Musculoskeletal Science and Practice 53 (2021) 102381

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Musculoskeletal Science and Practice

journal homepage: www.elsevier.com/locate/msksp

Original article

Exercises, Tubigrip and taping: can they reduce rectus abdominis diastasis
measured three weeks post-partum?
Jill Depledge a, *, Peter McNair b, Richard Ellis c
a
Community Rehabilitation Team, Auckland District Health Board, Auckland, New Zealand
b
Health and Rehabilitation Research Institute, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
c
Active Living and Rehabilitation: Aotearoa New Zealand, Health and Rehabilitation Research Institute, School of Clinical Sciences, Auckland University of Technology,
Auckland, New Zealand

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Rectus abdominis diastasis is regarded as a risk factor for abdominal muscle dysfunction and
Womens health reduced quality of life postpartum. It is thought that specific exercises and additional physical support might
Postpartum reduce the diastasis, with a need to establish efficacy in doing so.
Abdominal exercises
Objectives: Determine the effect of four abdominal exercises as well as Tubigrip or taping in reducing rectus
Diastasis
Rectus abdominis
abdominis diastases three weeks postpartum.
Design: Cross-sectional repeated measures comparison.
Methods: 32 women undertook a single session of ultrasound imaging. Ultrasound measurements of inter-rectus
distance were taken at rest and during: 1) crook lying abdominal “drawing in” exercise; 2) crook lying trunk curl-
up; 3) early Sahrmann level leg raise; 4) McGill side lying plank. The curl-up and abdominal “drawing in” ex­
ercises were assessed under two further conditions: a) wearing Tubigrip, b) taping across the diastasis. Data
analyses involved repeated measures ANOVA.
Results: At rest the mean inter-rectus distance above and below the umbilicus was 3.5 cm (SD:1.1) and 2.6 cm
(SD:1.2) respectively. A significant decrease (19%, p < 0.05) was observed at both measurement points during
the curl-up exercise. No other exercises elicited a significant difference compared to resting. At rest, wearing
Tubigrip reduced the inter-rectus distance (7%, p < 0.05). During exercise, there was no additional change in the
inter-rectus distance (p > 0.05) with supports.
Conclusion: The curl-up exercise was most effective in reducing inter-rectus distance. As no exercises invoked an
increase in the rectus diastasis, they could not be regarded as potentially detrimental. Tubigrip and taping did not
add to the effects of these exercises.

1. Introduction
It has been suggested from a mechanical perspective that the linea
alba is very important to the stability of the abdominal wall (Hernan­
dez-Gascon et al., 2013). Rectus Abdominis (RA) diastasis involves a
widening of the linea alba between the left and right recti muscles, and
may lead to dysfunction of this structure and the performance of asso­
ciated trunk muscles (Benjamin et al., 2019; Coldron et al., 2008). RA
diastasis commonly occurs during pregnancy as a result of biomechan­
ical stresses imposed by the growing uterus, as well as hormonal in­
fluences causing laxity and stretching of the abdominal muscles and
linea alba (Akram and Matzen, 2014; Mota et al., 2015b). This diastasis
may not always spontaneously resolve and can persist in 30–60% of
women (Liaw et al., 2011; Sperstad et al., 2016), and may lead to a
decreased quality of life (Benjamin et al., 2019).
There is uncertainty regarding the efficacy of physiotherapy for
women with postnatal RA diastasis (Akram and Matzen, 2014), and a
common treatment protocol has not been established (Michalska et al.,
2018). Current conservative treatment most often involves abdominal
muscle training and the use of abdominal binders/supports (Keeler
et al., 2012). It has long been thought that exercises should not induce an
increase in the inter-recti distance, and thereby place additional strain
on already lengthened tissues. However, this view has been challenged
by Lee and Hodges (2016). They suggested that the undulating

* Corresponding author.
E-mail address: jilldepledge@gmail.com (J. Depledge).

