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Establishing Expert-Based Recommendations for the Conservative Management of Pregnancy-Related Diastasis Rectus Abdominis: A Delphi Consensus Study

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Pregnancy-related diastasis rectus abdominis (DRA) is a prevalent condition. Consequences of a widened linea alba ultimately remain unknown. Current evidence on conservative management is conflicting, creating debate among practitioners. This study aims at developing a set of expert consensus-based recommendations for the assessment and conservative management of DRA. Selected Canadian women's health physiotherapists were invited to participate in a 3-phase Delphi consensus study. Phase I comprised 82 items divided into 6 domains, and to determine agreement, each item was rated on a 5-point Likert scale. Consensus was defined as agreement greater than 80%. In phase II, items receiving consensus were ranked and collapsed and summary descriptions were proposed. In phase III, final consensus was determined. A total of 21 of the 28 (75%) invited experts participated. Phase I generated 38 consensus statements. Phase II translated into 30 consensus statements as well as modifications to proposed summary statements for each data category. Remaining items did not reach consensus. Consensus for 28 expert-based recommendations was achieved in phase III. This study generated 28 expert-based recommendations achieved through a 3-phase consensus process for the assessment and conservative management of DRA. Nationally recognized Canadian expert physiotherapists in women's health agree that the impairments and dysfunctions related to DRA are multidimensional and emphasize the need for a global and tailored care approach. This is the first study to establish consensus across key stakeholders to assist in bridging the current evidence-practice gap regarding pregnancy-related DRA. Our findings point to matters that require further study. 5 (expert opinion). This article has a Video Abstract available at http://links.lww.com/JWHPT/A24.
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Journal of Women’s Health Physical Therapy © 2019 Section on Women’s Health, American Physical Therapy Association 73
ABSTRACT
Purpose: Pregnancy-related diastasis rectus abdominis
(DRA) is a prevalent condition. Consequences of a wid-
ened linea alba ultimately remain unknown. Current evi-
dence on conservative management is conflicting, creating
debate among practitioners. This study aims at developing
a set of expert consensus-based recommendations for the
assessment and conservative management of DRA.
Methods: Selected Canadian women’s health physiothera-
pists were invited to participate in a 3-phase Delphi con-
sensus study. Phase I comprised 82 items divided into
6 domains, and to determine agreement, each item was
rated on a 5-point Likert scale. Consensus was defined
as agreement greater than 80%. In phase II, items receiv-
ing consensus were ranked and collapsed and summary
descriptions were proposed. In phase III, final consensus
was determined.
Results: A total of 21 of the 28 (75%) invited experts
participated. Phase I generated 38 consensus statements.
Phase II translated into 30 consensus statements as well
as modifications to proposed summary statements for
each data category. Remaining items did not reach con-
sensus. Consensus for 28 expert-based recommendations
was achieved in phase III.
INTRODUCTION
Pregnancy-related diastasis rectus abdominis (DRA)
is an impairment to the linea alba (LA), a fibrous
raphe running along the sheaths of the rectus abdomi-
nis muscles.1,2 Mainly associated with the expanding
uterus during pregnancy, this impairment is currently
described as widening and thinning of the LA, creat-
ing a midline separation between the 2 rectus abdom-
inis muscles. Hence, DRA is presently defined by an
increased inter-recti muscle distance (IRD) from nor-
mal values.3 DRA is highly prevalent throughout the
perinatal period. During pregnancy, it is reported that
33% of women exhibit a wider LA during the second
trimester, which rises to 100% by the end of the third
trimester.4,5 Prevalence remains high after delivery,
with an estimated 23% to 32% of women present-
ing with a persistent DRA at 1 year postdelivery.4,6
1School of Rehabilitation Science, McMaster University,
Hamilton, Ontario, Canada.
2Department of Rehabilitation, Faculty of Medicine,
Université Laval, Quebec City, Quebec, Canada.
3Department of Obstetrics and Gynecology, School of
Medicine, McMaster University, Hamilton, Ontario,
Canada.
The authors declare no conflicts of interest.
