The Relationship between Abdominal Diastasis and Lumbar Pain Pressure Threshold in Women Who Have Given Birth between the Ages of 30 and 45 Years-An Observational Pilot Study.

Background and Objectives: Current evidence confirms that the magnitude of the inter-rectus distance (IRD) is associated with the severity of abdominal pain. Furthermore, evidence exists in the literature about the impact abdominal muscles have on low back pain, lumbopelvic pain, breathing and lumbar abdominal strength; however, no studies analysing the level of association between abdominal diastasis and lumbar pain pressure threshold (PPT) exist. The aim of this study was to analyse the level of association between the rectus abdominis distance and pain pressure threshold in the lumbar spinous processes in women who have given birth between the ages of 30 and 45 years. Secondly, it was to study the level of association between the time elapsed since the last delivery and low back pain in women who have given birth between 30 and 45 years of age. Material and Methods: This was a pilot observational study in which 21 females participated. The abdominal diastasis was measured by ultrasound, the pain pressure threshold was assessed by an algometer and the pain perception by the Mc Gill questionnaire. Results: There was no significant relationship between increased abdominal distance and increased lumbopelvic pain in women who gave birth between the ages of 30 and 45 years. However, there was a correlation between the time that had elapsed since the last delivery and low back pain. Conclusions: there was a correlation between the time that had elapsed since the last delivery and low back pain. Further studies analysing factors that may perpetuate the chronicity of symptoms, such as lifestyle and intrinsic factors, are needed.

Does diastasis recti abdominis weaken pelvic floor function? A cross-sectional study.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to compare pelvic floor muscle strength (PFMS) and the prevalence of urinary incontinence (UI) and pelvic organ prolapse(POP) in women with and without diastasis recti abdominis (DRA) at 6-8 weeks postpartum. METHODS: Three hundred and ten women underwent routine examinations, including POP quantification (POP-Q), PFMS measurement, DRA evaluation, and UI determination. Chi-squared tests and independent sample t test were used to compare the differences between women with DRA and without DRA. RESULTS: Women with DRA presented significantly lower prepregnancy body mass index (BMI), predelivery BMI, and postpartum BMI; greater gestational age; and higher birth weights than women without DRA(p < 0.05). Moreover, DRA incidence was significantly higher in those who underwent cesarean section (CS) than in those who underwent vaginal delivery (VD)(p = 0.045). Although the PFMS of the DRA group was weaker and the prevalence of UI and POP was slightly higher than those of the no DRA group, the results were not statistically significant. The PFMS of the CS group was stronger than that of the VD group. Urinary incontinence and prolapse incidence were higher in the VD group than in the CS group. Women who underwent CS had a shorter genital hiatus (Gh) and smaller Ba and Bp values than those in the VD group. Women without DRA had an increased chance of Bp ≥ -2 and Gh ≥ 3(p < 0.05). CONCLUSIONS: Women with DRA were not more likely to have weakened PFMS and increased UI or POP at 6-8 weeks postpartum.

Reliability and validity of surface EMG assessments combined with isometric muscle strength testing in patients with abdominal rectus diastasis and asymptomatic controls.

PURPOSE: Patients with abdominal rectus diastasis (ARD) may have muscular functional impairments, but clinics lack appropriate objective assessment tools. The aim was to establish the relative and absolute reliability, and convergent validity, of muscular activity using Surface Electromyography (SEMG) during isometric abdominal muscle strength testing in patients with ARD and controls without ARD. METHODS: Twenty-six patients with ARD were matched for age, sex and BMI with controls without ARD. Participants were tested twice during isometric muscular contractions using SEMG located on six abdominal sites. Mean amplitude, fatigue, and recruitment order were analyzed. Relative reliability was evaluated with Intraclass Correlation Coefficients (ICC), while absolute reliability was estimated by calculating the Standard Error of Measurement and Minimal Detectable Change. Convergent validity was addressed in relation to participant characteristics, functional ability, and symptoms. RESULTS: Mean SEMG amplitude for all abdominal wall muscle contractions showed moderate to excellent relative test-retest reliability, with ICC values ranging from 0.46 to 0.97. In contrast, fatigue and recruitment order displayed poor to moderate relative reliability in both groups. Absolute reliability measures were generally high. A moderate to high convergent validity (ARD: rho-value 0.41-0.70; Controls: rho-value 0.41-0.75) was observed for mean amplitude in relation to a functional sit-to-stand test, abdominal circumference, BMI, back pain, and quality-of-life. CONCLUSIONS: The results of applying SEMG during isometric abdominal muscle support practicing the method in clinics, although additional development is needed with further standardization and more functional testing. Furthermore, the method demonstrates construct validity in patients with ARD and in age- and sex-matched controls.