https://doi.org/10.1016/j.msksp.2021.102381
Received 3 September 2020; Received in revised form 11 April 2021; Accepted 14 April 2021
Available online 22 April 2021
2468-7812/© 2021 Elsevier Ltd. All rights reserved.
J. Depledge et al. Musculoskeletal Science and Practice 53 (2021) 102381

distortion observed when the diastasis is reduced by some exercises
might not optimally support abdominal contents and could elicit a less
desirable cosmetic appearance, as well as detrimentally affect the me­
chanical function of the linea alba. Hence Lee and Hodges (2016) would
recommend exercises that increase tension in the linea alba regardless of
the inter-recti distance.
To date most research concerning exercise has been focused on the
former perspective, that a reduction in the diastases is beneficial. A
systematic review published in 2014 by Benjamin et al. (2014) high­
lighted that support for particular exercise regimes relied primarily
upon small case series and single case studies and hence was limited.
Since this systematic review, Walton et al. (2016) undertook a small
clinical trial (N = 4–5 per group) and reported that after a six week
intervention period a core stability plank exercise programme was as
effective as a traditional supine exercise programme in reducing RA
diastasis. More recently in another small pilot trial (N = 7–8 per group)
with an intervention period of 12 weeks, Keshwani et al. (2019) found
that the exercises did not have a positive effect upon RA diastasis. In
contrast, another pilot study (N = 7–10 per group) by Tuttle et al. (2018)
showed that a 12 week programme of exercises that targeted transversus
abdominus (TA) in different postures led to significantly greater im­
provements in RA diastases compared to a control group. It is apparent
from these trials that quite varied exercises were utilised in the in­
terventions, and hence there is difficulty in determining which specific
exercises reduce or at least do not increase the RA diastasis.
To date, findings from cross-sectional studies utilising ultrasound
have provided considerable evidence that the abdominal trunk curl in­
duces a reduction in the diastasis (Beamish et al., 2019; Gluppe et al.,
2020; Lee and Hodges, 2016; Pascoal et al., 2014; Sancho et al., 2015).
Furthermore Beamish et al. (2019) utilised elastography to show that in
women without RA diastases, stiffness at the linea alba progressively
increased during head up and curl up exercises, however in those with
diastases stiffness did not increase, providing evidence of structural and
mechanical dysfunction. Researchers (Mota et al., 2015a; Sancho et al.,
2015) have also reported that the abdominal drawing in exercise that
focuses on TA activation induced increases in the RA diastasis, while
others (Gluppe et al., 2020; Theodorsen et al., 2019) have highlighted
increases in the RA diastase with combinations of the drawing in exer­
cise with pelvic floor activation. Of note, a number of these
cross-sectional studies have included women at a timepoint greater than
six weeks postpartum, and there would be merit in examining effects
earlier with a view that if women are able to undertake the exercises
effectively, they might limit the effects of disuse on muscle and associ­
ated soft tissues. This is particularly so in respect of core stability plank
exercises such as the side plank which place notable strain upon the
trunk, and has been found to be intolerable in individuals with chronic
back pain (Calatayud et al., 2019).
Of further importance, anecdotally it has been suggested that addi­
tional physical support in the form of binders, braces, corsets and taping
may provide an adjunct to exercise and impart a more perennial
reduction of the RA diastasis. Regarding these supports, Keeler et al.
