Intra- and Interimage Reliability of Inter-Rectus Distance Measurements Determined via Ultrasound Imaging by the Same or Different Testers in Women in the Early Postpartum Period.

OBJECTIVES: No consensus regarding the optimal position and location for the measurement of the inter-rectus distance (IRD) via ultrasound (US) has been reached. By investigating the intra- and interimage reliability of IRD measurements taken in different positions and at different locations within and between testers, this study provides a theoretical basis for the current situation. METHODS: The IRD was measured via US in 46 women at 42-60 days after delivery at the superior margin of the umbilicus and 3 cm above, 5 cm above and 3 cm below the umbilicus while the women were in the supine, crunch and standing positions. In the interimage test, every participant was tested 2 times by Physician X and 1 time by Physician Y; in the intraimage test, the images collected by Physician X during the first test were saved in the machines, and two measurements were performed by Physician X and one measurement was performed by Physician Y. Paired t tests and intraclass correlation coefficients (ICCs) were calculated. RESULTS: Only the first IRD measurements by tester X and tester Y at 3 cm below the umbilicus in the crunch position were significantly different (9.56 ± 6.00 versus 11.00 ± 5.55) (P < .05). All the ICCs were greater than .75, and the intratester ICCs were greater than or equal to the corresponding intertester ICCs. The ICCs at 3 cm below the umbilicus were the smallest in the supine and crunch positions and the largest in the standing position due to the increased frequency of IRD values of 0. The ICCs for the crunch position were greatest according to the intraimage test but smallest according to the interimage test. The interimage ICCs between the two testers in the supine position at the superior margin, 3 cm above, 5 cm above, and 3 cm below the umbilicus were .972, .974, .975, and .956, respectively. CONCLUSIONS: Ultrasound imaging (USI) is a reliable method for measuring the IRD in women in the early postpartum period. The dynamic measurement of the IRD at or above the umbilicus in the supine position by different testers in real time showed the highest reliability.

Assessment of diastasis recti abdominis: Clinimetric properties of four measuring instruments.

Objective: The aim of the study was to determine the intra- and inter-rater reliability of palpation technique, digital calipers, and diastometer, as well as their concurrent validity against ultrasound imaging. Methods: Ninety consenting parous women (20-45 years), recruited from a postnatal clinic in Enugu, Nigeria, participated in this observational study. Two physiotherapists and a sonographer measured their inter rectus distance at the level of the umbilicus, 4.5 cm above and below it, respectively, using each of the four modalities. The intra-rater measurements were taken at a week's interval. Data were analyzed with descriptive and inferential statistics of intraclass correlation coefficient and paired samples T-test, at an alpha level set at P < 0.05. Results: It showed the palpation technique (r = 0.749-0.967 and 0.658-0.917), digital calipers (r=0.750-0.955 and 0.685-0.904), and diastometer (r=0.762-0.958 and 0.471-0.902) demonstrated good inter- and intra-rater reliability. The concurrent validity of the palpation technique, digital calipers, and diastometer against the USI was poor at all three reference points. Conclusion: Palpation technique, digital calipers, and diastometer are reliable tools but not valid substitutes to ultrasound imaging for the clinical measurement of diastasis rectus abdominis.

Prevalence of rectus diastasis is higher in patients with inguinal hernia.

PURPOSE: To determine the prevalence of rectus diastasis (RD) in patients with inguinal hernia. MATERIAL AND METHODS: Multicenter, cross-sectional study. Patients with inguinal hernia were included in the study group (IH) and those with benign proctologic complaints created the control group (CG). Age, gender, BMI, family history for inguinal hernias, comorbid diseases, alcohol use, smoking, constipation, malignancy, chemotherapy, number of births, multiple pregnancies and prostate hypertrophy history of all patients in both groups were recorded. All patients were evaluated for RD and umbilical hernias by physical examination. RESULTS: A total of 528 consecutive patients were included in the study (292 IH / 236 CG). Overall prevalence of RD was 35.6% and it was significantly higher in IH than in CG (46.9% vs 21.6%, p < 0.001). Also, umbilical hernia was more frequently detected in the patients with inguinal hernia. Other risk factors for RD were age, BMI, DM, BPH and smoking. The mean inter-rectus distance for 528 patients was 18.1 mm; it was 20.71 ± 10.68 mm in IH and 14.88 ± 8.82 in CG (p < 0.001). It was determined that the increase in age and BMI caused an increase in the inter-rectus distance, and that the presence of DM, inguinal hernia and umbilical hernia increased the inter-rectus distance quantitatively. CONCLUSIONS: The prevalence of RD seems to be higher in patients with inguinal hernia comparing to that in general population. Increased age, high BMI and DM were found to be independent risk factors for RD development.