Relationships of diastasis recti abdominis with stress urinary incontinence and pelvic floor muscle dysfunction in postpartum women.

OBJECTIVES: To determine whether diastasis of the rectus abdominis muscles was related to stress urinary incontinence, dysfunction of pelvic floor muscles, and of hiatal area size in postpartum women. STUDY DESIGN: This observational prospective study included 150 women from 6 weeks to 6 months postpartum, with a mean age of 33.1 years. Diastasis Recti Abdominis is a condition in which the abdominal muscles are separated by an increased inter-rectus distance due to widening of the linea alba, measured using 2D ultrasound. Pelvic floor muscle function was examined using manometry, and the size of the hiatal area was examined using 3D/4D ultrasonography. Stress urinary incontinence symptoms were assessed using the International Incontinence Consultation Questionnaire (ICIQ-UI SF). RESULTS: We identified a significant weak correlation between diastasis of the rectus abdominis and symptoms of stress urinary incontinence (r = 0.283). We also found weak significant correlations of diastasis of the rectus abdominis with the maximum voluntary contraction (r = -0.278) and with the duration voluntary contraction (r = -0.274). No correlation was found between diastasis of the rectus abdominis and size of the hiatal area. CONCLUSIONS: Diastasis of the rectus abdominis was weakly related to stress urinary incontinence and also to pelvic floor muscle dysfunction.

Predictors of Disability Attributed to Symptoms of Increased Interrecti Distance in Women after Childbirth: An Observational Study.

OBJECTIVE: The purpose of this study was to investigate how various physical and psychological factors are linked to disability attributed to symptoms from increased interrecti distance (IRD) in women after childbirth. METHODS: In this cross-sectional observational study, 141 women with an IRD of at least 2 finger-widths and whose youngest child was between the ages of 1 and 8 years participated. A multiple linear regression model was performed, with disability as the outcome variable and fear-avoidance beliefs, emotional distress, body mass index, lumbopelvic pain, IRD, and physical activity level as predictor variables. RESULTS: The regression model accounted for 60% (R2 = 0.604, adjusted R2 = 0.586) of the variance in disability (F6,132 = 33.5). The 2 strongest predictors were lumbopelvic pain, with a regression coefficient of 1.4 (95% CI = 1.017 to 1.877), and fear avoidance, with a regression coefficient of 0.421 (95% CI = 0.287 to 0.555). The actual IRD, with a regression coefficient of -0.133 (95% CI = -1.154 to 0.888), did not contribute significantly to the variation in disability. CONCLUSION: Disability attributed to symptoms from an increased IRD is explained primarily by the level of lumbopelvic pain but also by the degree of fear-avoidance beliefs and emotional distress. IMPACT: This study highlights pain intensity and psychological factors as crucial factors for understanding disability attributed to increased IRD.

Effect of pelvic floor and transversus abdominis muscle contraction on inter-rectus distance in postpartum women: a cross-sectional experimental study.

