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Separation anxiety
Tuesday November 13, 2012

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To learn more about treating DRA

Exercises during pregnancy:
Elizabeth Noble. PT

Exercises and splinting, for men and women:
Julie Tupler
Tupler Technique


A relatively common condition, diastasis recti abdominis, a separation of the rectus abdominal muscles, often remains undiagnosed with patients frequently trying the wrong exercises or seeking plastic surgery when physical therapy may offer a solution. However, the recent introduction of new treatment techniques has drawn more attention to the diagnosis.

"Physical therapists can help with this problem," said Jennifer Mohns, DPT, a therapist at Boston Sports Medicine in Allston, Mass. "A lot of doctors and most patients donít know there is a cure for this."

DRA overview

Diastasis recti abdominis refers to a separation of the rectus abdominis muscles at the linea alba. Patients often experience a bulging abdomen, pain around the abdominal muscles and back pain because of the spine not having needed stability. It occurs in men, women and children, particularly premature infants, pregnant women and the obese. "It usually happens when there is a pendulous abdomen," said Linda Looser, PT, CLT-LANA, CES, therapist at New Horizons Physical Therapy in Hamilton, Mont.

In pregnant women, the pressure of a growing uterus causes the muscles to separate. "If you are obese but your extra weight is between the skin and the abdominal musculature, that is not as much of a risk factor as something on the inside pressing out," said Cynthia Chiarello, PT, PhD, assistant professor of clinical physical therapy at Columbia University in New York City. Previous abdominal surgeries and multiple births also appear to be risk factors.

Clinicians measure DRA by ultrasound, calipers and palpating fingers. But that is not enough. Chiarello recommended evaluating the entire pelvic girdle because of the interconnectedness of the muscles and fascia.

Mohns assesses all female patients, asking them to recline, with their knees bent, and do a partial situp while she measures at the navel, and 3 centimeters above and 3 centimeters below the navel. She also checks for hypermobility in the back.

Healthcare professionals do not know how commonly the condition occurs, Chiarello said, because it is not routinely assessed and no widespread studies exist, she said. She found in cadaver studies that it is more common than expected.

If a patient suspects he or she has DRA, Mohns recommends contacting a physician or PT immediately. "The sooner we catch it, the sooner we can fix it, before bad habits start or the separation grows further," Mohns said.

Preventing DRA

Jill Hoefs, MPT, a PT at Body Align Physical Therapy in New York City, teaches pregnant women exercises to help prevent DRA and educates them about posture, body mechanics and supporting the abdomen with a splint.

Chiarello researched the effects of exercise on DRA prevention in a study involving 24 pregnant women, reported in the Spring 2005 Journal of Womenís Health Physical Therapy, and found the DRA had larger separation and occurred more frequently in the group of women who were not exercising. The six-week exercise program included pelvic tilts, advanced pelvic tilts, transverse abdominis contraction head lifts with Kegels, and upper and lower extremity strengthening using an exercise band. Only 12.5% of the exercising women exhibited a DRA of greater than 2 centimeters, compared with 90% of those not exercising.

How PTs treat DRA

Exercising the bodyís core and pelvic floor, the deep abdominal musculature, combined with taping the abdomen or support from a brace are the most common treatments, along with education, good body mechanics and activity limitations.

"You need to do very specific exercises to draw the rectus abdominis muscles back together, approximate them and reduce the strain on the connective tissue," Looser said. "If itís to a significant degree, you have to teach the patient to brace themselves with certain abdominal support during the exercise, or if itís a very significant problem with diastasis, we will often prescribe a support they wear throughout the day."

DRA patients should not do regular situps, which will strain the connective tissue, increasing the diastasis. "Thatís a common mistake," Mohns said. "The situps make it worse."

In addition to avoiding situps, planks or any position that will push on the separation, Hoefs advises patients to avoid rotational activities, such as tennis or golf.

Mohns uses a taping technique to approximate the muscles. Then she teaches patients to isolate and activate the transverse abdominis muscle, the smallest and deepest muscle in the abdomen. Slowly, she instructs them in how to use it with other muscles, and when moving their arms or legs, in hopes it becomes natural for them.

"Anytime they bend forward or lift something heavy, that muscle is turning on and stabilizing them," Mohns said. "Using that muscle, it helps draw the other muscles that are separated back together because it moves horizontally." Over time, the rectus abdominis muscles will grow back together, closing the separation, she said.

Length of treatment depends on the severity of the DRA, both the width and depth between the separated muscles, Hoefs said. She sees patients about every three to four weeks as they perform transverse abdominis exercises at home and wear a splint fit to their size. She described the exercise as a modified situp or head lift and said patients typically find it difficult.

"Everyone has trouble using their traverse abdominal muscles," Hoefs said. "But once they use the transverse abdominals correctly, they see a nice result."

Debra Wood is a freelance writer.

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Tuesday November 13, 2012
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