Evaluación de las consecuencias físicas y psicosociales de la diástasis de rectos abdominales y su interferencia en la salud: un estudio mixto / Evaluation of the physical and psychosocial consequences of the diastasis of the rectus abdominis and its interference in health: A mixed study

Introducción: La diástasis de rectos abdominales (DRA) se define como la separación de los rectos abdominales a lo largo de la línea alba. Esta condición puede darse en ambos sexos, siendo frecuente en la mujer durante el embarazo y posparto. Existe poca evidencia sobre las consecuencias de la DRA en la calidad de vida de las mujeres. Objetivo: El análisis de la percepción de los síntomas de DRA y su repercusión a nivel físico, psicológico y social en mujeres afectadas por esta condición. Pacientes y métodos: Estudio observacional por medio de una encuesta online semiestructurada, compuesta por 30 preguntas cerradas y 2 abiertas. Los criterios de inclusión fueron mujeres adultas de habla hispana, que hubiesen dado a luz y que presentasen diástasis abdominal. Los datos se analizaron de forma cuantitativa y la información cualitativa se obtuvo mediante un análisis de contenido de las preguntas abiertas. Resultados: Trescientas diecinueve mujeres con DRA fueron incluidas. Los resultados mostraron una afectación negativa de la DRA en la calidad de vida, las capacidades funcionales y en la salud uroginecológica y digestiva. Así mismo se evidenció un impacto negativo a nivel emocional, en la imagen corporal y una mala salud autopercibida. Conclusión:La DRA tiene un impacto negativo en la salud de la mujer. Las mujeres con DRA presentan una afectación de la calidad de vida y de las capacidades funcionales, una alteración de la imagen corporal, sentimientos de abandono por parte de las instituciones sanitarias, vergüenza, tristeza, impotencia, falta de autoestima, resignación y presión social.(AU)

Introduction: Diastasis rectus abdominis (DRA) is defined as the separation of the rectus abdominis along the linea alba. This condition can occur in both sexes, being frequent in women during pregnancy and pospartum. There is little evidence on the consequences of DRA on the quality of life of women. Objective: The analysis of the perception of the symptoms of and its repercussion on a physical, psychological and social level in women affected by this condition. Patients and methods: Observational study through a semi-structured online survey, composed of 30 closed questions and 2 open ones. The inclusion criteria were adult Spanish-speaking women who had given birth and who presented abdominal diástasis. The data were analyzed quantitatively and the qualitative information was obtained through a content analysis of the open questions. Results: 319 women with DRA were included. The results showed a negative effect of DRA on quality of life, functional capacities, and urogynecological and digestive health. Likewise, a negative impact was evidenced at an emotional level, on body image and poor self-perceived health. Conclusion: DRA has a negative impact on women's health. Women with DRA present an impairment of the quality of life and functional capacities, an alteration in body image, feelings of abandonment by health institutions, shame, sadness, powerlessness, lack of self-esteem, resignation and social pressure.(AU)

[Evaluation of the physical and psychosocial consequences of the diastasis of the rectus abdominis and its interference in health: A mixed study]. / Evaluación de las consecuencias físicas y psicosociales de la diástasis de rectos abdominales y su interferencia en la salud: un estudio mixto.

INTRODUCTION: Diastasis rectus abdominis (DRA) is defined as the separation of the rectus abdominis along the linea alba. This condition can occur in both sexes, being frequent in women during pregnancy and pospartum. There is little evidence on the consequences of DRA on the quality of life of women. OBJECTIVE: The analysis of the perception of the symptoms of and its repercussion on a physical, psychological and social level in women affected by this condition. PATIENTS AND METHODS: Observational study through a semi-structured online survey, composed of 30 closed questions and 2 open ones. The inclusion criteria were adult Spanish-speaking women who had given birth and who presented abdominal diástasis. The data were analyzed quantitatively and the qualitative information was obtained through a content analysis of the open questions. RESULTS: 319 women with DRA were included. The results showed a negative effect of DRA on quality of life, functional capacities, and urogynecological and digestive health. Likewise, a negative impact was evidenced at an emotional level, on body image and poor self-perceived health. CONCLUSION: DRA has a negative impact on women's health. Women with DRA present an impairment of the quality of life and functional capacities, an alteration in body image, feelings of abandonment by health institutions, shame, sadness, powerlessness, lack of self-esteem, resignation and social pressure.

Differences in Inter-Rectus Distance and Abdominopelvic Function between Nulliparous, Primiparous and Multiparous Women.