OBJECTIVES: To investigate the effect of acute isometric contraction of the pelvic floor muscles (PFM) and transversus abdominis muscle (TrAM) on inter-rectus distance (IRD) from resting values in postpartum women with diastasis rectus abdominis (DRA). DESIGN: Cross sectional experimental study. SETTING: Physiotherapy clinic. PARTICIPANTS: Thirty eight postpartum women presenting with DRA of at least two finger widths. METHODS: Two dimensional ultrasound images of IRD were recorded using a linear probe (5 to 10MHz) at rest, during PFM contraction, during TrAM contraction, and during combined PFM and TrAM contraction. IRD data were normally distributed. MAIN OUTCOME MEASURE: Change in IRD. RESULTS: There was a significant increase in IRD during PFM and TrAM contraction compared with IRD at rest. At 2cm above the umbilicus, mean PFM was 26.9 [standard deviation (SD) 8.8] mm vs rest 25.7 (SD 8.5) mm {mean difference 1.2 [95% confidence interval (CI) 0.7 to 1.7] mm}; and mean TrAM was 28.4 (SD 9.0) mm vs rest 25.7 (SD 8.5) mm [mean difference 2.8 (95% CI 1.9 to 3.6) mm]. Similarly, 2cm below the umbilicus, mean PFM was 22 (SD 8.3) mm vs rest 21 (SD 7.9) mm [mean difference 0.9 (95% CI 0.4 to 1.6) mm]; and mean TrAM was 23.3 (SD 8.7) mm vs rest 21 (SD 7.9) mm [mean difference 2.3 (95% CI 1.5 to 3.1) mm]. Combined TrAM and PFM contraction measured 2cm above the umbilicus caused the greatest increase in IRD: mean PFM+TrAM 29.6 (SD 9.4) mm vs rest 25.7 (SD 8.5) mm [mean difference 3.9 (95% CI 2.8 to 5.0) mm]. CONCLUSION: Both PFM and TrAM contraction, and combined PFM and TrAM contraction increased IRD in postpartum women with DRA.

Differences in Linea Alba Stiffness and Linea Alba Distortion Between Women With and Without Diastasis Recti Abdominis: The Impact of Measurement Site and Task.

BACKGROUND: The biomechanical implications of diastasis recti abdominis (DRA) are unknown. OBJECTIVES: To (1) investigate the impact of DRA, measurement site, and task on inter-rectus distance (IRD), linea alba (LA) stiffness, and LA distortion measured at rest and during head-lift and semi-curl-up tasks; and (2) describe the relationships among IRD, LA stiffness, and LA distortion. METHODS: In this cross-sectional, observational cohort study, brightness-mode ultrasound imaging and shearwave elastography were used on a sample of 20 women. Inter-rectus distance, LA stiffness, and LA distortion were measured at 3 locations, while at rest and during head-lift and semi-curl-up maneuvers. All outcomes were compared between groups (DRA versus no DRA), sites, and tasks. Linear regression models were used to evaluate the relationships among IRD, mean and peak LA stiffness, and LA distortion. RESULTS: Eleven women with and 9 without DRA participated. Women with DRA demonstrated lower peak and mean LA stiffness and higher LA distortion compared to women without DRA. In women with DRA, IRD and LA distortion were not influenced by measurement site; IRD decreased, LA distortion increased, and LA stiffness did not change during the head lift and semi-curl-up compared to rest. In women without DRA, the LA was least stiff closest to the umbilicus; it increased in stiffness during the head lift and semi-curl-up and did not distort or change compared to rest. CONCLUSION: Diastasis recti abdominis was associated with low LA stiffness and with LA distortion during a semi-curl-up task; the amount of distortion was a function of IRD and LA stiffness. J Orthop Sports Phys Ther 2019;49(9):656-665. Epub 26 Mar 2019. doi:10.2519/jospt.2019.8543.

Cohort study of the effect of surgical repair of symptomatic diastasis recti abdominis on abdominal trunk function and quality of life.

Background: During pregnancy, women are at risk of developing persistent symptomatic diastasis recti abdominis (DRA), which may have a detrimental effect on their physical function and quality of life (QoL). The aim of this prospective cohort study was to determine the effect of surgical repair of DRA on abdominal trunk function, urinary incontinence and QoL in postpartum women with trunk instability symptoms resistant to training. Methods: Postpartum women with diagnosed DRA and training-resistant symptoms underwent double-row plication of the linea alba. Abdominal trunk function was evaluated as the primary endpoint using a multimodal examination tool, the Abdominal Trunk Function Protocol. Recurrence was assessed by CT, urinary incontinence was evaluated using the Urogenital Distress Inventory (UDI-6) and Incontinence Impact Questionnaire (IIQ-7), and QoL was assessed with the Short Form 36 (SF-36®) questionnaire. All subjects were examined before and 1 year after surgery. Results: Sixty women were recruited. There was no DRA recurrence at the 1-year follow-up. Self-reported abdominal trunk function had improved in 98 per cent of patients, with a mean score improvement of 79·1 per cent. In the physiological tests monitored by a physiotherapist, 76 per cent performed better and endured exercise tests longer than before surgery. All SF-36® subscales improved significantly compared with preoperative scores and reached levels similar to, or higher than, the normative Swedish female population. For the UDI-6 and IIQ-7, 47 and 37 per cent respectively reported fewer symptoms at follow-up than before surgery, and 13 and 8 per cent respectively reported more symptoms. Conclusion: In this series of postpartum women presenting with DRA and symptoms of trunk instability resistant to training, surgical reconstruction resulted in a significant improvement in abdominal trunk function, urinary incontinence and QoL.