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DOI: 10.1097/JWH.0000000000000130
Research Report
Establishing Expert-Based Recommendations
for the Conservative Management of
Pregnancy-Related Diastasis Rectus Abdominis:
A Delphi Consensus Study
Sinéad Dufour, PT, PhD1
Stéphanie Bernard, PT, MSc2
Beth Murray-Davis, PhD, RM3
Nadine Graham, PT, MSc1
VOLUME • NUMBER • 00 2019
Conclusions: This study generated 28 expert-based recom-
mendations achieved through a 3-phase consensus process
for the assessment and conservative management of DRA.
Nationally recognized Canadian expert physiotherapists in
women’s health agree that the impairments and dysfunc-
tions related to DRA are multidimensional and emphasize
the need for a global and tailored care approach.
Clinical Relevance: This is the first study to establish
consensus across key stakeholders to assist in bridging
the current evidence-practice gap regarding pregnancy-
related DRA. Our findings point to matters that require
further study.
Level of Evidence: 5 (expert opinion).
Key Words: conservative management, diastasis recti,
physical therapy, postpartum, pregnancy, rehabilitation
This article has a Video Abstract available at http://links.
lww.com/JWHPT/A24.
Research Report
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Research Report
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Although being a highly prevalent condition in
women, there is limited knowledge on the impacts
and long-term sequelae of an increased IRD in preg-
nant and postpartum women.5 With the many intrin-
sic anatomical links between the LA, the abdominal
musculature, and the thoracolumbar spine, it has
been suggested that DRA could affect trunk con-
trol.7–10 However, this relationship is not supported
by recent evidence.11 For instance, Fernandes da
Mota et al5 found no association between mild DRA,
as defined by a greater than 16-mm IRD measured at
2 cm below the umbilicus, and lumbopelvic pain at
6 months postpartum. It remains unknown whether
a correlation would be found in a group of women
exhibiting larger IRDs or accompanied by other
dysfunctions of the abdominal wall. Nonetheless, as
methods for measurement and criteria for diagnosis
remain unstandardized between studies, evidence on
the functional consequences of DRA is lacking.
The methods of a conservative care approach to
DRA therefore create much debate among health care
providers and women seeking care. It is well known
that exercise is one of the most common modalities
used by physiotherapists to address DRA during the
perinatal period.12 As for the effects of exercises dur-
ing pregnancy, a small study by Chiarello et al11 sug-
gested that abdominal strengthening exercises (includ-
ing transversus abdominis training), in addition to
pelvic floor muscle (PFM) training and education on
proper body mechanics, may be helpful to maintain
small IRD during the prenatal period. On the contrary,
Fernandes da Mota et al found5 that women exercising
regularly before and after pregnancy did not present
with a lower risk of widening IRD. Regarding clinical
practice with women who have previously given birth,
regardless of the time since delivery, a national survey
of women’s health physical therapists (USA), conducted
by Keeler et al,13 determined that 89.2% of respondents
used transversus abdominis exercises to address issues
related to DRA and 62.5% used the Elizabeth Noble
technique, where rectus abdominis muscles are manu-
ally approximated during a curl-up exercise. Despite
the obvious popularity of these exercises, a review
conducted by Benjamin et al12 in 2014 on the effects of
any pre- and postnatal exercises on DRA led to the con-
clusion that there was insufficient quality evidence to
support any particular exercise approach for this condi-
tion. As the number of studies and the level of evidence
remain limited, best conservative approach concerning
DRA during and after pregnancy is debatable. Given
that what presently constitutes the best approaches
for this condition needs further research exploration
and substantiation, we sought to bring together key
knowledge users regarding this condition to inform
practice through a systematic process of collecting
expert knowledge and building consensus among them.
Objective
The objective of this study was to establish a set of
expert-based recommendations for the assessment
and conservative management of pregnancy-related
DRA up to 12 months postpartum.
