Propel Physiotherapy

Physiotherapy management for tummy/abdominal separation

What is it?

Diastasis recti, also known as abdominal separation, is the separation of your rectus abdominus (6-pack muscle) and widening or stretching of the linea alba which commonly occurs during pregnancy. As the uterus expands during pregnancy and the relaxin hormones are released to help the body to stretch to accommodate for a growing baby, the abdominal separation then occurs. A widening of more than 2 fingers or 4.5cm postnatally is defined as a abdominal separation (Akram et al., 2013).

What causes it?

Abdominal separation is common for pregnant women, with 27% demonstrating this after their first trimester and approximately 2 in 3 demonstrating this in their third trimester. Almost 1 in 3 women will experience abdominal separation following delivery of their first child, and 2 in 3 following the delivery of their second or more children (Mota et al., 2014). A tummy separation closes the most in the first 8 weeks postnatally. Abdominal muscle strengthening and the abdominal separation can continue to close up to 6months postnatally, especially with intervention (Sperstad et al., 2018).

During pregnancy, there are a number of factors which can contribute to abdominal separation. These may include (Lin et al., 2024):

  • More than 1 pregnancy
  • Giving birth to a baby >4kgs
  • Genetic hypermobility
  • Weight gain during pregnancy
  • Stretching of the muscles of the abdominal wall

How do I know if I have it?

An abdominal separation can by rather tricky to assess, as it is one of the most common misdiagnosed postpartum condition by health professionals. If you do a curl-up or a crunch, you can sometimes see an abdominal bulge or abdominal doming.

Please note that we would prefer to check and diagnose face to face to calculate the inter-recti distance (the distance between the two 6 pack muscle heads).

What can I do about it?

Based on the latest systematic review, there is very strong evidence that exercise therapy that includes abdominal strengthening and deep trunk stabilizer exercises can effectively reduce abdominal separation and improve abdominal separation dysfunctions postpartum. There is a huge emphasis on the goals being to improve abdominal muscle strength and functional ability as full abdominal separation recovery may not always occur. The review has emphasized proper intra-abdominal pressure management and that patients should be taught to engage their deep trunk muscles during exercise and daily activities (Skoura et al., 2024). 

Activating deep transversus abdominus properly

It is very common to have poor transversus abominus activation and technique, especially in the postpartum population. Thus, it is very important that the trasnversus abdominus is activating well when cued, and that it is able to co-contract well with the other abdominal muscles, especially during functional activities (Skoura et al., 2024).

Doing targeted core home exercise programs

Once you are able to contract the deep transversus abdominals well, we would encourage you to layer other core exercises properly with the program. We recommend doing the tailored core exercise program daily to encourage further healing of the abdominal separation (Skoura et al., 2024).

Doing pelvic floor exercises

The pelvic floor muscles which help to support continence, and supports the bladder, uterus and bowels. These muscles are weakened during pregnancy and/or childbirth. Pelvic floor dysfunction occurs in 83% of women with abdominal separation (Fei et al., 2021). Thus, pelvic floor muscles have to contract and work together with the deep core to further reduce abdominal separation (Thompson et al., 2006).

Wearing tight compressions support garments or abdominal binding

Abdominal binding coupled together with exercise therapy has shown to create good results for abdominal separations (Thabet et al., 2019). We normally recommend wearing SRC leggings. We have found very good results with this product. Wearing these garments may help to improve the abdominal separation, and support the core and protect your lower back and pelvis as well.

Doing clinical pilates

To further compliment the home exercise program, it is best to start participating in clinical pilates. Clinical pilates allows for a targeted and a tailored exercise program, which aids to further improve the abdominal separation (Skoura et al., 2024).

What should I avoid?

Avoid doing high impact activities

High impact activities (eg: running, HIIT exercises)should be avoided until further assessment of the deep core has been completed. High impact activities could lead to further stress on the pelvic floor and abdominal system and could lead to other symptoms such as stress urinary incontinence, lower back pain and pelvic girdle pain (Wu et al., 2004).

Avoid heavy lifting and repetitive lifting

As a general rule, we would recommend only lifting up to the current weight of the baby. The only exception is lifting the pram or baby capsule out of the car. We highly recommend usage of a trolley or pram for grocery shopping and asking for assistance from others to aid with any repetitive lifting, or heavier items.

Avoid any demanding core exercises

Demanding core exercises, like situps, or in functional life, such as getting out of bed in a situp position could contribute to further stress and strain on an already stretched abdominal wall. It is important that the abdominal separation and deep core contraction has been checked prior to further recommendation on more demanding core exercises, and more demanding functional activities.
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The Propel Physiotherapy difference

Based on research, we know that the most intensive, spontaneous healing of abdominal separation occurs during the first 8 weeks postnatally. The research has also recommended early timing of core rehabilitation interventions and emphasized an individualization of core rehabilitation programs based on abdominal severity and goal (Skoura et al., 2024).

Thus, here at Propel Physiotherapy, we aim to maximize the outcome of recovery of the abdominal separation by checking on the abdominal separation throughout your pregnancy, and would provide you with advice and exercise modifications as you continue throughout your pregnancy.

Then, we would highly recommend and encourage you to come in at the 4week postpartum period to check in on your tummy separation.

During the 4 week checkup, we will:

  • Assess your abdominal separation
  • Assess deep core control especially the deep transversus abdominus and correct the technique.
  • Provide relevant home exercise program to match your deep core strength and activation
  • Provide education and advice about the abdominal separation
  • Discuss the prognosis of your abdominal separation and a plan to improve your symptoms

Discuss joining physiotherapy-led clinical pilates classes:

***Please note that we highly recommend joining our physiotherapy-led clinical pilates classes. These classes are completely tailored to your abdominal separation, core activation patterning, and will aid with further improvement with your deep core activation, strength and endurance.

Citations:

  1. Akram, J., & Matzen, S. H. (2013). Rectus abdominis diastasis. Journal of Plastic Surgery and Hand Surgery, 48(3), 163–169.
  1. Mota P G, Pascoal A G, Carita A I, Bo K 2014 Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Man Ther 2014
  1. Sperstad, J. B., Tennfjord, M. K., Hilde, G., Ellström-Engh, M., & Bø, K. (2016). Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. British journal of sports medicine, 50(17), 1092–1096.
  1. Lin, S., Lu, J., Wang, L. et al. Prevalence and risk factors of diastasis recti abdominis in the long-term postpartum: a cross-sectional study. Sci Rep 14, 25640 (2024).
  1. Skoura, A., Billis, E., Papanikolaou, D.T. et al. Diastasis Recti Abdominis Rehabilitation in the Postpartum Period: A Scoping Review of Current Clinical Practice. Int Urogynecol J 35, 491–520 (2024).
  1. Thabet,A., Alshehri, M.A. Efficacy of deep core stability exercise program in postpartum women with diastasis recti abdominis: a randomised controlled trial. J. Musculoskelet. Neuronal Interact., 19 (2019), pp. 62-68
  1. Fei, H., Liu, Y., Li, M. et al. The relationship of severity in diastasis recti abdominis and pelvic floor dysfunction: a retrospective cohort study. BMC Women’s Health 21, 68 (2021).
  1. Thompson J A, O’Sullivan P B, Briffa N K et al 2006 Altered muscle activation patterns in symptomatic women during pelvic floor muscle contraction and valsalva manouevre. Neurourology and Urodynamics 25: 268.
  1. Wu W H, Meijer O G, Uegaki K et al 2004 Pregnancy-related pelvic girdle pain (PPP), I: Terminology, clinical presentation, and prevalence. European Spine J 13(7): 575