Diastasis Recti Abdominis (DRA)

    Diastasis Recti Abdominis (DRA) is the excessive widening or separation of the rectus abdominis muscles, and usually occurs in women in the later stages of pregnancy (Fig-1 Diastasis).  Partial recovery occurs naturally within the first 8 weeks post-partum, however, there is no further evidence of healing up to a full year after childbirth. DRA can contribute to ineffective abdominal contractions during 2nd stage of labor, abdominal muscle weakness, back pain, decreased ability to generate/maintain intra-abdominal pressure, poor core stability, and ineffective transference of forces down kinetic chain.

Treatment suggestions for women postpartum with DRA:

Stage 1: Patient lies in hook-lying position and approximates the abdominal muscles in a cross-belly technique while pressing abdominals flat activating core musculature.

Stage 2: Patient lifts head and/or a modified curl up. Inferior angle of scapulae should remain on surface, and progression should take place only if there is no abdominal bulging.

Stage 3: Once DRA has resolved, progression includes functional training of transverse abdominis and multifidi.

*Exercises should also include pelvic floor training if there is evidence of weak pelvic floor musculature. Exercise suggestions below:

1) Contract the pelvic floor muscles and maintain contraction for 10 seconds, release, and repeat 5-10 times.

2) Contract pelvic floor muscles progressively tighter to a count of 5, and then slowly release on a count of 5, 5-10 repetitions.

Tell patient to relax legs and buttocks. No contraction or tension of the abdominals, gluteal, or adductors should occur.

Pelvic floor exercises should be repeated 2-3 times a day, and build up to 25-50 repetitions. If fatigue occurs quickly, fewer repetitions and increased frequency throughout the day is recommended. 

Postural Deviations

    Musculoskeletal complaints are common among pregnant women, including approximately half of women reporting low back pain at some point during their pregnancy (Fig-2 Postural Deviations). Several finding suggest the following postural changes that occur during pregnancy that may lead to low back pain:

  • Decreased joint stability
  • Muscular fatigue, referred pain, and pull or pressure on structures of the musculoskeletal system (increased lordosis, forward head)
  • Relaxin of the posterior longitudinal ligament of the spine allows for disk herniation
  • Direct pressure on the lumbosacral nerve roots due to the increased size of uterus or herniated disks

    These changes can create stretch weakness of the muscles beyond neutral, specifically mid/lower trapezius and lower abdominals. Adaptive shortening can occur in the low back, anterior shoulder, and hip flexors, not allowing these muscles to return to their lengthened position at rest.  Physical therapy includes strengthening of the lengthened/weak muscles, stretching of the shortened musculature, and abnormal postural corrections.