METHODS
Study Design
An expert consensus process was conducted. A Delphi
methodology was performed to collate expert knowl-
edge and build systematic consensus. The Delphi
technique is designed as a group communication pro-
cess to achieve convergence of opinion on a specific
issue.14–17 The Delphi method in its simplest form
solicits the opinions of “experts” through a series of
carefully designed questionnaires interspersed with
information and opinion feedback.15 For this study,
a 3-phase Web-based survey (SurveyMonkey Inc,
2017; San Mateo, California) design was adopted.
Consensus was determined by level of agreement
defined a priori. Following principles of participant
anonymity, iterative questionnaire presentation and
feedback of analysis were administered to participants
in each phase.18–20 Informed by the “Knowledge to
Action” framework of the Canadian Institutes for
Health Research and principles of practice-based
inquiry, identified experts were invited by e-mail to
participate in this Delphi consensus.21–23 In each of
the 3 phases, the feedback process within the Delphi
method allowed for and encouraged the participants
to reassess their initial judgments pertaining to infor-
mation provided in previous iterations and provide
comments.
Participants
Following ethical approval from the Hamilton
Integrated Research Ethics Board (#2319), an expert
panel was purposively assembled and individuals
were invited to participate. Participants were deemed
to be “experts” through identification as nation-
ally (Canadian) credentialed women’s health phys-
iotherapists, with evidenced clinical and/or academic
achievements. Specifically, participants were either
designated “Women’s Health Clinical Specialist”
through the Canadian Physiotherapy Association or
involved in research, academic teaching or clinically
oriented teaching outside of academia. To avoid selec-
tion bias, the research team collaborated with key
stakeholders, including the members of the Executive
Committee of the Women’s Health Division of the
Canadian Physiotherapy Association, to recognize
all physiotherapy experts in women’s health across
Canada. A total of 28 experts were identified, from
various clinical and academic backgrounds, ensuring
a comprehensive representation (maximum variation
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Research Report
Journal of Women’s Health Physical Therapy © 2019 Section on Women’s Health, American Physical Therapy Association 75
sampling) of the field of women’s health in physio-
therapy in Canada.
Item Development
A 3-step process was followed to develop the initial
list of 82 items related to conservative management
strategies for DRA that formed the items examined
in phase I (see the Figure). The first step identified key
relevant domains. This was achieved by the mem-
bers of the research team, with the help of research
assistants, by completing a comprehensive scop-
ing review of the scientific literature. The research
team comprised health disciplines in physiotherapy,
medicine, and midwifery. Specifically, 4 databases
were searched (CINAHL, MEDLINE, PubMed, and
Google Scholar) and 4 separate search strategies were
performed in each one: (1) diastasis rectus abdominis
AND conservative care, (2) diastasis rectus abdominis
AND assessment, (3) diastasis rectus abdominis AND
management, and (4) diastasis rectus abdominis
AND pregnancy. In addition to scoping published
peer-reviewed literature, the team also reviewed
“gray literature,” specifically content of nonaca-
demic postgraduate courses, published theses, and
white papers. From this process, 6 domains related
to the conservative management of DRA emerged, 4
of which pertained to different perinatal stages: (1)
general perceptions on DRA, (2) prenatal period, (3)
intrapartum, (4) early postpartum period, defined as
the first 3 months following birth, (5) late postpar-
tum, defined as period between the third month up to
1 year following birth, and (6) assessment. The sec-
ond step involved the research team generating items
within each domain from the literature base gathered
during step 1. The final step involved reorganizing
and restructuring the generated items so that they
were written in an appropriate format to be rated for
agreement vs disagreement in phase 1 of the Delphi.
A pretest survey with 6 women’s health physiothera-
pists was conducted to ensure clarity and appropri-
ateness of each item of the survey. Once these steps
were accomplished, the final version of phase I survey
was sent out to participants.
Data Collection
In phase I, participants were asked to rate each item
of the online survey, indicating their degree of agree-
ment on a 5-point Likert scale, with 1 being “strongly
disagree” and 5 being “strongly agree.” Consensus
for item inclusion was defined a priori as greater than
80% agreement of respondents based on mean score
calculations. Statements that had a mean ranking
below 40% were removed and those with a mean
ranking between 41% and 79% were kept for phase II
for further exploration and consideration. In addition,
points raised by participants in phase I (with a mean
ranking of 41% or higher) in free-form text sections
were added for further consideration in phase II.
