Effectiveness of Manual Therapy and HEP Program for Diastasis Recti and Pubic Symphysis

Pain in an Outpatient Setting

Kelsie Buchkovich, SPTA
Introduction
Diastasis recti is a condition that many women experience during and after pregnancy. This
condition is characterized by a separation of the rectus abdominis muscles along the length
of the linea alba. During pregnancy, the rectus abdominis is stretched to accommodate the
growing baby. This causes the abdominals to weaken. If the rectus abdominis is weak it is
unable to provide the necessary support the back, pelvis, and internal organs. Women with
diastasis recti may also have back pain, pelvic pain, or the separation may lead to a hernia
(1).
There are multiple treatment options available for women with diastasis recti. More
conservative treatment includes exercises, manual techniques, and modalities. Others may
promote the use of external supports such as abdominal binders. There are also some
different surgical options as well to close the separation between the abdominal muscles
(1).
The purpose of this case study is to examine the effectiveness of treating diastasis recti and
pubic symphysis pain in a post-partum woman with primarily manual techniques and a
home exercise program.
Patient
The patient was a 35-year-old white female with diastasis recti and pubic symphysis pain
due to separation and instability. She was a stay-at-home mom to her four children. She
had five pregnancies that were all delivered via c-section. She was 2.5 years post-partum at
the time of treatment. Her pubic symphysis pain started while she was pregnant with her
fourth child in 2012. Her pain went away after delivering her child, but returned with her
fifth pregnancy in 2015. The pain went away a few months after delivering this child but
the pain returned again six or seven months later. The patient was very active and enjoyed
exercising and running frequently. She would sometimes get pain while exercising but not
always. The patient reported that when she would get the pain, it made it difficult to stand
up, roll over in bed, and put pants on. The patient also stated that she usually felt the pain
in a specific spot in her pubic symphysis, but sometimes she could feel the pain in her
pelvic floor as well. She was diagnosed with diastasis recti by her doctor. She had not
received any treatment for diastasis recti or pubic pain prior to coming to outpatient
physical therapy. The patient was not taking any medications at the time of treatment.
Examination
A physical therapist performed the following examination of the patient on August 27,
2018.

Pain 4/10, pain is 7/10 at its worst

Posture Bilateral overpronation of feet, pelvis shifted forward, knees
hyperextended
Range of Motion Thoracolumbar AROM WFL
 Pelvic Alignment L posterior pubic bone, R outflare of ilium, R sacral rotation, R
coccyx rotation
Pubic Symphysis ½ inch separation
Diastasis Recti 2 finger separation below umbilicus, 3 finger separation above
umbilicus; multiple trigger points in rectus abdominis
Special Tests Positive Gillets on left

The physical therapist wrote the following assessment in the patients evaluation note:
Patient is a 35-year-old female presenting with complaints of pubic symphysis pain and
diastasis recti. Eval findings indicate several impairments and faulty biomechanics as noted
in the objective section contributing to poor spine and pelvis stability, SI joint dysfunction,
and pelvic malalignment. Patient also has significant overpronation of feet which
contributes to pelvic instability. Functional activity limitations include transitional
movements. Skilled physical therapy is required to address these impairments and
improve functional limitation, thereby allowing patient to return to previous level of
function without pain or restriction and with an improved quality of life.
Patient responded well to today’s session as noted by good understanding of trigger-point
and scar tissue self-massage and how restrictions in tissues related to diastasis recti and
instabilities. Discussed importance of proper foot support and taped feet today. Also
discussed postural correction as patient stands with significant forward pelvis and
hyperextended knees. Follow up on this next visit and discuss orthotics if appropriate.
Patient’s coccyx is still out at end of session, so follow up on this next session. Patient may
also benefit from taping pelvis for instability.

