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Study Design Cross-sectional repeated measures. Background Rehabilitation of diastasis rectus abdominis (DRA) generally aims to reduce the inter-rectus distance (IRD). We tested the hypothesis that activation of the transversus abdominis (TrA) before a curl-up would reduce IRD narrowing, with less linea alba (LA) distortion/deformation, which may allow better force transfer between sides of the abdominal wall. Objectives This study investigated behavior of the LA and IRD during curl-ups performed naturally and with preactivation of the TrA. Methods Curl-ups were performed by 26 women with DRA and 17 healthy control participants using a natural strategy (automatic curl-up) and with TrA preactivation (TrA curl-up). Ultrasound images were recorded at 2 points above the umbilicus (U point and UX point). Ultrasound measures of IRD and a novel measure of LA distortion (distortion index: average deviation of the LA from the shortest path between the recti) were compared between 3 tasks (rest, automatic curl-up, TrA curl-up), between groups, and between measurement points (analysis of variance). Results Automatic curl-up by women with DRA narrowed the IRD from resting values (mean U-point between-task difference, -1.19 cm; 95% confidence interval [CI]: -1.45, -0.93; P&lt;.001 and mean UX-point between-task difference, -0.51 cm; 95% CI: -0.69, -0.34; P&lt;.001), but LA distortion increased (mean U-point between-task difference, 0.018; 95% CI: 0.0003, 0.041; P = .046 and mean UX-point between-task difference, 0.025; 95% CI: 0.004, 0.045; P = .02). Although TrA curl-up induced no narrowing or less IRD narrowing than automatic curl-up (mean U-point difference between TrA curl-up versus rest, -0.56 cm; 95% CI: -0.82, -0.31; P&lt;.001 and mean UX-point between-task difference, 0.02 cm; 95% CI: -0.22, 0.19; P = .86), LA distortion was less (mean U-point between-task difference, -0.025; 95% CI: -0.037, -0.012; P&lt;.001 and mean UX-point between-task difference, -0.021; 95% CI: -0.038, -0.005; P = .01). Inter-rectus distance and the distortion index did not change from rest or differ between tasks for controls (P≥.55). Conclusion Narrowing of the IRD during automatic curl-up in DRA distorts the LA. The distortion index requires further validation, but findings imply that less IRD narrowing with TrA preactivation might improve force transfer between sides of the abdomen. The clinical implication is that reduced IRD narrowing by TrA contraction, which has been discouraged, may positively impact abdominal mechanics. J Orthop Sports Phys Ther 2016;46(7):580-589. doi:10.2519/jospt.2016.6536.

Behavior of the Linea Alba During a Curl-up Task in Diastasis Rectus Abdominis: An Observational Study