Following phase II, redundancy was identified and
relevant items were collapsed or removed. In phase III,
participants were asked to rank consensus items from
phase II into 2 categories: (1) primary importance,
meaning the recommendation is believed to be of high
priority by the participants; and (2) secondary impor-
tance, for when the recommendation is thought to be
important but not of primary importance to include.
The summary statements were developed on the basis
of an iterative process whereby the research team assem-
bled these statements through thematic content analysis
of free-text comments and feedback through phase I.
Draft versions of these summaries were provided to par-
ticipants in phase II, eliciting feedback before determin-
ing consensus in phase III. In phase III, the procedure
for consensus outlined for phase II was repeated. Final
consensus was determined on all recommendations
from phase III presented as primary versus secondary
importance based on the priority given by participants.
Each phase lasted 4 to 6 weeks, with 2 reminder e-mails
distributed to nonrespondents in each phase.
Data Analysis
All data were extracted from the online survey and
coded into a Microsoft Excel (2014) spreadsheet.
Visual inspection of the data allowed identification
of any missing or aberrant data. Coding of results
allowed to pool data from the expert panel for each
question. At each phase, the mean score for each
Figure. Flow of the study.
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Research Report
76 © 2019 Section on Women’s Health, American Physical Therapy Association Volume 43 • Number 2 • April/June 2019
individual item was calculated and transformed into
a percentage using standard descriptive Microsoft
Excel’s statistical functions. Again, agreement was
determined for mean score of 4 or more (80.0%).
RESULTS
Response Rate
A total of 21 participants, out of 28 invited experts
(75.0% participation rate), made up the panel in
phase I, with representation spanning 6 provinces in
Canada. All participants were female. Demographic
characteristics of participants are presented in Table 1.
A total of 11 (39.2%) participants contributed in
phase II, and 17 (60.7%) participants contributed
in phase III. All 21 participants who contributed in
phase I also contributed in phase II, phase III, or both
(see the Figure).
Delphi Phases I and II
After phase I, 38 of the 82 items achieved con-
sensus for agreement among participants, 20 of
which had a high percentage (>90%) of agree-
ment. Disagreement was determined for 9 of the 82
statements, and the remaining 40 required further
exploration. Results from phase II translated into 28
statements that received consensus for agreement; 4
statements received consensus for disagreement and
were removed. The remaining items received mixed
perspectives, requiring further exploration. For brevity
purposes, only items achieving high agreement during
phase I or II are reported and summarized in Table 2.
Table 1. Demographic Characteristics of Participants
Demographic Characteristicsa
Number of
Participants
Locationb
Atlantic provinces 2
Quebec 7
Ontario 9
Saskatchewan 1
Alberta 1
British Columbia 3
Years in practice
0-9 5
10-19 11
20+7
University faculty (PhD) 8
Community education faculty 14
Researchers 12
Clinical specialists: Canadian Physiotherapy
Association designation 4
Fellows of the Canadian Academy of Manipulative
Practitioners 8
aAll participants were female.
bTwo participants work (teach) out of 2 provinces.
Table 2. Results of Items Achieving Consensus—Phases I and II
Items Achieving Consensus With High Agreement
During Phases I and II
Phases
I and II (%)
Prenatal period
Avoid exercises that concentrically engage
the superficial abdominal muscles.a83.2
Facilitate optimal coactivation of the inner unit
during exercises.b87.4
Promote effective tension-free diaphragmatic
breathing, such as breathing with a freely
moving abdomen.
