Stretching and thinning of the recti abdominis muscles are a natural occurrence during pregnancy due to abdominal growth, with at least 1 study suggesting that up to 66% of pregnant women have a significant diastasis recti abdominis (DRA) by the end of their third trimester.1 For the majority of these women, this condition will resolve during the early postpartum period. However, in some women, a weakened abdominal wall persists well into the postpartum period, impairing their ability to perform activities of daily living.1–6 Diastasis recti abdominis is defined as a separation and thinning of the recti abdominis muscles and stretching of the linea alba, a fibrous connective tissue structure formed by the fusion of the aponeuroses of the recti muscles.7 The linea alba connects the medial borders of the left and right recti muscles and extends the length of the abdomen from the xiphoid process to the symphysis pubis.7 This fascial structure plays an integral role in maintaining the integrity of the anterior abdominal wall. Lee et al8 described the abdominal musculature and fascia as a “functional and anatomical construct” forming the anterior half of a “canister” containing the entire pelvic girdle contents that include viscera, organs, thoracic and lumbar vertebrae, and the bony pelvis. Together, these structures work as a unit to maintain stability with load transfer (weight shift) activities such as standing, walking, bending, lifting, and squatting.3,8,9 When the linea alba and recti muscles thin and stretch during pregnancy, there is increased risk of impaired tension and poor coordination of the recti muscles, the internal and external obliques, and the transversus abdominis muscles.3,8–12
Pregnancy is the most frequent cause for development of a DRA due to the enlarged abdomen from gestational weight gain and hormonal influences.1,2,13–15 Other suggested causes for DRA include improper weightlifting or abdominal strength training, advanced maternal age (>34 years), a history of midline or cesarean surgery, multiparity, multiple gestation, Caucasian or Asian ethnicity, lack of regular exercise, and child care responsibilities.16–18 A DRA can also occur in males due to conditions that increase intra-abdominal pressure such as chronic obstructive pulmonary disease or obesity.17 In both genders, a diastasis can occur above or below the level of the umbilicus or may be present through entire length of the linea alba, but most frequently occurs at the level of umbilicus.1
Several studies have shown that a DRA does not return to normal values after pregnancy. One cross-sectional study of primiparous and nulliparous women found that 36% still had a significant diastasis at 5 to 7 weeks following delivery.1 Longer duration studies found significant DRA persisting in postpartum women at 6- to 12-month follow-up.5,10
A DRA is considered pathologic when the interrecti distance (IRD) measurement exceeds 2.5 to 2.7 cm width and severity ranges from mild (2.5-3.4 cm) to severe (5-20 cm or greater).8–10,17,19–21
The gold standard for diastasis recti measurement is computed tomography; however, it is rarely used because of expense and impracticality for the clinic setting.17 The most common clinical measurement of DRA is finger width measurement, where the measurement is considered significant if more than 2 fingers can horizontally be placed in the interrecti space (with each finger approximating 1.5 cm).1,14 This method is less frequently used in current research because of poor interrater reliability and validity due to differences in finger size.22,23 Other popular clinical measures for DRA with acceptable intrarater reliability include real-time ultrasound8,9 and Vernier (digital) or nylon dial calipers.22,23 Tape measurement using a flexible plastic or nylon tape is taught in women's health continuing education courses24 as a reasonable and accurate alternative for measuring DRA in the clinic. However, reliability and validity of this measure have not yet been established.24,25
Currently, clinical guidelines for physical therapy treatment for DRA are lacking, although past studies suggest that training the transversus abdominis may be a critical component for restoring abdominal muscle function for lumbopelvic stability during load transfer tasks and in reducing the IRD.8,9,11,13,14,24,26 Among postpartum women with a pathologic DRA, Lee27 suggested that physical therapy intervention can effectively restore strength of the deep abdominal muscles during load transfer activities with or without closure of the diastasis.
Diastasis recti abdominis also has suggested as a precursor to problems later in life. In a retrospective chart review, Spitznagle et al2 established a correlation between the presence of a DRA and 1 or more supportive pelvic floor dysfunctions that included stress urinary incontinence, fecal incontinence, and pelvic organ prolapse.
The purpose of this case report was to describe physical therapy management of a postpartum woman with a large DRA. Specifically, the plan of care emphasized progressive therapeutic exercise of local postural muscles (transversus abdominis, multifidi, levator ani) with progression to coactivation with large global muscle dynamic stabilizers during load transfer activities.