Interventions
After completing the initial evaluation, the physical therapist wrote the following long-term
goals for the patient’s treatment:
Long-Term Goals:
1. Pt will decrease pain to manageable levels in order to perform daily activities
without restriction.
2. Pt will demonstrate self-assessment and self-correction of pelvic alignment in order
to prevent flare ups of pain and for proper muscle conditioning.
3. Pt will be able to participate in desired activity at previous level of function without
pain or at least be independent with pain management techniques to decrease
discomfort with activity.
This patient was initially seen twice a week for two weeks. Her treatments were then
decreased to once a week and then decreased to once every two weeks as she progressed.
Her initial treatment plan included therapeutic exercise, neuro re-education, manual
therapy, functional dry needling (FDN), strapping/taping of pelvis and feet for stabilization,
kinesio-taping for support, electrical stimulation, ultrasound, and heat/cold for pain relief.
Pelvic Corrections
During the initial examination, the physical therapist found that the patient’s pelvis was out
of neutral alignment as described in the examination portion of this report. The pelvic
alignment was assessed by comparing the heights of the right and left sides of the pubic
symphysis and the right and left anterior-superior iliac spines. The physical therapist
corrected the patient’s alignment by placing a two-inch diameter foam roller horizontally
under the left side of the patient’s pubic symphysis with the patient in the supine position.
The foam roller was left in place for two to three minutes. The foam roller was then placed
under the patient’s right ilium at a 30-degree angle with the patient still in supine. The
foam roller was left in this position for two to three minutes as well. The pubic symphysis
and anterior-superior iliac spines were then re-assessed. When neutral alignment was
achieved, the therapist would place her hands on the medial aspects of the patient’s knees
with the knees bent and instruct her to squeeze her knees together. The therapist would
then place her hands on the lateral aspects of the patient’s knees and instruct the patient to
push out. The therapist would alternate the squeeze and the pushing out several times to
set the pelvis in place. The pelvic corrections were performed at the start of each treatment
and the patient was instructed to perform the same corrections at home at least once a day.
The purpose of this treatment was to align the pelvis in a more neutral position which
would improve the biomechanics of the surrounding musculature and decrease pelvic pain.
Soft Tissue Mobilization
As noted in the examination section, the physical therapist found that the patient had
multiple trigger points in her rectus abdominis. During follow-up visits, she was also found
to have spasms in other muscles including bilateral psoas major, obliques, adductors,
gluteus maximus, gluteus medias, gluteus minimis, and piriformis. These spasms were
released using manual techniques, Graston tools, and functional dry needling. Spasms were
released in order to decrease pain and improve the biomechanics of the muscles.
Joint Mobilization
Joint mobilization techniques were used on the patient’s sacrum, coccyx, and occasionally
on the ribs to return the structures to neutral positions. The goal of this intervention was to
keep bony structures in alignment and to keep musculature in an optimal position to
facilitate better muscle contraction. The joint mobilization also allowed the structures to
give better support to the body and decrease pain. Grades 1, 2, and 3 joint mobilizations
were used on the bony structures.
Bracing/Taping
Leuko tape was applied to the patient’s feet during the first few visits to prevent
overpronation of the feet and to provide adequate support. After the first few visits, the
patient was advised to wear shoes with arch support and was told to consider getting
custom orthotics if shoes alone did not provide enough support.
Muscle Energy Technique for Pubic Symphysis
In order to help decrease the separation between the pubic symphysis, a muscle energy
technique was used. The patient was positioned in supine with her knees bent and feet
planted firmly on the plinth. A sturdy strap was placed under the patient’s pelvis and the
ends of the strap were crossed once in the front of the pelvis. One therapist stood on either
side of the patient and grasped one end of the strap in their hands. The soft ball was placed
in between the patient’s knees. The patient was instructed to squeeze the ball between her
knees while the therapists simultaneously pulled on their end of the straps, this
pulling/squeezing was held for three to five seconds and was repeated five times. At the
end of the fifth repetition, the pubic symphysis was re-assessed for its width. This
technique was performed up to three times until the pubic symphysis separation had
significantly decreased. Over time, the patient’s separation decreased and required fewer
repetitions.
Therapeutic Exercise
Treatment did not often focus on therapeutic exercise. Instead, treatments primarily
consisted on the pelvic corrections and manual techniques as explained previously.
Therapeutic exercise was instead given mostly as part of a home exercise program. The
following exercises were first explained verbally to the patient and then demonstrated
step-by-step. As the patient practiced the exercise, verbal and tactile cues were given to
correct her form. After the patient had successfully completed one to two sets of the
exercise, she was instructed to perform the exercise at home. The therapist would follow-
up with the home exercises and progress them as appropriate.
- Bridging: 3 sets of 10, performed 1x/day
- Piriformis stretch: hold for 30 seconds 3-5 times, performed 2x/day
- Latissimus dorsi stretch: hold for 30 seconds 3-5 times, performed 2x/day
- Transverse Abdominis Activation with tiny steps: 5 minutes duration, 1x/day
o Progressions
 Transverse abdominis activation with one leg in table top and the
other leg performing tiny steps: 5 minutes durations, 1x/day
 Transverse abdominis activation with marching: 5 minutes
duration, 1x/day
 Transverse abdominis activation with leg extension: 5 minutes
duration, 1x/day
The transverse abdominis activation exercise and its progressions was used with this
patient to stabilize the pelvis, core, and back. Its purpose was also to help close the
diastasis recti without causing unnecessary strain to the rectus abdominis.
Home Exercise Program
In addition to the therapeutic exercises and stretches described above, the patient was
instructed to perform scar tissue mobilization to the site of her cesarean sections to break
up adhesions and increase pliability of the scar. She was also instructed to perform her
pelvic corrections and was given a standing posture handout to correct her posture.
Outcomes
Although the patient had not yet reached discharge at the time this report was written, she
had made significant progress towards her goals. The following data was collected after
three months of physical therapy:
Pain 0/10, pain is at its worst at 3/10; patient only notices pain
during her menstrual cycle
Pelvic Alignment L posterior pubic, R outflare, R sacral rotation; pelvis continues
to go out of alignment but is correctly more easily
Diastasis Recti 1 finger width below umbilicus, 2 finger width above umbilicus
Pubic Symphysis ¼ inch separation