Antecedentes: Durante el embarazo, las mujeres tienen el riesgo de desarrollar una diástasis rectoabdominal persistente y sintomática (diastasis rectoabdominis, DRA) que puede tener un efecto perjudicial en su función física y en la calidad de vida (quality of life, QoL). El objetivo de este estudio de cohortes prospectivo fue determinar el efecto de reparación quirúrgica de la DRA en la función de la musculatura de la pared abdominal, la incontinencia urinaria y la QoL en mujeres con síntomas postparto de inestabilidad de la musculatura abdominal resistentes al entrenamiento. Métodos: Sesenta mujeres diagnosticadas en el postparto de DRA y con síntomas resistentes al entrenamiento se sometieron a una plicatura de doble capa de la línea alba. El objetivo primario fue evaluar la función de la musculatura de la pared abdominal mediante una herramienta de examen multimodal, el protocolo de la función de la pared abdominal (abdominal trunk function protocol, ATFP). La recidiva se evaluó mediante tomografía computarizada, la incontinencia urinaria utilizando los cuestionarios UDI­6 y IIQ­7 y la calidad de vida con el cuestionario SF­36. Todas las participantes fueron examinadas antes de la cirugía y un año después de la misma. Resultados: Tras un año de seguimiento, no hubo recidiva de la DRA. Según informaron las pacientes, la función de la musculatura abdominal había mejorado en el 98,2% de los casos, con una mejoría en la puntuación media del 79,1%. En las pruebas fisiológicas controladas por un fisioterapeuta, el 76,0% presentó mejoría y aumentó la duración en las pruebas de resistencia en comparación con antes de la cirugía. Todas las subescalas del SF­36 mejoraron significativamente en comparación con las puntuaciones preoperatorias y alcanzaron niveles similares o superiores a los de la población femenina sueca normal. Para el UDI­6 y el IIQ­7, el 46,7% y el 36,7% respectivamente, manifestaron menos síntomas en el seguimiento que antes de la cirugía, mientras que el 13,3% y el 8,3% respectivamente, reportaron más síntomas. Conclusión: En esta serie de mujeres que presentan DRA en el posparto y síntomas de inestabilidad de la musculatura abdominal resistente al entrenamiento, la reconstrucción quirúrgica produjo una mejora significativa en la función de la musculatura abdominal, la incontinencia urinaria y la calidad de vida.

Relationship Between Interrectus Distance and Symptom Severity in Women With Diastasis Recti Abdominis in the Early Postpartum Period.

Background: Diastasis recti abdominis (DrA) is associated with negative body image, musculoskeletal pain and dysfunction, and perhaps urogynecological complaints. The severity of DrA has traditionally been determined by measuring the interrectus distance (IRD); however, the relationship between IRD and symptoms in women with DrA is unclear. Objective: The objective of the study was to investigate the relationship between IRD and symptom severity in women with DrA in the early postpartum period. Design: This study used a cross-sectional design. Methods: Thirty-two women with DrA were assessed at 3 weeks postpartum. The IRD was measured using ultrasound imaging. Symptom severity was assessed using the Multidimensional Body-Self Relations Questionnaire subscales (body image), visual analog scales (abdominal, low back, and pelvic pain intensity), the Modified Oswestry Index (disability due to low back pain), and the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire (urogynecological dysfunction). Spearman correlation coefficients (ρ) between IRD and each outcome were calculated and tested using 1-tailed significance (adjusted α = .009). Results: The group median IRD was 2.97 cm (interquartile range = 1.65 cm), with the largest IRD in the sample being 7.97 cm. The IRD was significantly correlated with worst abdominal pain in the last 24 hours (ρ = 0.45, P = .005) and with overall body image (ρ = -0.44, P = .006) but not with the other outcomes. Limitations: Women in the sample were primiparous, were in the early (3 weeks) postpartum period, had relatively low body mass indexes (mean = 25.0 kg/m2) considering that they had recently given birth, were all breast-feeding, and had a narrow age range (27-35 years old). These factors limited the generalizability of our results to all women with DrA. Conclusions: This preliminary work suggests that, in the early postpartum period, IRD as a measure of DrA severity is meaningful for body image.