Patient History/Subjective Findings
A 32-year-old (G2P2) African American woman at 7 weeks postpartum was referred to a physical therapist by her obstetrician for management of a large diastasis recti and abdominal muscle weakness. The patient had an uncomplicated pregnancy with a weight gain of 30 lb. Pre-pregnancy body mass index (BMI) was within normal range per the World Health Organization classifications for BMI.28 She indicated that most of the weight gain occurred during the last few weeks of the pregnancy. The patient had a spontaneous full-term vaginal delivery with epidural of a healthy 8#2-oz infant. Pushing time was less than 1 hour and she delivered without perineal tearing. She denied problems with stress urinary incontinence or urinary frequency in the postnatal period.
The patient was newly married and lived with her spouse and her 13-year-old son. She had a strong social support network of family and friends. The patient was college-educated with an undergraduate degree in sports medicine and nearing completion of a master's degree in international relations. She was not working but was active in her church and frequently performed as a public speaker on behalf of her mother's nonprofit organization. She was an active runner through most of her pregnancy but had stopped exercising during her third trimester because of untreated back pain and general discomfort. She also had stopped taking classes because prolonged sitting for the 45-minute driving commute to her school exacerbated her back pain.
The patient scored 0/9 on the Edinburgh Postnatal Depression Scale–3 intake questionnaire, indicating low risk for postpartum depression.29
The patient reported sharp fleeting or burning abdominal pain rated 3 to 8 of 10 on the Pain Visual Analog Scale (VAS)12 during lifting, bending, standing, and walking activities. She recently discontinued breastfeeding because it was difficult to sit and hold her child for more than 5 to 10 minutes and the uterine contractions that coincide with breastfeeding in the postpartum period increased abdominal pain. The patient reported her abdominal muscles felt achy and weak with any activity that involved abdominal contraction, a sickening feeling like her “spine was going to collapse.” She stated that she felt like her “insides were going to fall out.” She denied lower back pain, leg pain, tingling or numbness, or urogenital symptoms, including stress urinary incontinence. Although she reported concerning abdominal pain, her primary concern was abdominal muscle weakness and fatigue limiting activities of daily living. The patient's goals were to be able to pick up her baby out of the crib with minimal difficulty, hold and carry her baby for up to 30 minutes, and stand and walk for up to 60 minutes to tolerate exercise and daily activities. She reported that her physician had offered to refer her to a plastic surgeon but she declined stating that she wanted to avoid surgery. She had not had previous physical therapy.
The patient denied a history of cardiovascular or pulmonary disease or symptoms, diabetes, or cancer. She had lost her pregnancy weight, followed a healthy diet, and was in otherwise excellent health. The patient's vitals were blood pressure 110/75 mmHg, heart rate 65 beats per minute, height 5′7″, weight 130 lb, and BMI30 of 21.6 kg/m2.
The patient's medical history was not significant other than for migraine headaches; however, she denied having migraines postpartum. The integumentary system screen revealed an abnormal finding of a widened linea alba with sunken appearance between the left and right recti muscles at rest in supine and stretch damage to the overlying abdominal skin. A linea nigra was present along the entire length of the linea alba (Figure). Patellar reflexes (L2-L4) were sluggish 1+/5 but symmetric.31 Sensation to light touch was intact for upper and lower extremity dermatones. Cervical and upper extremity screen indicated full pain-free active range of motion. Manual muscle testing for upper extremities was graded 5/5 throughout.32
Figure. An 8-cm dias...Image Tools
The systems screen did not reveal red flags suggestive of nonmusculoskeletal causes for the patient's reported symptoms, or indications for stopping the evaluation for referral back to the physician. The findings of the integumentary system screen and history intake guided the examination focus on confirming the extent of postpartum DRA and related musculoskeletal and functional impairments.
EXAMINATION/TESTS AND MEASURES
The patient presented with a flexed trunk posture seated and standing while bracing her abdomen with her hands providing pressure to approximate the left and right recti muscles. Active range of motion using an inclinometer indicated that lumbar flexion, side bending, and rotation assessed in a standing position were within normal limits without compensatory torsion, minimal abdominal discomfort, and without increased back pain.33 However, trunk extension from a fully flexed standing position was slow and difficult and required abdominal bracing (using her hands to approximate the left and right recti muscles) to complete. Static stand in fully erect posture (0° on inclinometer) was difficult for the patient, causing moderate abdominal pain and a sensation of “pulling” in the abdomen.
