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.

Effect of Electrical Stimulation Followed by Exercises in Postnatal Diastasis Recti Abdominis via MMP2 Gene Expression.

Since abdominal muscle training is one of the most important ways to treat rectal diastasis, it is necessary to design and provide appropriate exercises to treat this problem. One of the complementary methods to achieve higher intensity training is the use of electrical muscle stimulation along with voluntary activity, which causes maximum recall in muscle units. Therefore, in the current study, the effect of electrical stimulation followed by exercises was evaluated in postnatal diastasis recti abdominis via MMP2 gene expression. For this purpose, we studied on thirty-two women who had rectal diastasis for six months and were referred to a physiotherapy clinic by a gynecologist. They were divided into the control group (n=16) and the intervention group (n=16). The distance between the two blocks of the rectus abdominis muscle and the thickness of the abdominal muscles at rest was determined by ultrasound. In the intervention group, electrical stimulation and strengthening exercises of oblique muscles were performed for six weeks. The control group did not perform any specific exercises. After six weeks, another ultrasound was performed. The expression of the MMP2 gene was measured by the real-time PCR method. Comparison of the distance between the two blocks of rectus abdominis muscle (above the umbilicus and below the umbilicus) before and after six weeks showed that in the experimental group after intervention in both areas had a significant decrease (above the umbilicus = 0.001 and below the umbilicus P = 0.03), while this distance in the control group did not decrease significantly (p >0.05). Also, in the upper part of the umbilicus, the distance between the two rectus abdominis muscle blocks in two groups after the intervention showed a significant difference (p = 0.04). Evaluation of MMP2 gene expression showed that there was no significant difference between the two groups before the intervention (p >0.05). However, after the intervention, the expression of this gene decreased significantly in the intervention group (p = 0.007). In general, the present study results showed that electrical stimulation of abdominal muscles with strengthening exercises of internal and external oblique muscles could reduce rectal diastasis and increase the thickness of these muscles in people with rectal diastasis.

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.

Women's experiences of living with increased inter-recti distance after childbirth: an interview study.

BACKGROUND: Although an increased inter-recti distance, also known as diastasis recti, is common after pregnancy, evidence-based knowledge about the condition is relatively limited. In particular, little is known about the consequences as perceived by the women. The objective of the present study was to describe how postpartum women with increased inter-recti distance experience the condition as well as the contacts they have had with healthcare providers regarding their symptoms. METHODS: A purposeful sampling approach was used to recruit 19 participants from an existing study cohort of 144 women. All participants had an inter-recti distance of at least two finger widths and at least one child, with the youngest child between the ages of 1 and 6 years. Individual interviews based on a semi-structured interview guide were performed and subsequently analysed using qualitative content analysis. RESULTS: Four categories emerged from the interviews: the body's function and ability has changed; the body does not look like it used to; uncomprehending attitudes and treatment in their surroundings; and trying to acquire an understanding of and strategies to cope with the diastasis. The findings reveal that women with increased inter-recti distance might experience fear of movement and engage in avoidance behaviour. In combination with feelings of physical instability in the midsection of their bodies and body dissatisfaction, many of the women restrict their everyday lives and physical activities. CONCLUSIONS: The findings indicate that increased inter-recti distance is a complex phenomenon that affects the women in a multitude of ways, highlighting the importance of considering the condition for each individual in her own context from a biopsychosocial perspective.

Histology and Function of the Rectus Abdominis Muscle in Patients With Incisional Hernia.