82.2
Emphasize postures that reduce excessive
sustained intra-abdominal pressure. 90.6
Encourage optimal elimination habits to reduce
straining. 86.4
Early postpartum period
Avoid exercises that concentrically engage
the superficial abdominal muscles.a83.2
Avoid exercises in which continence mechanism
is not maintained. 94.8
Avoid high-impact exercise. 86.4
Facilitate optimal coactivation of the inner unit
muscles during exercises.b87.4
Late postpartum period
Avoid exercises that cause doming or invagination
of the LA. 93.6
Introduce front loaded exercises if tension through
the LA is maintained. 90.0
Avoid exercises in which continence mechanism is
not maintained. 87.8
Progress core training if appropriate tension
through the LA is achieved. 90.0
Address contributing pelvic girdle and thoracic
movement impairments. 86.6
Assessment of DRA
Assess development of tension through the LA with
voluntary PFM and transverse abdominis
coactivation.
88.8
Ensure optimal PFM contraction through a digital
examination. 84.4
Assess for doming or invagination of LA during
exercises. 82.2
A nonfunctional DRA is determined when tension
of LA cannot be developed voluntarily. 81.2
Abbreviations: DRA, diastasis rectus abdominis; LA, linea alba;
PFM, pelvic floor muscle.
aRefers to exercise that shortens the rectus abdominis muscles,
external obliques, and internal obliques.
bRefers to exercise including pelvic floor and transversus abdominis
muscles.
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Delphi Phase III
The output of the Delphi consensus process trans-
lated into 28 expert-based recommendations,
organized according to the 6 previously indicated
domains, prioritized into 2 categories: (1) primary
importance and (2) secondary importance. In addi-
tion, the expert-based recommendations from each
domain were accompanied by a summary statement.
The first domain reflects general perspectives, and
these recommendations translated into 1 summary
description. The breakdown of recommendations
within each domain was as follows: domain 2
(prenatal) = 5 recommendations; domain 3 (intra-
partum) = 4 recommendations; domain 4 (early
postpartum) = 7 recommendations; domain 5 (late
postpartum)= 9 recommendations; and domain 6
(assessment) = 3 recommendations. A complete list
of established consensus-based summary statements
and expert-based recommendations is presented in
Table 3.
Several items from each domain did not reach
consensus. For example, experts did not agree on
the activity counseling item in domain 2 (prenatal).
Participants generally indicated the importance of
counseling pregnant women on appropriate activity;
however, some did not feel this should be outlined
as specific to DRA and others felt it should be more
tailored to individual goals that encompass more than
DRA. All recommendations in domain 3 (intrapar-
tum) were reframed from phase I and approached
from the perspective of the physiotherapists’ advo-
cacy role based on participant’s feedback. One item
in domain 4 (early postpartum), on avoiding front
loaded positions, did not achieve consensus as it was
indicated by many that there is too much individual
variability related to this item for it to translate into
a recommendation. For domain 5 (late postpartum),
3 items from phase II did not achieve consensus. Like
the early postpartum domain, avoiding front loaded
activities was deemed to implicate too many individ-
ual barriers. Counseling related to nutrition (73.4%)
and sleep (63.6%) did not reach consensus either; the
experts’ perspectives were very mixed on these issues,
although trending toward consensus. Consensus to
remove 2 discussion items from phases I and II was
also achieved during phase III. The first item was
regarding highlighting exercises that eccentrically
lengthen superficial abdominal muscles, referring
to the rectus abdominis, and external and internal
oblique muscles. Generally, the participants agreed
by phase III that there was not enough evidence to
support this item. The second item was the use of
abdominal support; the main issue communicated
was the lack of evidence to use abdominal binding
as a corrective technique, although several partici-
pants did indicate they may use this tool in certain
situations. Related to domain 6 (assessment), the
expert panel was not able to establish consensus on
the items regarding measuring LA doming or invagi-
nating, described as identifying through palpation a
slackened LA that is collapsing inwardly or bulging
out, as an assessment technique to identify failure to
transfer load in the LA that may be seen in DRA.
In addition, the experts were unable to establish
consensus on what constitutes a “significant” or
“severe” DRA. Several participants indicated palpable
abdominal pulse or contents; however, agreement was
not reached. Finally, the notion of ensuring that all
recommendations did not elicit excessive or irrational
fear among women surfaced across all domains. As
such, some of the language in the final recommenda-
tions and summary statements reflects this prevailing
sentiment.