Lower extremities were within normal limits for active range of motion.33 Manual muscle testing of the lower extremities revealed 5/5 muscle grades with the exception of 2-/5 hip flexion bilaterally limited by abdominal pain.33 Hip extension and hamstring strength were assessed in alternative positions, those recommended for pregnant women,24 as the patient could not tolerate the prone position. These positions included standing bent over raised table (for hip extension) and seated (for hamstrings).24
In the supine position, passive extension of the hip flexors was assessed with the therapist slowly lowering the leg off the side of the table in a modified Thomas test32 (performed without contralateral end range hip flexion). The patient was unable to tolerate hip extension due to abdominal pain. Tightness was noted in bilateral hamstrings with passive straight leg raise at approximately 60° of hip flexion, without abdominal pain.33 Flexibility assessment of the piriformis, hip adductors, and external and internal hip rotators33 were deferred because of patient discomfort and increased nausea after passive range-of-motion testing of hip flexion and extension. Palpation of pelvic landmarks and lumbar vertebrae in standing, sitting, or supine positions did not reveal alignment asymmetries.31
External assessment of levator ani contraction was performed because, along with the lumbar and abdominal musculature, the pelvic floor muscles are an integral component in maintaining stability through the pelvis during load transfer activities. The patient was positioned sidelying with the therapist lifting the top gluteal with one hand and palpating the levator ani medially of the ischial tuberosity and just lateral of the anus with the other hand. The therapist gently palpates keeping a rigid hand/forearm positioned palm up moving in a cephalic direction toward the anterior superior iliac spine.24 The patient was then instructed to contract her pelvic floor muscles, causing the therapist's fingers to sink deeper into the perineal tissue thereby confirming the presence of a voluntary contraction of the levator ani.24
Abdominal strength during observation of functional transfers (sit to stand, sit to sidelying, side-lying to supine) was noted as weak because the patient needed to approximate her recti muscles by self-bracing with her hands to perform all position changes during the evaluation. She reported abdominal pain and difficulty changing positions and could not tolerate prone positioning. With the patient positioned in supine hooklying, transversus abdominis could be palpated with verbal cueing: “Imagine fogging a mirror and feel your belly button moving in towards your spine a little. Hold that position while you continue to breathe.” However, the patient was unable to hold an isolated contraction of transversus abdominis. She could perform a head raise but was unable to perform a shoulder curl-up, suggestive of poor abdominal muscle strength during trunk flexion.32
Diastasis recti abdominis was assessed with the patient resting in a supine hook-lying position. With assistance provided by the therapist, the patient was instructed to perform a curl-up by lifting her head and shoulders off the plinth with her arms extended toward her knees.3,24 The therapist palpated the scapular spine until it cleared the mat.24 The IRD was palpated using horizontal finger placement at the level of umbilicus to identify the medial rectal borders. The IRD was then measured using a flexible nylon tape measure taken during active contraction of the recti muscles with the curl-up. Interrecti distance measurements were taken at the level of umbilicus, 4.5 cm above, and 4.5 cm below the umbilicus between the medial borders of the left and right recti muscles to establish position, width and estimated length of the diastasis.24
Subsequent measurements were all taken by the same therapist in the same manner, marking 4.5 cm above and below the level of umbilicus each time for consistency. Measurements were taken in 3 places along the linea alba as previous research suggests that a diastasis can occur at several places along the linea alba, and stretch the entire length of the linea alba.1,3,5,34
During palpation, the fingers of both the therapist's hands sank deeply into the interrectal space. The aortic pulse could be palpated through the linea alba, suggestive of poor protection of the aortic artery.8,35
The IRD of more than 5 cm indicated that the patient had a large significant DRA.17 Interrecti distance measured 11.5 cm at the level of the umbilicus; 8.0 cm at 4.5 cm above the level of the umbilicus; and 3.0 cm below the level of umbilicus with vertical measurement of at least 9 cm in length. There was no visible reduction of the IRD noted and there was no palpable tension in the linea alba during the curl-up (Figure).
