blog gives you a little more information to help reduce anxiety during your pregnancy and postpartum. Reading about DR can be a black hole of endless information, here is a summary of some basics. Keep in mind, everyone is different. Talk with a pelvic floor PT to learn what will work best for your own body.
How to manage DR at home?
Emphasis should be put on the Inner Unit muscles with deep core exercises to learn how to brace properly. In order to manage DR, we need to activate your muscles to fire correctly and provide stability. Remember: exercises should not cause excess intra-abdominal pressure which reinforces the “coning” of DR. For example: avoid sit ups or double leg lifts, if they cause “coning”.
There’s a research article by Thabet and Alshehri about women with DR at 3-6 months postpartum. One group performed abdominal bracing exercises (diaphragmatic breathing, planks, isometric contractions, etc) along with a traditional core program. The control group only completed the traditional core program. It was found that those who performed both abdominal bracing + traditional core exercises had improved outcomes compared to the control. Abdominal bracing exercises may seem boring and tedious, but they serve as quite literally a foundation for all core based exercises. Get these correct first before moving on!
Step One: Isolated Activation and Breathing
Start with a basic understanding of how your muscles activate. Each muscle can be isolated - this will give you some body awareness.
Transverse Abdominis (TA): Lie on your back with your knees bent. Put your fingers on your muscle just inside the front pelvic bones. Use these cues: “Imagine you are pulling your pelvic bones together (towards your belly button) in a straight line”. Activate TA + hold for 3-5 seconds, repeat 10x. Check that there is no arching of the back, coning, flaring of the rib cage or sucking in during activation.
Pelvic Floor: Lie on your back with your knees bent. “Imagine trying to stop the flow of urine”. Activate and hold for 3-5 seconds, repeat 10x. Check that you don’t squeeze your glutes, move your legs or change position of your spine during activation.
Diaphragm: Lie on your back with your knees bent. Put both hands on the lower half of your ribcage. Practice breathing into your hands without moving your chest. A trick is to “sniff” into your hand on the belly to encourage diaphragmatic breathing. Next, focus on 360* breathing. This means you're not just breathing into your chest or belly (known as: belly breathing). Instead, your inhale should create expansion of the rib cage in all 360 degrees: front, sides and back.
Be mindful of your breath and bring awareness to your inhale/exhale to promote natural work of the deep inner core system.
Try this:
Fully exhale, then hold for 5 seconds to reset the system
Inhale 360 degrees with focus on lateral rib movement
Tip:
Put a pillow (or two) in front of your abdominals during your breathing exercises. This can force the pressure into your back and sides, instead of the front. You will get better back and side expansion!
Practice these foundational exercises in different positions:
Sitting, Sidelying, Standing, Squatting, Walking
Now, put it all together -> 360* breathing + TA with gentle pelvic floor contraction
Step Two: Build Upon the Foundation
Continue using the principles learned above to maintain proper form while trying more advanced exercises.
Double check your abdominals during each exercise to make sure you are managing pressure properly (NOT “coning”) and maintaining a neutral spine.
90/90 Breathing
Pallof Press Rotations in Lunge Position
Bird Dog
Front Plank with Adductor Squeeze
Step Three: Work the Entire Kinetic Chain
It’s important to look at how your whole body is moving. Work on your posture and proper alignment. Are your ribs stacked over your pelvis? Are you still hanging forward into your hips/arching your back? Do you have weak glutes or hamstrings? Overactive paraspinals? How is your pelvic floor? All of these questions are great to think about during your self evaluation.
The Posterior Chain
With a posture that puts you into the anterior tilt (arched back), your abdominals are in a constant lengthened position. Think about during pregnancy with a larger belly adding weight to the front, pulling you into an arched back position, This puts additional pressure on the abdominal wall & linea alba, in turn making it harder to heal DR.
The hamstrings and glutes are key players in maintaining a neutral pelvis and pulling you out of an anterior tilt. Incorporate Posterior Chain-focused exercises into your work outs for a well-rounded session.
Bridges Isometric Holds
Hip Thrusts
Split Squats
Single Leg Deadlift
Upper Body
Other influencing factors that may impact DR healing include Serratus, Middle and Lower Trap weakness. All of these exercises require abdominal activation in addition to scapular stabilization and strength.
Serratus Wall Press
Side Planks
Band Pullovers
Should I Use an External Brace/Abdominal Binder?
An abdominal external brace can provide additional support and comfort for the abdominals.
If you choose to wear a brace, here are my thoughts:
) Wear it postpartum for about 8 weeks, if necessary. Stop wearing it as soon as possible.
) Stop wearing it if you have the ability to activate the Inner Unit/deep core muscles independently.
) Do not rely on the brace, you should always be performing exercises to regain control of the Inner Unit in conjunction with the brace.
) Talk to your doctor about the correct way to wear a brace (example: wrap bottom up to avoid increased pressure on your pelvic organs, gentle compression only).
Overall, use caution and talk with your physical therapist to see if it’s right for you.
RESOURCES
Ptaszkowski, paprocka-borowicz. Assessment of bioelectrical activity of synergistic muscles during pelvic floor muscles activation in postmenopausal women with and without stress urinary incontinuence: a preliminary observational study. Clinical Interventions in Aging. 2015;1521-1528.
Dufour S, Bernard S, Murray-Davis B, Graham N. Establishing expert-based recommendations for the conservative management of pregnancy-related diastasis rectus abdominis: A Delphi consensus study. Journal of Women’s Health Physical Therapy. 2019 Apr 1;43(2):73-81.
Thabet AA, Alshehri MA. Efficacy of deep core stability exercise program in postpartum women with diastasis recti abdominis: a randomised controlled trial. Journal of musculoskeletal & neuronal interactions. 2019;19(1):62.
Resources from the APTA (American Physical Therapy Academy), Choose PT. https://www.choosept.com/guide/physical-therapy-guide-diastasis-rectus-abdominis
Hills NF, Graham RB, McLean L. Comparison of trunk muscle function between women with and without diastasis recti abdominis at 1 year postpartum. Phys Ther. 2018;98(10):891–901. Article Summary on PubMed
Keshwani N, Mathur S, McLean L. Relationship between interrectus distance and symptom severity in women with diastasis recti abdominis in the early postpartum period. Phys Ther. 2018;98(3):182–190. Article Summary on PubMed.
Kamel DM, Yousif AM. Neuromuscular electrical stimulation and strength recovery of postnatal diastasis recti abdominis muscles. Ann Rehabil Med. 2017;41(3):465. Article Summary on PubMed.
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. Article Summary on PubMed.
Sharma G, Lobo T, Keller L. Postnatal exercise can reverse diastasis recti. Obstet Gynecol. 2014;123 Suppl 1:171S.
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.
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