Discussion
Although the patient would still require further treatment to completely correct her
impairments the patient made notable progress. The patient’s pain had significantly
decreased, her pubic symphysis separation had decreased, and her diastasis recti had also
improved. Additional physical therapy treatments were necessary to continue to progress
the patient and resolve her separations.
The role of physical therapy in treating diastasis recti and pelvic pain in post-partum
women is still not strongly supported by research. There are only a few studies that have
addressed this topic and the results of these studies are not consistent. One case series
reported that women who participated in therapeutic exercises had decreased diastasis
recti separation than women who did not participate in therapeutic exercises (1). Another
study found that women who performed pelvic stabilization exercises were able to
decrease their pelvic pain and increase their pelvic floor muscle function (2). However, a
systematic review published in 2014 found that data was inconclusive on the effectiveness
of treating diastasis recti with exercise (3). A possible explanation for this is the variety of
exercises that are given to women to treat this condition. A standard protocol for diastasis
recti has not yet been established for physical therapy. Therefore, treatments vary greatly
between therapists. There is also a lot of misinformation on what is appropriate exercise
for pregnant and post-partum women. A quick internet search reveals many different
opinions for professionals and bloggers on what the best way to strengthen weakened
abdominals and correct diastasis recti. More research needs to be done on this subject to
determine the best physical therapy treatments for diastasis recti and pelvic pain.

References
1. Hanif, S. (2017). Therapeutric Exercise in the Reduction of Diastasis Recti: Case
Reports. Pakistan Journal of Medical Research. 2017: 56: 104-107.
2. Teymuri, Z., Hosseinifar, M., Sirousi, M. (2018). The Effect of Stabilization Exercises
on Pain, Disability, and Pelvic Floor Muscle Function in Postpartum Lumbopelvic
Pain: A Randomized Controlled Trial. American Journal of Physical Medicine &
Rehabilitation. 2018: 97: 885-891.
3. Benjamin, D.R., van de Water, A.T.M., Peiris, C.L. (2014). Effects of Exercise on
Diastasis of the Rectus Abdominis Muscle in the Antenatal and Postnatal Periods: A
Systematic Review. ELSEVIER. 2014: 100: 1-8.