Effect of a Postpartum Training Program on the Prevalence of Diastasis Recti Abdominis in Postpartum Primiparous Women: A Randomized Controlled Trial.

Background: Diastasis recti abdominis affects a significant number of women during the prenatal and postnatal period. Objective: The objective was to evaluate the effect of a postpartum training program on the prevalence of diastasis recti abdominis. Design: The design was a secondary analysis of an assessor-masked randomized controlled trial. Methods: One hundred seventy-five primiparous women (mean age = 29.8 ± 4.1 years) were randomized to an exercise or control group. The interrectus distance was palpated using finger widths, with a cutoff point for diastasis as ≥2 finger widths. Measures were taken 4.5 cm above, at, and 4.5 cm below the umbilicus. The 4-month intervention started 6 weeks postpartum and consisted of a weekly, supervised exercise class focusing on strength training of the pelvic floor muscles. In addition, the women were asked to perform daily pelvic floor muscle training at home. The control group received no intervention. Analyses were based on intention to treat. The Mantel-Haenszel test (relative risk [RR] ratio) and the chi-square test for independence were used to evaluate between-group differences on categorical data. Results: At 6 weeks postpartum, 55.2% and 54.5% of the participants were diagnosed with diastasis in the intervention and control groups, respectively. No significant differences between groups in prevalence were found at baseline (RR: 1.01 [0.77-1.32]), at 6 months postpartum (RR: 0.99 [0.71-1.38]), or at 12 months postpartum (RR: 1.04 [0.73-1.49]). Limitations: The interrecti distance was palpated using finger widths, and the sample included women with and without diastasis. Conclusions: A weekly, postpartum, supervised exercise program, including strength training of the pelvic floor and abdominal muscles, in addition to daily home training of the pelvic floor muscles, did not reduce the prevalence of diastasis.

Measurement methods to assess diastasis of the rectus abdominis muscle (DRAM): A systematic review of their measurement properties and meta-analytic reliability generalisation.

STUDY DESIGN: Systematic literature review. BACKGROUND: Diastasis of the rectus abdominis muscle (DRAM) has been linked with low back pain, abdominal and pelvic dysfunction. Measurement is used to either screen or to monitor DRAM width. Determining which methods are suitable for screening and monitoring DRAM is of clinical value. OBJECTIVES: To identify the best methods to screen for DRAM presence and monitor DRAM width. METHODS: AMED, Embase, Medline, PubMed and CINAHL databases were searched for measurement property studies of DRAM measurement methods. Population characteristics, measurement methods/procedures and measurement information were extracted from included studies. Quality of all studies was evaluated using 'quality rating criteria'. When possible, reliability generalisation was conducted to provide combined reliability estimations. RESULTS: Thirteen studies evaluated measurement properties of the 'finger width'-method, tape measure, calipers, ultrasound, CT and MRI. Ultrasound was most evaluated. Methodological quality of these studies varied widely. Pearson's correlations of r = 0.66-0.79 were found between calipers and ultrasound measurements. Calipers and ultrasound had Intraclass Correlation Coefficients (ICC) of 0.78-0.97 for test-retest, inter- and intra-rater reliability. The 'finger width'-method had weighted Kappa's of 0.73-0.77 for test-retest reliability, but moderate agreement (63%; weighted Kappa = 0.53) between raters. Comparing calipers and ultrasound, low measurement error was found (above the umbilicus), and the methods had good agreement (83%; weighted Kappa = 0.66) for discriminative purposes. CONCLUSIONS: The available information support ultrasound and calipers as adequate methods to assess DRAM. For other methods limited measurement information of low to moderate quality is available and further evaluation of their measurement properties is required.