BACKGROUND: The aim of the current study was to examine different features of the rectus abdominis muscle (RA) in patients with and without a midline incisional hernia to characterize the effects of a hernia on abdominal wall skeletal muscle. MATERIAL AND METHODS: RA tissue from patients undergoing surgical repair of a large midline incisional hernia (n = 18) was compared with that from an intact abdominal wall in patients undergoing colorectal resection for benign or low-grade malignant disease (n = 18). In addition, needle biopsies were obtained from the vastus lateralis muscle (VL) of all subjects. Outcome measures were muscle fiber type and size, preoperative truncal flexion strength and leg extension power measured in strength-measure equipment, and RA cross-sectional area measured by computed tomography. RESULTS: In both the RA and VL, the fiber cross-sectional area was greater in the patients with a hernia. The RA cross-sectional area correlated significantly with the truncal flexion strength (r = 0.44, P = 0.015). Patients in the hernia group had a significantly reduced ratio between truncal flexion strength and RA cross-sectional area compared with the control group (41.3 ± 11.5 N/cm2versus 51.2 ± 16.3 N/cm2, P = 0.034). CONCLUSIONS: Anatomical displacement of the RA and lack of medial insertion in the linea alba rather than dysfunction secondary to alteration of muscle fiber structure may contribute to impairment of abdominal wall function in patients with midline incisional hernias. The study was registered at http://www.clinicaltrials.gov/(NCT02011048).

Endovascular embolisation treatment in a rare acute abdomen spontaneous rectus sheath haematoma.

BACKGROUND: In this study, we aimed to review spontaneous rectus sheath hematoma (RSH) and the results of endovascular therapy in patients presenting with a rare acute abdomen. METHODS: We evaluated the patients with RSH because of acute abdominal pain and applied endovascular embolization treatment who were admitted to our hospital emergency department retrospectively between December 2016 and December 2018. RESULTS: Rectus muscle sheath bleeding is an extremely rare and urgent emergency intervention. In the etiology, chronic severe cough crises and trauma may be the cause of haemorrhage in the elderly patient group; spontaneous bleedings may be seen with the increase in the use of anticoagulants. In this study, a total of six patients, 53-95 years old (mean 75.5) endovascular embolization treatment was administered on who were admitted to our hospital with the diagnosis of RSH and long-term anticoagulant use. In our series, physical examination findings, laboratory values, computed tomography (CT), CT angiography and digital subtraction angiography (DSA) findings were presented. The findings showed an active extravasation from the superficial circumflex iliac artery in two patients and the inferior epigastric artery in three patients. We had no bleeding focus in only one patient. An ultrasound-guided 5 Fr arterial sheath was placed on the side of the hematoma in the procedure. Then, the inferior epigastric artery and deep circumflex arteries were selectively catheterized using the Vertebral Diagnostic Catheter (5 Fr or 4 Fr). Superselective catheterization, with the help of microcatheter from the existing diagnostic catheter, was used to embolize the arteries and branches with active extravasation using a detachable coil. In the control angiographies performed after embolization, pathological staining disappeared, and complete embolization was achieved. There were no complications associated with the endovascular procedures. No active extravasation was detected in angiography examination, and inpatient follow-up, blood transfusion, antibiotics and analgesic support were performed in only one patient. However, it was ex as a result of reasons related to advance heart failure. CONCLUSION: RSH is a life-threatening condition that may cause acute abdominal pain, and endovascular embolization is a safe and effective treatment option that can be applied quickly in this patient group.

Study protocol to investigate biomolecular muscle profile as predictors of long-term urinary incontinence in women with gestational diabetes mellitus.