(2012) reported that 38–40% of physiotherapists instructed patients
with RA diastasis to wear an abdominal binder while performing exer­
cises or during daily living tasks. There is limited research assessing the
ability of abdominal supports/binding at rest or during a specific exer­
cise to reduce the RA diastasis. From a non-randomised clinical trial,
El-Mekawy et al. (2013) reported that an exercise group reduced RA
diastases significantly more (34%) than an abdominal binder only group
(18%) over a six week period. More recently, a pilot study by Keshwani
et al. (2019) compared a 12 week intervention that included an
abdominal binder group and found no difference in change of the RA
diastases between that group (50% reduction) and a control group (60%
small number of participants, the different research designs and
different supports do not allow a firm conclusion concerning their
benefits. Additionally, despite its notable use in clinical practice, Tubi­
grip has not been assessed. While perhaps not as tight a support as a
binder or belt, Tubigrip has an advantage in that it can be worn
comfortably for greater periods of time and hence is worthy of
assessment.
Given the above mentioned points, it was thought beneficial to
reassess some previous findings, and build upon research to date with
the inclusion of previously untested exercises and abdominal supports.
Hence, the current study assessed the effects of 1) abdominal curl up, 2)
drawing in exercise, 3) early Sahrmann level leg raise; and 4) a modified
McGill side plank. Additionally the effect of Tubigrip and taping in
reducing the RA diastasis at rest and during exercise was assessed in
women three weeks post-partum which is notably earlier postpartum
compared to most previous research.
2. Materials and methods
2.1. Study design
A cross-sectional repeated measures comparison.
2.2. Participants
Thirty-two women were recruited from Auckland Birthcare and
Auckland City Hospital (Table 1). Based on previous reliability testing
(Iwan et al., 2014) of the primary dependent variable (diastasis dis­
tance), and with power set at 0.8 and an alpha level of 0.05, the number
of subjects required to observe a moderate effect was 30. An initial
clinical assessment by an experienced women’s health physiotherapist
determined whether the women met the inclusion criteria: vaginal birth,
RA diastasis greater than two finger breadth, able to speak and under­
stand English, available between 2 and 4 weeks postpartum for an USI
examination. Exclusion criteria were: a significant history of notable
back and pelvic pain, previous abdominal surgery, any medical condi­
tions that would prohibit active abdominal muscle activation.
2.3. Procedures
The procedures were approved by the Northern Region Health and
Disability Ethics Committee and the Auckland District Health Board
Research Review Committee. All participants signed a document of
consent prior to participation.
All participants undertook a single session of USI. B-mode ultrasound
images were recorded on a Philips iU22 scanner with either a 4–12 MHz
linear or a 4–9 MHz curvilinear transducer (Philips Medical Systems Co.,
Eindhoven, The Netherlands). The scanning was undertaken by a single
experienced ultrasonographer who had participated in a reliability study
associated with the technique (Iwan et al., 2014). Our reliability in the
techniques utilised by Mota et al. (2012) was found to be high with ICC
values greater than 0.91.
Measurements were obtained at two locations, 2 cm above and below
the umbilicus. The focus, depth, and gain settings were manipulated
individually to increase image clarity of the rectus abdominis borders
Table 1
Demographic variables of the participants.
Statistic Age Mass Height Baby Time Parity LLTQ
(years) (Kg) (cm) mass P–P (N) (ADL)
(Kg) (days) (/40)

