What is the recommended physiotherapy approach for divarication of recti (diastasis recti)?

Physiotherapy Approach for Diastasis Recti

The recommended physiotherapy approach for diastasis recti includes specific exercises that decrease interrecti distance, such as head lift and twisted curl-up exercises, while avoiding exercises that increase the separation like isolated pelvic floor muscle contractions and abdominal in-drawing maneuvers.

Assessment and Diagnosis

• A thorough evaluation should include measurement of the interrecti distance using ultrasonography to accurately assess the severity of the diastasis 1
• Assess for associated conditions that may contribute to or worsen diastasis recti, such as obesity, which is a common comorbidity 2

Recommended Exercise Protocol

Effective Exercises (Shown to Decrease Interrecti Distance)

• Head lift exercise: This exercise has been shown to significantly decrease the interrecti distance both above and below the umbilicus (mean reduction of 10 mm above umbilicus and 6.1 mm below umbilicus) 1
• Twisted curl-up exercise: Similar to head lift, this exercise effectively reduces the interrecti distance (mean reduction of 9.4 mm above umbilicus and 3.5 mm below umbilicus) 1

Exercises to Avoid (May Worsen Diastasis)

• Isolated pelvic floor muscle contractions: These exercises have been shown to increase the interrecti distance, particularly below the umbilicus (mean increase of 2.8 mm) 1
• Maximal abdominal in-drawing: This technique increases the interrecti distance below the umbilicus (mean increase of 4.7 mm) 1
• Combined pelvic floor contraction with maximal in-drawing: This combination increases the interrecti distance below the umbilicus (mean increase of 5.0 mm) 1
• Traditional abdominal curls: These should be avoided, especially during pregnancy, as they may worsen the condition 3

Preventive Measures

• Walking and appropriate aerobic exercise during pregnancy is associated with decreased odds of developing diastasis recti 3
• Pregnant women should seek physiotherapy advice before engaging in abdominal strengthening exercises 3

Treatment Progression

• Begin with the exercises that have been shown to acutely decrease interrecti distance (head lift and twisted curl-up) 1
• Progress gradually, monitoring the interrecti distance response to exercise
• For postpartum women, physiotherapy consultation is recommended before resuming abdominal strengthening exercises 3

Important Considerations and Caveats

• While physiotherapy is the first-line approach, it's important to note that surgical correction may be considered for persistent cases, with reported high patient satisfaction rates 2, 4
• The most common complications of surgical intervention include seroma formation (7%), abdominal hypoesthesia (6%), and surgical site infection (2%) 2
• Recurrence rates after surgical correction may be as high as 40%, highlighting the importance of proper physiotherapy as a first-line approach 4
• There is currently insufficient evidence from randomized controlled trials to determine if the acute reduction in interrecti distance from specific exercises leads to permanent narrowing of the gap 1
• Patients should be advised that diastasis recti, while potentially unsightly, does not carry the same risks as actual herniation 4

Monitoring Progress

• Regular reassessment of interrecti distance using ultrasonography is recommended to monitor progress 1
• Patient-reported outcomes regarding functional improvement and cosmetic satisfaction should be tracked throughout the treatment process 2