BACKGROUND: Pelvic floor muscles (PFM) and rectus abdominis muscles (RAM) of pregnant diabetic rats exhibit atrophy, co-localization of fast and slow fibers and an increased collagen type I/III ratio. However, the role of similar PFM or RAM hyperglycemic-related myopathy in women with gestational diabetes mellitus (GDM) remains poorly investigated. This study aims to assess the frequency of pelvic floor muscle disorders and pregnancy-specific urinary incontinence (PS-UI) 12 months after the Cesarean (C) section in women with GDM. Specifically, differences in PFM/RAM hyperglycemic myopathy will be evaluated. METHODS: The Diamater is an ongoing cohort study of four groups of 59 pregnant women each from the Perinatal Diabetes Research Centre (PDRC), Botucatu Medical School (FMB)-UNESP (São Paulo State University), Brazil. Diagnosis of GDM and PS-UI will be made at 24-26 weeks, with a follow-up at 34-38 weeks of gestation. Inclusion in the study will occur at the time of C-section, and patients will be followed at 24-48 h, 6 weeks and 6 and 12 months postpartum. Study groups will be classified as (1) GDM plus PS-UI; (2) GDM without PS-UI; (3) Non-GDM plus PS-UI; and (4) Non-GDM without PS-UI. We will analyze relationships between GDM, PS-UI and hyperglycemic myopathy at 12 months after C-section. The mediator variables to be evaluated include digital palpation, vaginal squeeze pressure, 3D pelvic floor ultrasound, and 3D RAM ultrasound. RAM samples obtained during C-section will be analyzed for ex-vivo contractility, morphological, molecular and OMICS profiles to further characterize the hyperglycemic myopathy. Additional variables to be evaluated include maternal age, socioeconomic status, educational level, ethnicity, body mass index, weight gain during pregnancy, quality of glycemic control and insulin therapy. DISCUSSION: To our knowledge, this will be the first study to provide data on the prevalence of PS-UI and RAM and PFM physical and biomolecular muscle profiles after C-section in mothers with GDM. The longitudinal design allows for the assessment of cause-effect relationships between GDM, PS-UI, and PFMs and RAMs myopathy. The findings may reveal previously undetermined consequences of GDM.

Physiotherapists' and midwives' views of increased inter recti abdominis distance and its management in women after childbirth.

BACKGROUND: Physiotherapists and midwives in primary healthcare often encounter women with an increased separation between the two rectus abdominis muscle bellies after pregnancy, a so-called increased inter recti distance (IRD). There are few studies on the contribution of increased IRD to the explanation of post-partum health complaints, and very little guidance in the literature for health professionals on the management of increased IRD. The aim of this study was to describe how physiotherapists and midwives in primary healthcare perceive the phenomenon of increased IRD and its management in women after childbirth. METHODS: A purposeful sampling approach was used to select physiotherapists and midwives working in primary healthcare in three large county council healthcare organisations in Sweden having experience of encountering women with increased IRD after pregnancy. Sixteen physiotherapists and midwives participated in focus group discussions. Four focus groups with four participants in each were undertaken. A semi-structured topic guide was used to explore responses to the research questions and the discussions were analysed using qualitative content analysis. RESULTS: We identified an overarching theme: Ambivalence towards the phenomenon increased IRD and frustration over insufficient professional knowledge. The theme included three categories: Uncertainty concerning the significance of increased IRD as a causal factor for functional problems; perceived insufficient professional knowledge base for the management of increased IRD; and lack of inter-professional collaboration and teamwork in the management of patients with increased IRD. Due to sparse and somewhat contradictory research findings and absence of clinical guidelines, the health professionals lacked basic preconditions for applying an evidence-based practice concerning increased IRD. They obtained their information about increased IRD from the media and fitness coaches, and hence were somewhat unsure about what to believe regarding the phenomenon. CONCLUSIONS: There was no consensus among the health professionals on how to best approach increased IRD in the clinical setting. Our findings stress the importance of more research to increase the professional knowledge base among physiotherapists and midwives. The findings highlight the urgent need for policies and clinical guidelines advising health professionals in the management of increased IRD and for facilitating inter-professional collaboration and teamwork.

Effect of a corrective exercise program on gait kinetics and muscle activities in older adults with both low back pain and pronated feet: A double-blind, randomized controlled trial.

BACKGROUND: Low back pain is among the most common health problems seen in primary care. This study aimed to evaluate the effect of a corrective exercise program on GRF components, back pain, disability score, and muscle activities in back pain patients with pronated feet during walking. RESEARCH QUESTION: What is the effect of corrective exercise program on gait kinetics, back pain, disability score, and muscle activities in back pain patients with pronated feet during walking? METHODS: Thirty-six older adults with both back pain and pronated feet volunteered to participate in this study. They were randomly divided into two equal groups (experimental and control groups). Kinetic and EMG data were recorded during both pre and posttest. Visual analog pain scale and Roland-Morris disability questionnaire were used to assess back pain and disability values, respectively. RESULTS: In the experimental group but not in the control group, walking speed was significantly increased from pre to posttest (p = 0.001). The loading rate and free moment values were similar during both the pre and posttest (p > 0.05). In the experimental group but not in the control group, the disability score, back pain, tibialis anterior activity, and rectus abdominis activity were decreased during the posttest than that in the pretest (p < 0.001). SIGNIFICANCE: Higher walking speed, lower muscle activity and pain, lower disability score along with similar loading rate and free moments in the experimental group compared with the control group after the training protocol demonstrate the improvement of gait efficiency.