reduction. Concerning taping, a pilot study by Tuttle et al. (2018) re­ Mean 32 65 166 3.6 21 1.75 37
ported that changes in RA diastases in a kinesiotape alone group (19%) SD 4.6 7.9 5.9 0.47 4 0.9 3.6
were not significantly different from a control group (8%) following an Abbreviations: P–P postpartum; LLTQ (ADL) Lower limb Tasks Questionnaire
12 week intervention period. Across the above studies, the relatively (activities of daily living).

2
J. Depledge et al.
and therefore the RA diastasis, and to differentiate signals from sur­
rounding anatomical structures. Images were recorded immediately
following relaxed exhalation (Teyhan et al., 2007) with the participant
in a stable position that they held for a 3–4 s period.
All participants were given time to practice the exercises immedi­
ately prior to the ultrasound measurements to ensure they were per­
formed correctly. All participants undertook all conditions, undertaken
in a random order. A standardised set of instructions was presented to
each participant. As part of standard care postpartum, all participants
had received instructions related to pelvic floor and TA activation ex­
ercises 2–3 days post-partum, and they had been advised to utilise these
exercises when they were doing tasks such as lifting at home. Two
repetitions were collected for data analysis for each condition. These
were separated by a few seconds, with a 1–2 min interval between the
different conditions to limit the possibility of fatigue. The mean of these
repetitions was used for statistical analyses. The analyses were under­
taken with blinding of the condition present on scans.
As well as a resting position, four exercises were assessed (Fig. 1):
1. Abdominal drawing-in with pelvic floor activation attempting to stop
the flow of urine: the participant was in supine with hip and knee
joints flexed to 90◦ .
2. Crook lying trunk curl up: with hip and knee joints flexed to 90◦ the
participant was asked raise the head and shoulder blades just off the
plinth. During this exercise they moved their hands along their thighs
toward the knee.
3. Early Sahrmann level single leg raise with abdominal drawing-in
(Sahrmann, 2002): from supine lying, participants flexed one leg to
90◦ hip flexion.
4. Modified McGill side-lying plank: from a side lying position, partic­
ipants raised the hip vertically from the plinth to align the trunk and
thigh. The modification to the traditional side plank was in the
alignment, which normally involves the hip and knee joints being
raised. There was a rest period of 1 min between trials and exercises
were presented randomly (computer based numbering algorithm).
Additionally, we assessed the effects of taping and Tubigrip (Tubi­
grip, Mölnlycke Health Care Ltd, UK) during the abdominal drawing in
and the trunk curl up exercise. For the taping condition, two pieces of 10
cm wide Kinesiotape (RockTape Inc., Durham, NC, USA) were laid
across the anterior abdomen above and below the umbilicus closely
adjacent to the ultrasound measurement points. These were centred on
Fig. 1. Exercises performed: A: abdominal drawing in with pelvic floor activation; B: trunk curl up with scapula just off the plinth; C: Sahrmann leg raise with hip
flexion to 90◦ ; D: modified McGill side lying plank.
3
Musculoskeletal Science and Practice 53 (2021) 102381
the midline and extended laterally to approximately be in line with the
left and right anterior superior iliac spines. The tension in the tape was to
a level of approximately 40% of maximal extension that the tape
allowed. In the Tubigrip condition, a double layer of size ‘L’ Tubigrip
was utilised. The order of all exercises and conditions (Tubigrip/taping/
no support) was randomly assigned.
2.4. Statistical analyses
Statistical procedures were undertaken in SPSS Version 19 (Statis­
tical Package for the Social Sciences, IBM Corp., Armonk, NY, USA).
Separate analyses were undertaken for data collected from the two
scanning locations (above and below the umbilicus). The normality of
the data’s distributions was assessed by the Shapiro-Wilk test and
descriptive statistics were calculated. Mauchly’s test was utilised to
determine if the variances across conditions and the covariances be­
tween pairs of conditions were equal (Field, 2013). Where violated, the
Greenhouse-Geisser correction to the F ratio was applied. A single factor
repeated measures analysis of variance (ANOVA) was utilised for the
comparison across rest and exercises. A second single factor ANOVA
compared no support, Tubigrip and taping. A two factor (support and
exercise) repeated measures ANOVA was utilised for the comparison
across supports and exercise. Where significant main effects were
observed, pairwise comparisons (Sidak test) were utilised to determine
where the differences across levels of a factor arose. The alpha level was
set to 0.05.
3. Results
Three participants were unable to be tested as their diastases were
greater than the width of the ultrasound probe (5.0 cm). All other
women (N = 29) completed all of the procedures and conditions without
pain. Table 1 shows the demographics of the group. In summary, their
mean age was 32 years and they were of a typical build with mean height
and mass being 166 cm and 65 kg respectively. At the time of testing
(mean: 21 days postpartum), they were able to perform activities of
daily living with little difficulty as indicated by their mean score of 37/
40 on the Lower Limb Task Questionnaire (McNair et al., 2007) where a
score of 40 is indicative of no difficulties.
At rest, the mean and standard deviation (SD) of the inter-rectus
distance above and below the umbilicus was 3.5 (SD:1.1) and 2.6
(SD:1.2) cm respectively. At both these measurement points, a
J. Depledge et al. Musculoskeletal Science and Practice 53 (2021) 102381

significant decrease (19%, p < 0.05) was observed when performing the
curl up exercise. No other exercises elicited a significant difference
compared to the resting condition (Fig. 2).
At rest in a crook lying position, in respect of Tubigrip versus taping
versus the no support condition, wearing Tubigrip led to a significant (p
< 0.05) reduction (7%) in the inter-rectus distance (Fig. 3). During the
two exercises (curl up and drawing in), there was no significant effect (p
> 0.05) across supports above and below the umbilicus (Fig. 4).