Widening of the inter-rectus distance (IRD) is highly prevalent among postpartum women and can lead to dysfunction of abdominopelvic muscles. The aim of this study was to evaluate the differences in IRD and abdominopelvic function between nulliparous, primiparous and multiparous women. A cross-sectional study was conducted on 75 women (25 nulliparous, 25 primiparous and 25 multiparous at 6 months postpartum). The participants underwent ultrasound assessment under three conditions (at rest, abdominal draw-in maneuver (ADIM) and curl-up) at two locations (2 cm above and 2 cm below the umbilicus). Furthermore, abdominopelvic muscle function was determined by prone, supine and side bridge tests. In all conditions and locations, the IRD were significantly higher (p < 0.05) in the primiparous and multiparous women than in the nulliparous. The multiparous women presented greater (p > 0.05) IRD at rest and during ADIM compared to the primiparous women. Regarding abdominopelvic muscle function, differences were only significant (p < 0.05) between the nulliparous with primiparous women in prone and supine conditions. These findings suggest that parity influences IRD: women at 6 months postpartum present greater IRD compared to nulliparous women; multiparous women present greater IRD at rest and during the activation of deep abdominal muscles than primiparous women; and primiparous women exhibit worse abdominopelvic muscle function than nulliparous women.

The effect of visceral manipulation on Diastasis Recti Abdominis (DRA): A case series.

BACKGROUND: Diastasis recti abdominis (DRA) is a condition that affects many postpartum and older women, often due to pregnancy-related issues and heavy lifting. Published research on nonsurgical DRA treatment has primarily focused on exercise to correct or prevent this dysfunction. A survey of women's health physical therapists identified that visceral manipulation and other interventions are utilized to treat DRA. No literature exists to identify the specifics of visceral manipulation or its effect on DRA. STUDY DESIGN: This case series is a retrospective chart review of three female patients with DRA who received visceral manipulation. CASE DESCRIPTION: The ages of the patients were 33, 37, 39 years old and all were positive for DRA based on inter-rectus distance (IRD) described as greater than two finger-width measurements at one of three measurement sites. Patients presented with chief complaints of low back pain, abdominal pain, and vulvar burning and itching. All women were gravida two and para two. Each patient received at least four treatments of visceral manipulation (VM). OUTCOMES: VM decreased the IRD, decreased numeric pain rating scores, and improved functional activities in three women with DRA. Improvements were also seen in bladder and bowel symptoms. DISCUSSION: Four treatments of visceral manipulation appear to be effective in decreasing DRA measurements in three women. DRA measurements improved to two finger-widths or less above, at, and below the umbilicus. The changes remained stable for six to sixteen months.

Investigate Correlation between Diastasis of Rectus Abdominis Muscle and Low Back Pain in Obese Women.

BACKGROUND: Rectus abdominis is the main core muscle. Weakness or any alteration in it may increase the pressure over the lower back, in obese women diastasis of rectus abdominis muscle found to be very common condition. Therefore, there may be a correlation between diastasis of rectus abdominis muscle and low back pain in obese women that needs to be explored, as there is no literature available. METHODS: In this study, 72 female subjects with Body Mass Index <30 kg/m2 were recruited by snowball sampling method. Demographic (name, age) and anthropometric characteristics (height, weight and body mass index) were recorded. The separation in the rectus abdominis muscle was assessed with vernier calliper. RESULTS: Total subjects were included in the study; all the subjects were Female without any recent abdominal surgical history. The subjects included in the study with age of 30 years to 55 years old with body mass index of the included females must be (30-30.9) kg/m2 i.e. women must come under obese category. Diastasis of rectus abdominis muscle was another variable used that must be present in each women. Low back pain was also used as the variable that may be present or may not be present in the women with diastasis of rectus abdominis muscle. The collected data were analysed by the appropriate statistical analysis tools. The p-value was found more than 0.05 (the alpha level set was less than 0.05) which is non-significant. CONCLUSION: The study concluded a non-significant correlation between the diastasis of rectus abdominis muscle and low back pain in obese women. The present study concludes that it is not necessary that all obese women with low back pain always propose to have diastasis of rectus abdominis muscle.

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.

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.

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

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<.001 and mean UX-point between-task difference, -0.51 cm; 95% CI: -0.69, -0.34; P<.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<.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<.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.

Ultrasound Imaging in Postpartum Women With Diastasis Recti: Intrarater Between-Session Reliability.