DISCUSSION
The main objective of this consensus study was
to identify a set of expert-based recommendations
for the assessment and conservative management
of pregnancy-related DRA for up to 12 months
postpartum. Through a diverse panel of recognized
experts from different backgrounds and regions of
Canada, and a rigorous and systematic study design,
this study allowed for the gathering and exploration
of participants’ knowledge and experiences.23 The
importance of engaging knowledge users throughout
the various steps of research represents an approach
that is currently advocated for as it harnesses a
potential to garner results that will directly impact
clinical practice.21 From a predetermined thresh-
old for determining agreement or disagreement
among participants, a total of 28 recommendations
were established after a 3-phase Delphi consensus.
Interestingly, most recommendations that achieved
agreement regarding management of DRA point
toward the need to understand, assess, and approach
impairments of the LA as an integrative component
of the thoracopelvic abdominal system. To provide
the most appropriate care for any woman present-
ing pregnancy-related DRA, practitioners first need
to assess and determine the extent of the problem.
One notable finding from this study relates to using
IRD as the main or only criterion for assessing and
diagnosing impairments of the LA. Such notion was
challenged by the participating experts, and this
perspective is shared by other authors as well.25 For
instance, experts from this study emphasized the
need to assess various anatomical and functional
aspects of the LA in addition to the measure of IRD,
such as palpation at rest to appreciate the integrity
of the anatomical structure aspects of the LA, as well
as fascial tension, or passive resistance at palpation,
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Table 3. Final Expert-Based Summary Statements (A) and Recommendations (B) Derived From Items Achieving Consensus During Phase III
Expert-Based Recommendations
Domain 1: General perspectives on DRA
A. Summary statement
Pregnancy-related DRA represents an important and under-recognized concern. All relevant health and tness providers working with pregnant
women should know how to promote best care practices for this condition; however, general agreement of what constitutes the best approach
is lacking. Given that the complex 3-dimensional tissue of the LA is intrinsic to the thoracopelvic abdominal manometric system, compromised
integrity of the LA needs to be considered within the context of this system. As experts in women’s health, we have come to understand that
the impairments and dysfunctions related to DRA as multidimensional and multifactorial. Furthermore, in line with other thoracic, lumbar, and
pelvic conditions we manage in the profession of physiotherapy, the interaction between the musculoskeletal, nervous, and immune systems
represents a central aspect of our global care approach, which is then individually tailored. Thus, our approach allows for the integrated target-
ing of modifiable factors that are potential drivers of DRA and associated impairments or participation restrictions across multiple dimensions.
As a group, we have agreed that a set of practice principles are needed when working with women to guide clinical decision-making with
respect to pregnancy-related DRA. These practice principles have been developed with intent of guiding practice of all relevant care providers.
B. Recommendations
None identied.
Domain 2: Prenatal
A. Summary statement
As experts in women’s health, we understand the importance of promoting health for women and their developing babies. We recognize the pre-
natal period as a time of transition that warrants mindfulness related to exercise and movement strategies to promote optimal physical function
through the pregnancy, limit potential functional impairment, and prepare for birth and postpartum recovery. As a group, we have agreed on 5
practice principles as they relate to prenatal care when considering DRA.
B. Recommendations
1. Emphasize static and dynamic postures that reduce excessive intra-abdominal pressures (ie, maintaining a relaxed neutral spine).a
2. Encourage habitual activity patterns that reduce repeated increases in intra-abdominal pressure (ie, rolling to the side to get up; avoid
straining on the toilet).a
3. Commence inner unit exercises that facilitate optimal isolated and synergistic activation of the inner unit, and once control is achieved,
progress with tailored outer unit and functionally oriented exercises.a
4. Avoid exercises that concentrically engage the superficial abdominal muscles (ie, sit-ups).b
5. Encourage a breathing pattern that promotes a tension-free diaphragmatic pattern (eg, downward motion of diaphragm and lateral costal
expansion on inhale).b
Domain 3: Intrapartum
A. Summary statement
As experts in women’s health, we approach intrapartum care from the perspective of promoting strategies that are least likely to result in impair-
ment to the pelvic tissues or dysfunction in the thoracopelvic abdominal manometric system. Our perspectives are congruent with best prac-
tice guidelines for physiologic birth published by the Society of Obstetricians and Gynecologists of Canada.24 As a group, we have agreed on 4
practice principles related to intrapartum care, considering DRA within the context of global pelvic health.