4. Discussion

The current research contributes to previous findings concerning the

curl up exercise, and extends our knowledge concerning other exercises
(Sahrmann leg lift and the modified McGill side lying plank exercise),
which are often prescribed for enhancing trunk muscle performance,
and have been utilised in interventions for RA diastases (Keshwani et al.,
2019; Walton et al., 2016). We also provide novel results concerning
Tubigrip and taping.
It is difficult to compare our mean values for RA diastasis with those
Fig. 3. A comparison of the inter-rectus distance (cm) with no support, Tubi­
of other authors primarily due to the considerably longer time point at
grip and taping when in a crook lying resting position. Data are means and
which measurements took place in previous studies. The size of the RA standard deviations.
diastases at rest has been shown to decrease over the months post­
partum. For instance, Coldron et al. (2008) reported a mean of 42 mm at
one day postpartum which had reduced to 23 mm within eight weeks.
Our findings fit within this range with a mean of 35 mm observed at
three weeks postpartum. In the current study, all participants were able
to perform the exercises with correct form at three weeks postpartum
without concern or adverse events, hence providing support for their
inclusion in early postpartum exercise regimes.
Concerning specific exercises, the abdominal trunk curl reduced the
RA diastasis by 19% and this was in agreement with previous research
(Beamish et al., 2019; Gluppe et al., 2020; Lee and Hodges, 2016; Pas­
coal et al., 2014; Sancho et al., 2015) reporting reductions ranging from
11% to 35%. This reduction likely reflects the technique performed
when undertaking the exercise. Specifically trunk flexion is limited. It
seems likely that the traditional curl up, where considerably greater
trunk flexion occurs, would generate increased intraabdominal pressure
and consequently have more potential to increase the diastases, partic­
ularly postpartum. Relatedly a biomechanical study by Brown and
McGill (2008) showed that RA is the primary muscle able to generate

Fig. 4. A comparison of the inter-rectus distance (cm) with no support, Tubi­

grip and tape during the curl up and the ‘drawing in’ exercises. Data are means
and standard deviations.

Fig. 2. A comparison of the inter-rectus distance (cm) at rest in crook lying and
during the four exercises. Data are means and standard deviations.
forces that will resist the strain imparted upon the linea alba. Their
findings highlight that this effect is most apparent at low force levels.
Brown and McGill (2008) suggest that the multiple tendinous sections
throughout the RA provide it with an increased ability to resist laterally
directed forces. In the current context, where the linea alba is stretched
and possibly damaged, it is important that the RA is activating and also
has sufficient strength to counter laterally directed forces produced by
transversus abdominis (TA) and the oblique muscles. It has been re­
ported by Benjamin et al. (2019) that there is a negative association
between the RA diastasis width and abdominal flexor muscle strength.
Traditionally, there was a greater focus upon retraining of the rectus
abdominis in patients postpartum (Noble, 2003). However, the advent
of motor learning strategies for addressing poor trunk control in in­
dividuals with lower back pain led to increased emphasis being placed
upon facilitating activity in other abdominal muscles, particularly the
TA. (Keeler et al. (2012). Overall, for the reasons highlighted above, it
would seem important that clinician’s continue to give some attention to
improving RA performance.
In the current study, the drawing in exercise which is thought to
selectively activate TA did not affect the inter-rectus distance. It seems
likely that sufficient RA activity was present to counter the activity of