The patient tested positive for the following lumbopelvic stability tests: Active Straight Leg Raise,36,37 Single Leg Stance,38 Stork test,39 and Trendelenburg37 test (all bilaterally). She also tested positively for the “squat to floor” test.38 These tests were chosen because they have shown good reliability and validity in the literature.36–39 The Active Straight Leg Raise, Single Leg Stance, and Stork tests have been validated for the pregnant and postpartum population.24,38,40
OUTCOME ASSESSMENT TOOLS
The Patient Specific Functional Scale (PSFS)12 was chosen as an outcome measure because of its simplicity. Although the PSFS is not yet validated in pregnant or postpartum women, it has been established as a valid and reliable functional outcomes measurement tool for various chronic and acute musculoskeletal and other dysfunctions (r = 0.67 concurrent validity with Roland Morris for chronic pain; IRR = 0.97 for chronic pain).12 It is a recommended outcomes measure taught in several women's health continuing education courses.24 With the PSFS, the therapist asks patients to identify up to 3 activities they are having difficulty with and then score those activities using a numeric scale from 0 (unable to perform) to 10 (able to perform without difficulty). Minimal detectable change for the total score is 3 points and a 2-point change for an individual task. A PSFS goal score of 24/30 (minimal difficulty) for 3 activities identified by the patient was established (Table).
Table. Summary of Ou...Image Tools
The Pain VAS41,42 was used to assess pain during functional tasks. Pain is rated on the Pain VAS from no pain (0/10) to worse imaginable pain (10/10) by pointing to associated pictures of facial expressions.12,42 The Pain VAS has been shown to have high reliability for assessment of abdominal pain (P < .001, ICC = 0.99, 95% CI).41,42 A goal of less than 3/10 average pain for the VAS during daily activities was established (Table).
The patient presented with a large DRA with impaired muscle strength and poor recruitment of the abdominal muscles resulting in posture dysfunction, impaired biomechanics, decreased lumbopelvic stability during load transfer activities, and poor tolerance for activities of daily living. She was at risk for injury to the aortic artery from a blow to the abdomen because of a weakened abdominal wall with a large interrecti separation.8,35 This patient's impairments classified her under Musculoskeletal Practice Pattern 4D in the Guide to Physical Therapist Practice—”Impaired joint mobility, motor function, muscle performance and range of motion associated with connective tissue dysfunction.”43 The patient's physical therapy diagnosis was Diastasis Recti 728.84. Her prognosis was documented as “fair” because there are currently no clinical prediction rules for physical therapy rehabilitation of patients with severe DRAs exhibiting poor abdominal muscle contractility with lack of tension through the linea alba weakening the abdominal wall.
PLAN OF CARE
An initial plan of care included 2 to 3 sessions per week over 2 to 3 weeks to address goals for promoting adherence with biomechanical strategies, wearing a binder, and a progressive home exercise program focused on activating abdominal, trunk, and pelvic floor muscles to promote efficient load transfer.3,8,11,13,14,24 The patient was advised to avoid abdominal exercises that may further separate the interrecti muscles such as sit-ups, crunches, aggressive stretching of the abdominals, and rotational trunk exercises.13,24,44
Patient education included (a) avoidance of activities that may further separate the recti muscles (ie, quadruped position due to gravitational forces, excessive lumbar extension due to increased stretch of the recti muscles, or ValSalva maneuver to avoid intra-abdominal pressure)13,24; (b) symmetrical weight-bearing in standing and sitting positions to prevent excessive load transfer13,45; (c) good postural alignment with sitting and standing activities for optimal muscle activation13,45; (d) biomechanical strategies activating abdominals, pelvic floor muscles with diaphragmatic breathing during functional transfers (rolling over, supine to sit, sit to stand) and during lifting activities)3,13,45; and (e) self-bracing her abdomen using her hands or a pillow to approximate the recti muscles to reduce abdominal pressure during coughing, laughing, or sneezing.13,24,45
The patient had not been issued an abdominal support garment postpartum and was not wearing one when she arrived for the evaluation. An abdominal support garment was recommended because of the size of her diastasis to provide more stability during functional activities and additional protection for the aortic artery.13,16,17,24 Abdominal support garments consist of a thick layer of elastic fabric that binds tightly around the abdomen, approximating the recti muscles. For reasons of personal comfort, the patient chose to purchase an over-the-counter lingerie corset without stays instead of a standard postpartum elastic support garment typically issued in hospitals. The garment provided adequate support indicated by the patient's ability to maintain erect trunk posture and reported decreased pain while engaging in sitting and standing activities of daily living.