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.

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.

Surgical Management of Diastasis Recti: A Systematic Review of Insurance Coverage in the United States.

BACKGROUND: As elective surgery becomes more popular, the stringency of insurance coverage policies has increased exponentially. Many patients with diastasis recti (DR) are denied coverage of the corrective surgery that has been shown to improve function and quality of life in this patient population. Plastic surgeons are frustrated by the lack of guidelines and sparsity of coverage for surgical correction of DR. METHODS: Fifty-four US insurance companies and Medicare were reviewed to determine their policies of coverage. These policies were compared with the guidelines set forth by the American Society of Plastic surgery and current literature on DR. RESULTS: Insurance company policy for DR repair is not clear nor well established. Of the 55 policies reviewed in this study, 51 had an established policy. Forty of these companies would not cover abdominoplasty to repair DR under any circumstances. Eleven companies required preauthorization to ensure that the patient met the requirements of medical necessity. These requirements differed from company to company. A comprehensive list was compiled of details required for preauthorization. CONCLUSIONS: Insurance company policies do not recognize the spectrum of patients with DR and the necessity of abdominoplasty to relieve symptoms of patients with severe debilitation. The current Common Procedural Terminology coding classifies abdominoplasty to repair DR solely as a cosmetic procedure. Policies for DR repair should be amended to include a functional procedure reimbursement for severe DR and include detailed guidelines for coverage requirements to simplify the reimbursement process.

Redefinição natural do abdome em abdominoplastia com uso de lipoaspiração convencional: estudo prospectivo / Redefining natural abdominal anatomy in abdominoplasty using conventional liposuction: a prospective study

Introdução: A evolução da abdominoplastia se mantém constante desde 1899. Atualmente, com o avanço das técnicas de lipoaspiração, o conceito de lipoaspiração de alta definição tem como objetivo de corrigir estigmas causados pelo procedimento, como o aspecto "tenso" e a falta de convexidades e concavidades naturais abdominais. Métodos: Apresentamos uma proposta de busca da redefinição natural do abdome, através da lipoabdominoplastia tradicional com lipoaspiração seletiva, procurando obter resultados cirúrgicos com padrão natural, reproduzível para a maioria dos pacientes. Foram realizadas 21 abdominoplastias, entre novembro de 2018 e maio de 2019, utilizando a técnica descrita. Resultados: A técnica demonstrada apresentou resultados estéticos satisfatórios em obter a aparência abdominal natural através da lipoaspiração profunda e superficial, em áreas de sombras abdominais. Conclusão: O trabalho demonstrou-se seguro sob o ponto de vista vascular, além de ser reprodutível ao passo que utiliza lipoaspiração convencional, utilizada pela ampla maioria dos cirurgiões plásticos.

Introduction: Abdominoplasty techniques have constantly evolved since 1899. With modern liposuction techniques, the concept of high-definition liposuction aims to correct stigmas secondary to the procedure, such as a "tense" appearance and lack of natural abdominal convexity and concavity. Methods: Here we propose a technique to redefine the natural abdominal anatomy using traditional lipoabdominoplasty with selective liposuction to achieve more natural-looking surgical results that are reproducible for most patients. This study included 21 abdominoplasty procedures using the described technique performed between November 2018 and May 2019. The technique showed satisfactory ability to achieve a natural abdominal appearance using deep and superficial liposuction in abdominal shadow areas. Conclusion: The study showed that the technique is safe from a vascular point of view and reproducible due to the use of conventional liposuction, which is available to the vast majority of plastic surgeons.

Abdominal functional electrical stimulation to assist ventilator weaning in critical illness: a double-blinded, randomised, sham-controlled pilot study.