B. Recommendations
1. Advocate for the ability to be mobile during labor.a
2. Avoid directed pushing practices that increase intra-abdominal pressure for sustained periods and close the glottis (ie, Valsalva maneuver).a
3. Advocate for sacrum freeing rather than recumbent birth positions.b
4. Advocate for practices that reduce the likelihood of operative birth procedures.b
Domain 4: Early postpartum period
A. Summary statement
As experts in women’s health and pelvic health, we approach the early postpartum period, the fourth trimester, as an important time to promote
optimal recovery. Movement is important through this period and should not be feared; however, the emphasis is on gentle restorative exer-
cises that are tailored to each woman’s needs. Given the incredible healing and restoration that takes place in the fourth trimester, a diagnosis
of DRA should be reserved for after this period.
B. Recommendations
1. Emphasize static and dynamic postures that reduce excessive intra-abdominal pressures (ie, maintaining a relaxed neutral spine).a
2. Encourage habitual activity patterns that reduce repeated increases in intra-abdominal pressure (ie, rolling to the side to get up; straining
on the toilet).a
3. Avoid exercises that concentrically engage the superficial abdominal muscles (ie, sit-ups).a
4. Encourage a breathing pattern that promotes a tension-free diaphragmatic pattern (ie, downward motion of diaphragm and lateral costal
expansion on inhale).a
5. Commence inner unit exercises that facilitate optimal isolated and synergistic activation of the inner unit, and once control is achieved, prog-
ress with tailored outer unit and functionally oriented exercises.a
6. Avoid high-impact exercise.b
7. Avoid exercises in which continence mechanism is not maintained.b
(continues)
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Journal of Women’s Health Physical Therapy © 2019 Section on Women’s Health, American Physical Therapy Association 79
of the LA during a voluntary contraction. Although
there is scarce evidence on abdominal muscle func-
tion in the presence of increased IRD,8 a recent study
by Hills et al26 in 2018 corroborated poorer trunk
function associated with larger IRDs. This suggests
that anatomy, structure, and function of the LA, as
well as strength and endurance of the abdominal
muscles, appear to be relevant to assess and identify
dysfunction in DRA. The expert-based recommen-
dations presented in this article support the need to
reconsider actual criteria for identifying pathological
DRA to acknowledge the anatomical and physio-
logical relationships between the LA and abdominal
muscle function, thoracopelvic static and dynamic
stability, and breathing patterns.10,27 This may
explain why the final recommendations presented in
this study do not address the different measures of
IRD, such as calipers or ultrasound imaging, which
have been extensively covered in the literature.28–31
Exploring assessment of other parameters that could
be associated with diastasis-related abdominal wall
dysfunction appears to be important according to
the opinions of the participating experts. What
constitutes the most important characteristics of a
pathological LA has yet to reach unanimity and as
such concepts supporting these recommendations
need further exploration.
Many of the established recommendations in
this study corroborate with the existing scientific
literature. For instance, experts in this study believe
and agree that it is important to encourage habitual
activity patterns that reduce repeated increases in
intra-abdominal pressure. This particular recommen-
dation is concordant with findings by Sperstad et al,4
Table 3. Final Expert-Based Summary Statements (A) and Recommendations (B) Derived From Items Achieving Consensus During
Phase III (Continued)
Expert-Based Recommendations
Domain 5: Late postpartum
A. Summary statement
As experts in women’s health, we approach the presence of pregnancy-related DRA from a biopsychosocial perspective, with particular atten-
tion to the thoracopelvic abdominal manometric system. Although movement and exercise will be modified to effectively address DRA, it is
important that exercise and movement are embraced by women rather than feared. Furthermore, it is important that language emphasizing
neuromuscular physiology rather than structure or “gap” is used when working with these women. An evolved understanding of restoring the
integrity of the LA does not translate into “closing the gap,” as it has been understood in the past. As such, the expert panel does not recom-
mend using the popular “Noble technique” or other similar forms of splinted head lifts or crunches to address the complexity of pregnancy-
related DRA.