The patient met the short-term goals established by her fifth visit. The plan of care was extended for 11 more sessions for a total of 18 visits from the initial evaluation to discharge over a 4-month time period. Interventions during the extended sessions addressed the patient's long-term functional goals established for sitting, standing, and lifting/carrying her infant, and to improve abdominal muscle contractility to reduce the IRD to less than 2.5 cm for reduced risk of injury to aortic artery from a blow to the abdomen.8,35
Initially interventions focused on therapeutic exercises isolating retraining and strengthening deep local postural muscle stabilizers (TA, pelvic floor muscles, multifidi) in a neutral spine position.3,9,13,26,46 Once local stabilization was improved, therapeutic exercise to strengthen global hip and trunk musculature (that included addressing thinned and overstretched recti muscles) were added to achieve stability with mobility and assist with restoring abdominal wall integrity.3,9,13,19,24,46 The patient continued to wear her abdominal support garment during physical therapy interventions until the 10th visit. By that time, the patient's trunk strength had improved enough to maintain stability for therapeutic exercises, standing, and walking short distances without it, and her IRD had reduced to 5 cm measured at the widest point of separation during a head and shoulder curl-up.
Cardiovascular endurance for daily activities progressed from walking on a treadmill at light intensity (levels 10-11) using the Borg Rate of Perceived Exertion (RPE) Scale47 and advancing to using an elliptical trainer and light jogging on a treadmill at levels 12-13 (“somewhat hard”) on the Borg RPE Scale.47
A detailed summary of the progression of therapeutic exercises organized by interventions provided over visits 1 to 3, 4 to 10, and 11 to 18 in the table format is provided in the Appendix. The table describes interventions performed in the clinic as well as those prescribed for a home exercise program. Exercises were progressed from stable to dynamic starting with supine and seated exercises because those were the most tolerable for the patient. Initially the patient could perform only 1 to 5 repetitions of 3 to 4 exercises before fatiguing. As her strength and endurance improved, more exercises were introduced and repetitions increased until the patient could perform 10 to 20 repetitions of multiple exercises. The exercises through the 10th visit are listed in order of difficulty and not all exercises were performed every visit. By the 11th visit, all exercises were high-level dynamic global muscle and cardiovascular challenges not listed in any particular order. Quadruped exercises were avoided until the patient could maintain contraction of the transversus abdominis against gravity to prevent bulging of the linea alba.
Appendix-a. Summary ...Image Tools
All functional goals were met after 18 physical therapy sessions from evaluation to discharge over a 4-month period. The patient was able to lift her child out of a car seat and hold and carry her infant for 30 minutes without abdominal pain or fatigue. She reported that she had walked for 2 hours the previous weekend before her last treatment during a parade without pain or fatigue. Scores on the PSFS for functional activity goals improved from combined score of 4/30 (severe difficulty) to 30/30 (no difficulty), exceeding the PSFS goal set for 24/30 (minimal difficulty). She had resumed light jogging and reported no difficulty or pain on average (0/10 on the Pain VAS41,42 with daily activities (Table). The patient was discharged from physical therapy with goals met. She was advised to return to her prior jogging duration and intensity slowly using the RPE47 to monitor her tolerance and avoid overfatigue.
This case discusses how the physical therapy interventions of a progressive therapeutic exercise program of retraining TA and local postural muscles for coactivation with larger muscle groups during dynamic activities successfully reduced IRD, restored functional strength, and reduced risk of aortic artery injury due to severe DRA and a weakened abdominal wall. Currently, prognostic studies are not published regarding the outcomes of conservative treatment of physical therapy for patients with DRAs that are based on severity of the IRD. The patient in this case had an IRD measuring 11.5 cm, more than twice the minimal criteria for a severe DRA. Physical therapy intervention reduced the IRD sufficiently to achieve the patient's goals and her desire to avoid a surgical consult. However, in some cases, sufficient tension through the abdominal wall is not restored with a therapeutic exercise program and surgical repair may be warranted.27 Because diverticulation of the recti muscles does not pose a risk for strangulation or incarceration of abdominal contents, surgical repair of a DRA is an elective cosmetic procedure in most cases but one that many women consider because of dissatisfaction with the flaccid appearance of their postpartum abdomen and DRA.15,26