BACKGROUND: For every day a person is dependent on mechanical ventilation, respiratory and cardiac complications increase, quality of life decreases and costs increase by > $USD 1500. Interventions that improve respiratory muscle function during mechanical ventilation can reduce ventilation duration. The aim of this pilot study was to assess the feasibility of employing an abdominal functional electrical stimulation (abdominal FES) training program with critically ill mechanically ventilated patients. We also investigated the effect of abdominal FES on respiratory muscle atrophy, mechanical ventilation duration and intensive care unit (ICU) length of stay. METHODS: Twenty critically ill mechanically ventilated participants were recruited over a 6-month period from one metropolitan teaching hospital. They were randomly assigned to receive active or sham (control) abdominal FES for 30 min, twice per day, 5 days per week, until ICU discharge. Feasibility was assessed through participant compliance to stimulation sessions. Abdominal and diaphragm muscle thickness were measured using ultrasound 3 times in the first week, and weekly thereafter by a blinded assessor. Respiratory function was recorded when the participant could first breathe independently and at ICU discharge, with ventilation duration and ICU length of stay also recorded at ICU discharge by a blinded assessor. RESULTS: Fourteen of 20 participants survived to ICU discharge (8, intervention; 6, control). One control was transferred before extubation, while one withdrew consent and one was withdrawn for staff safety after extubation. Median compliance to stimulation sessions was 92.1% (IQR 5.77%) in the intervention group, and 97.2% (IQR 7.40%) in the control group (p = 0.384). While this pilot study is not adequately powered to make an accurate statistical conclusion, there appeared to be no between-group thickness changes of the rectus abdominis (p = 0.099 at day 3), diaphragm (p = 0.652 at day 3) or combined lateral abdominal muscles (p = 0.074 at day 3). However, ICU length of stay (p = 0.011) and ventilation duration (p = 0.039) appeared to be shorter in the intervention compared to the control group. CONCLUSIONS: Our compliance rates demonstrate the feasibility of using abdominal FES with critically ill mechanically ventilated patients. While abdominal FES did not lead to differences in abdominal muscle or diaphragm thickness, it may be an effective method to reduce ventilation duration and ICU length of stay in this patient group. A fully powered study into this effect is warranted. TRIAL REGISTRATION: The Australian New Zealand Clinical Trials Registry, ACTRN12617001180303. Registered 9 August 2017.

Effect of corporal suspension and pendulum exercises on neuromuscular properties and functionality in patients with medullar thoracic injury.

BACKGROUND: Traumatic spinal cord injury (TSCI) is one of the most devastating injuries that has a physical impact on patients. The CHORDATA® method involves suspension and pendulous exercises and has been clinically used to treat patients with TSCI. Although empirically used to treat neurological patients, there is no scientific evidence of the efficacy of this method. PURPOSE: To evaluate the chronic effects of CHORDATA® method on torque, muscle activation, muscle thickness, and functionality in patients with traumatic spinal cord injury. METHODS: Twenty-six male patients with medullar thoracic injury were randomly categorised into two groups: intervention group (n = 14) and control group (n = 12). Rehabilitation program comprised of 16 sessions of body suspension and pendulum exercises (twice/week). The maximal voluntary isometric trunk flexion and extension torques, muscle activation and thickness (external and internal oblique, rectus and transversus abdominis, longissimus, and multifidus muscles), and functionality (adapted reach test) were evaluated before and after of rehabilitation program. FINDINGS: A significant increase was observed in maximal voluntary isometric torque (flexion, 58%; extension, 76%), muscle activation of the rectus abdominis muscle, and muscle thickness of all intervention group muscles, without changes in the control group. Compared to the pre-intervention period, the intervention group also showed improvement in functionality at post-intervention, but no such differences were noted in the control group. INTERPRETATION: The corporal suspension and pendulum exercises training improved rectus abdominis muscle activation, trunk muscles structure and strength, and reaching capacity in medullar thoracic injury patients.

Diagnosis of Rectus Sheath Hematoma by Point-of-Care Ultrasound.