STUDY DESIGN: Clinimetrics. OBJECTIVES: To investigate the intrarater between-session reliability of inter-rectus distance (IRD) measurement using ultrasound imaging in postpartum women with diastasis recti. BACKGROUND: Diastasis recti, a separation of the rectus abdominis muscles at the linea alba, occurs as a result of pregnancy and is characterized by increased IRD. The measurement of IRD in this population is of interest to determine changes in diastasis recti severity over time, or in response to treatment. Ultrasound imaging has been proposed as a useful tool to measure IRD in women with diastasis recti; however, the consistency of IRD measurement in this population using ultrasound imaging has, to our knowledge, never been investigated. METHODS: Ultrasound imaging was used to measure IRD in 20 women with diastasis recti on 2 different occasions. On each testing occasion, images were acquired at 4 locations along the linea alba while participants remained relaxed and while they performed a head lift to activate the rectus abdominis muscles. Reliability statistics included intraclass correlation coefficients, Bland-Altman analyses, minimum clinically important difference, and standard error of the measurement. RESULTS: Between-session reliability of IRD measurement was high, particularly when measuring IRD at or above the umbilicus, as indicated by intraclass correlation coefficients greater than 0.90 and low standard error of the measurement and minimum clinically important difference values (below 0.17 cm and 0.46 cm, respectively). Reliability coefficients were poorer when measuring IRD below the umbilicus. CONCLUSION: When performed by an experienced investigator, ultrasound imaging is a reliable tool by which to measure IRD in postpartum women who have diastasis recti.

Abdominal exercises affect inter-rectus distance in postpartum women: a two-dimensional ultrasound study.

OBJECTIVES: To compare inter-rectus distance (IRD) at rest between women who had a vaginal delivery with women who had a caesarean section, and to describe the effect of different abdominal exercises on IRD. SETTING: Physiotherapy practice. DESIGN: Cross-sectional experimental study. PARTICIPANTS: Thirty-eight postpartum primiparous mothers with a singleton baby (vaginal delivery: n=23; caesarean section: n=15). INTERVENTIONS: Two-dimensional ultrasound images from the abdominal wall were recorded at rest and at the end position of abdominal crunch, drawing-in and drawing-in+abdominal crunch exercises. IRD measurements at rest, above and below the umbilicus, were compared between the two groups (vaginal delivery and caesarean section). IRD was also measured above and below the umbilicus during three abdominal exercises in both groups. MAIN OUTCOME MEASURES: IRD 2 cm above and below the umbilicus. RESULTS: No significant differences in IRD, either above or below the umbilicus, were found between the vaginal delivery and caesarean section groups. IRD above the umbilicus was significantly reduced during abdominal crunch exercises compared with at rest {mean 21.7 [standard deviation (SD) 7.6]mm vs 25.9 (SD 9.0) mm; mean difference 4.2 mm; 95% confidence interval (CI) 0.5 to 7.9}. IRD below the umbilicus was significantly greater during drawing-in exercises compared with at rest [16.0 (SD 8.1) mm vs 11.4 (SD 4.9) mm; mean difference 4.5 mm; 95% CI 1.6 to 7.4]. CONCLUSION: In contrast to existing recommendations for abdominal strength training among postpartum women, this study found that abdominal crunch exercises reduced IRD, and drawing-in exercises were ineffective for reducing IRD. Further basic studies and randomised controlled trials are warranted to explore the effect of abdominal training on IRD.

Inter-rectus distance in postpartum women can be reduced by isometric contraction of the abdominal muscles: a preliminary case-control study.

OBJECTIVES: To determine the effect of isometric contraction of the abdominal muscles on inter-rectus distance in postpartum women. DESIGN: Preliminary case-control study. SETTING: Research laboratory. PARTICIPANTS: Ten postpartum women {mean age 30 [standard deviation (SD) 4] years; mean weight 58 (SD 7) kg; mean height 159 (SD 4) cm} and 10 nulliparous (control) women [mean age 28 (SD 2) years; mean weight 56 (SD 6) kg; mean height 160 (SD 6) cm]. INTERVENTIONS: Ultrasound images from the anterior abdominal wall were recorded at rest (supine position) and during an abdominal isometric contraction, with the subject actively performing an abdominal crunch (crook lying position). Two-way analysis of variance was used to compare the inter-rectus distance between groups (postpartum vs control) and between levels of abdominal muscle activation (rest vs isometric contraction). MAIN OUTCOME MEASURES: Inter-rectus distance 2cm above the level of the umbilicus. RESULTS: The inter-rectus distance was significantly greater in the postpartum group compared with the control group [14.7 (SD 3.1) mm vs 9.6 (SD 2.8) mm; mean difference 5.1mm; 95% confidence interval (CI) 3.4 to 6.8]. The inter-rectus distance was significantly lower during isometric contraction compared with rest [10.7 (SD 3.1) mm vs 13.4 (SD 3.1) mm; mean difference 2.8mm; 95% CI 1.2 to 4.5]. No interaction was found between group and muscle contraction. CONCLUSIONS: The inter-rectus distance was significantly higher in postpartum women compared with controls, and significantly lower during isometric contraction of the abdominal muscles (abdominal crunch) compared with rest.