4
J. Depledge et al.
the TA and oblique muscles. Our finding was in contrast to work by other
researchers (Gluppe et al., 2020; Mota et al., 2015a; Sancho et al., 2015;
Theodorsen et al., 2019) who observed significant increases in the
inter-recti distance during the drawing in exercise in women post­
partum. Contrary to such findings, Tuttle et al. (2018) reported signifi­
cant reductions in the RA diastasis after 12 weeks of exercise focused
upon TA exercises in a small randomised trial (N = 5–10 per group).
A widely utilised progression of the drawing in exercise is the
addition of hip flexion to 90◦ . This exercise which is part of the Sahr­
mann five level core stability test protocol has not previously been
assessed in a cohort with RA diastases. Our findings showed no change
in the RA diastases during this exercise and we speculate that this is
related to the level of the test that our cohort performed, with the heel of
the contralateral leg on the plinth. Chan et al. (2020) have shown that
RA activation as well as that of TA/IO and EO are significantly lower
when the heels are upon the plinth compared to the next level of diffi­
culty where the heels remains off the plinth.
The modified McGill side plank has also not previously been assessed
independently in an RA diastases cohort but has been included within an
exercise programme for RA diastases (Keshwani et al., 2019). Addi­
tionally a small RCT undertaken by Walton et al. (2016) has highlighted
the increasing use of core stabilising exercises for RA diastases. Concern
related to this exercise has been reported by Calatayud et al. (2019) who
found that the majority of their participants with lower back pain could
not tolerate this exercise when undertaken with the foot being the distal
contact point with the floor. Our findings showed the RA diastasis was
unchanged when undertaking this exercise and there were no negative
comments or inability to perform the task in our cohort. The modified
position utilised in the current study, where the knee remains upon the
ground, reduces the amount of mass to be lifted hence lessening the
muscle force required to maintain limb alignment, thus providing a
more feasible exercise in the early weeks postpartum, and one which can
be progressed by raising the knee and performing the unmodified
version.
Keeler et al. (2012) reported that nearly 40% of physical therapists
recommend some form of additional support (binders and corsets) when
patients with RA diastasis undertake exercise or daily activities. It is
thought that these supports may generate mechanical forces that might
reduce strain, and also provide additional sensory feedback that could
alter muscle activation (McNair and Heine, 1999). The current finding of
a seven percent decrease in the RA diastasis when at rest provides
limited evidence of Tubigrip’s efficacy. Additionally, during the curl up
or the drawing in exercise, no significant additional reduction was
gained by wearing either Tubigrip or taping. Our finding that taping was
not effective in reducing the RA diastasis was in agreement with Tuttle
et al. (2018) who used a similar type of tape in a longitudinal study
where participants were asked to wear it intermittently over a 12 week
period.
There are some limitations to be considered. Firstly, its cross-
sectional design precludes making judgements on the longer term ef­
fects of exercises, Tubigrip and taping. Additionally, we were not able to
include potential participants who had RA diastases wider than the
scanning width of the probe (5 cm). This led to three participants not
able to participate. Alternative imaging techniques in ultrasound (e.g.
use of panoramic views) would allow such individuals to be included.
5. Conclusion
The curl up exercise was the most effective exercise in reducing inter-
rectus distance, but further work is needed to test its efficacy over a long
term training program. As no exercises led to increases in the RA dia­
stasis, none could be regarded as unsafe. In respect to external supports,
Tubigrip provided a statistically significant reduction at rest only, but its
magnitude is unlikely to be clinically relevant. Taping was not effective
in reducing the RA diastases in the conditions tested. Overall, the find­
ings provide information that can enhance the prescription of exercises
5
Musculoskeletal Science and Practice 53 (2021) 102381
for women with RA diastases.
Source(s) of support
The work was supported by a grant from the A+ (Auckland District
Health Board) Charitable Trust.
Ethics approval
This study was approved by the Northern Region Health and
Disability Ethics Committee and the Auckland District Health Board
Research Review Committee.
Declaration of competing interest
The authors have no conflicts of interest to declare.
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