BACKGROUND: Rectus sheath hematoma is a rare but dangerous cause of undifferentiated hypotension and abdominal pain in the emergency department (ED). Point-of-care ultrasound is a useful tool in its identification. CASE REPORT: A 75-year-old woman presented to the ED with hypotension of an unclear etiology. She was found, via point-of-care ultrasound, to have a large and expanding rectus sheath hematoma. She ultimately had embolization of a lacerated epigastric artery, likely caused by enoxaparin injection. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Rectus sheath hematomas are a dangerous and often unrecognized source of abdominal pain and shock in anticoagulated patients. Commonly applied point-of-care ultrasound algorithms to assess hypotension may miss this entity.

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.

A Preliminary Assessment of Abdominal Wall Tension in Patients Undergoing Retromuscular Hernia Repair.

A common technique for ventral and incisional hernia repair is the retrorectus repair (Rives-Stoppa). The posterior rectus sheath is incised bilaterally, and mesh is placed retromuscularly. There is little information on how this component separation technique affects abdominal wall tension. We evaluated abdominal wall tension in patients undergoing retrorectus repair of abdominal wall hernias. Patients undergoing retrorectus repair of their ventral hernias were enrolled in a prospective, Institutional Review Board-approved protocol to measure abdominal wall tension from 8/1/2013 to 8/2/2017. Demographic information and operative details were documented. Abdominal wall tensions were measured using scales attached to Kocher clamps that were clamped to the fascia and brought together in the midline. Measurements were made before and after incising the posterior rectus sheaths. Data were analyzed with a repeated measures analysis of variance (ANOVA), and differences between individual groups were analyzed by least square differences. Forty-five patients had tension measurements. Average age was 58 years (range 29-81)-78% Caucasian, 51% female, an average body mass index (BMI) of 35 kg/m2 (range 20-62), and 38% recurrent hernias. The average hernia defect was 121.9 cm2, and the average mesh size was 607.8 cm2. There was a significant reduction in tension after bilateral posterior rectus sheath incision (3.1 lbs vs. 5.6 lbs, p<0.0001). In this evaluation, abdominal wall tension measurements are shown to be a feasible adjunct during open hernia repair with retrorectus repair. Transection of the posterior rectus sheath decreases tension during hernia repair and may help guide surgeons regarding when to use this procedure.

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.

Dry needling in chronic abdominal wall pain of uncertain origin.

BACKGROUND: Abdominal wall pain is considered as pain that arises from the abdominal muscles rather than the underlying viscera or the spine. It is frequently overlooked and is often misdiagnosed, as these patients continue to suffer with pain. Many such patients would have even been subjected to a psychiatric evaluation in view of the absence of any ostensible clinical cause for the pain. In this study, we describe the role of myofascial trigger points in the abdominal wall pain that could be a cause of chronic pain and present our findings of pain relief by dry needling technique. OBJECTIVES: To report the effect of dry needling treatment for patients who suffer from chronic abdominal wall pain of uncertain etiology and in whom specific myofascial trigger points were identified. METHODS: Twelve patients diagnosed with chronic abdominal wall pain were included in the study. All patients were clinically evaluated and subjected to a combination of imaging techniques. Once categorized as patients suffering from chronic abdominal wall pain, they were subjected to a thorough palpation of the abdominal wall to identify the presence of myofascial trigger points (MTrPs) over the abdominal muscles. All had MTrPs over one or more abdominal muscles either unilaterally or bilaterally. Dry Needling using a standard technique was done based on the side and localization of the myofascial trigger points. Numerical pain rating scale (NPRS) was used to measure pain before and after treatment and at the end of four months. All patients were then seen by the primary clinician and re-evaluated. RESULTS: Eleven out of twelve patients had significant reduction with a mean difference 5.95 in NPRS in their pain levels at four months follow up. Seven patients had complete resolution of the pain. Some patients had improvement in complaints such as Dysmenorrhea, Urinary Frequency and constipation. CONCLUSION: Dry Needling can be a useful adjunct in treating chronic abdominal wall pain especially in those patients in whom Myofascial Trigger Points in the muscles of abdomen are identified by palpation. LEVEL OF EVIDENCE: Level 4.