There are various surgical techniques for DRA repair utilizing abdominoplasty or lipoabdominoplasty described in the literature, all of which involve some sort of plication of the rectus sheath. All have associated risks, including hematoma or seroma formation, wound infection, incision dehiscence, necrosis of the skin flaps, hypertrophic scarring, and deep vein thrombosis.15,48–50 Lipoabdominoplasty involves repair of the rectus sheath and liposuction of abdominal fat for a contoured appearance.50 A recent small randomized controlled trial by Benatti et al,48 investigating the effects of abdominal liposuction in 36 normal-weight women, showed that the surgery effectively removed superficial abdominal fat but triggered compensatory abdominal visceral fat in the nonexercising cohort within 6 months postsurgery. Visceral fat did not increase in postsurgical cohort who participated in a supervised exercise program. The authors concluded that a supervised exercise graded exercise program might be an effective and safer alternative to liposuction surgery because visceral fat is associated with increased cardiometabolic risks.48
Currently, there are no clinical guidelines or standardized criteria for surgical candidates with a severe DRA in the literature.27 Only 1 study specific to postpartum women was identified that included the preoperative IRD (mean = 11 cm; range of 8-14 cm) prior to “Venetian blinds” abdominoplasty.49 The patients had surgery an average of 10 months postpartum (range, 8-14 months) but did not state whether the patients had tried conservative treatment prior to surgery.49
Lee27 hypothesized that surgical consult might be warranted after 1 year if (1) a “proper multi-modal program” to restore lumbopelvic stability with load transfer activities had failed; (2) urinary incontinence had not resolved; (3) the IRD was greater than mean values21; abdominal contents could be palpated through the linea alba; and (4) the Active Straight Leg Raise Test36 was positive while neural tension tests and lumbar articular tests were negative.8,27
Although DRA is common in postpartum women, as of yet there are no clinical protocols established in the literature to guide management. However, a recent survey of 296 women's health physical therapists conducted by Keeler et al17 revealed that therapists are using multiple intervention techniques for treatment of DRA. The most popular interventions reported included general TA training (89.2%), TA training during load transfer activities (82.8%), and the Noble Technique.14,17 Other therapists incorporated manual therapy techniques (59%) and therapeutic modalities that included biofeedback and real-time ultrasound (81.2%).17 Further research is needed to assess the effectiveness of different interventions commonly used in the clinic to establish evidence-based treatment guidelines.
Limitations of this case report included the method of measurement used to establish IRD. Dial or digital calipers22,23 and real-time ultrasound8,9 are preferred methods for measuring IRD in the clinic setting because of good reliability and validity; however, neither of these standardized measurement tools was available to the therapist. Finger width measurement1 is commonly used in the clinic, but has poor reliability and validity,22,23 and was not practical to use in this case because the IRD exceeded 8 finger widths. Tape measurement, using a flexible nylon tape, was chosen as the only reasonable alternative readily available to the therapist at the time of evaluation (other than finger width measurement) for clinical assessment of the IRD.1,14 Reliability and validity of using tape measurement for assessment of IRD have not yet been established, however. Other limitations included lack of randomized control studies assessing treatment interventions for DRA, lack of clinical guidelines in the literature, and a lack of validated outcome measures specific to postpartum females with DRA. Also, this case report describes successful physical therapy intervention for a single patient and therefore the results cannot be generalized.
This case report described physical therapy interventions based on a therapeutic exercise program with emphasis on progressive stabilization exercises beginning with retraining the TA and other postural muscles in a postpartum female with a severe DRA. The patient successfully reduced IRD, restored functional strength during load transfer activities, and avoided surgery. This patient was a well-educated woman with an undergraduate degree in sports medicine. She understood the cause and implications of her diastasis and the rationale for treatment and was motivated to avoid surgery. She adhered to her home exercise program and recommended precautions to avoid exacerbation of the DRA and biomechanical strategies to promote lumbopelvic stability during daily activities that likely contributed to her successful outcome. More research is needed to determine the effectiveness of physical therapy interventions for patients with severe DRA to establish evidence-based clinical guidelines for prognosis and effective management.
The author thanks Dr. Jena Ogston, PhD, PT, for her encouragement, guidance, and editing of this case report, and Dr. Rebecca G. Stephenson, PT, DPT, MS, WCS, CLT, for her invaluable advice and support during treatment of this patient. Additionally, the author thanks Trevor Williams, PTA, photographer, and Sarah McKaig, SPT, model for appendix exercise photos.
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diastasis recti abdominis; linea alba; women's health
Appendix-b. Summary ...Image Tools
Appendix-c. Summary ...Image Tools
Appendix-d. Summary ...Image Tools
Appendix-e. Summary ...Image Tools
Figure A1. Advanced ...Image Tools
Figure A2. Head shou...Image Tools
Figure A3. Modified ...Image Tools
Figure A4. Birddog e...Image Tools
Figure A5. Lunge wal...Image Tools
Figure A6. Bosu lung...Image Tools
Figure A7. Bosu alph...Image Tools
Figure A8. Total gym...Image Tools
Figure A9. Total gym...Image Tools
Copyright © 2014 by the Section on Women's Health, American Physical Therapy Association.