B. Recommendations
1. Advocate neutral spine posture and alignment.a
2. Encourage a breathing pattern that promotes a tension-free diaphragmatic pattern (ie, downward motion of diaphragm and lateral costal
expansion on inhale).a
3. Encourage optimal body mechanics and motor activation strategies for everyday tasks (ie, pushing stroller, carrying baby).a
4. Encourage habitual activity patterns that reduce repeated increases in intra-abdominal pressure (ie, rolling to the side to get up; straining on
the toilet).a
5. Commence inner unit exercises that facilitate optimal isolated and synergistic activation of the inner unit, and once control is achieved,
progress with tailored outer unit and functionally oriented exercises.a
6. Correct or modify exercises that cause doming or invagination of the LA.b
7. Approach exercises that concentrically engage the superficial abdominals with caution.b
8. Address contributing pelvic girdle and thoracic movement impairments.b
9. Approach exercises in which continence mechanism is not maintained with caution.b
Domain 6: Assessment
A. Summary statement
As experts in women’s health, we acknowledge the evolving understanding of pregnancy-related DRA such that measurement of the inter-recti
distance does not provide sufficient and meaningful clinically relevant data. Rather, we agree that assessing aspects of the thoracopelvic
abdominal manometric system garners a more relevant approach that acknowledges recent advances in clinical research and aligns with our
respective clinical experience.
B. Recommendations
1. Assess generation of tension in LA with voluntary PFM contraction.a
2. Assess pelvic floor function—digital examination or via ultrasound study.a
3. Assess LA at rest via palpation to determine integrity via depth and qualitative assessment of LA.a
Abbreviations: DRA, diastasis rectus abdominis; LA, linea alba; PFM, pelvic floor muscle.
aPrinciple rated as first priority by participants.
bPrinciple rated as secondary priority by participants.
Copyright © 2019 Section on Women’s Health, American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
Research Report
80 © 2019 Section on Women’s Health, American Physical Therapy Association Volume 43 • Number 2 • April/June 2019
where a greater possibility for pregnant women to
develop DRA was reported for those heavy lifting
more than 20 times per week. In addition, the expert
panel in this study agreed with the rehabilitation
approach studied by Mesquita et al,32 favoring early
inner unit exercises, defined as PFM and transversus
abdominis exercises, done postdelivery. Furthermore,
participants agreed that when assessing DRA, it was
important to appreciate the functional aspect of ten-
sion generation through the LA during pelvic floor
and transversus abdominis coactivation, which are
in accordance with the theories proposed by Lee and
Hodges.7
However, some recommendations agreed upon
by the experts of this study are not concordant with
evidence previously published. For example, partici-
pants in this study consider it important that during
the late postpartum period, exercise that concentri-
cally engaged the superficial abdominals must be
approached with caution and that a lack of tension
in the LA during an exercise must be corrected. This
opposes the conclusions by Sancho et al,33 where the
authors suggest achieving reduction in IRD through a
small crunch exercise (head and scapula lift), which is
a concentric exercise similar to the Noble technique.
Participants in this study agreed with a high degree of
consensus (>90%) that the “Noble technique” was
not an appropriate management strategy to use and
that pregnancy-related DRA represents more than a
“gap” that needs to be narrowed. This perspective does
conflict with practice patterns described by women’s
health physical therapists in the United States in the
Keeler et al13 study and requires testing in an appropri-
ate scientific trial. Canadian experts in this study also
believe and agree that abdominal binding should not
be recommended as a first-line treatment and should
be reserved for use in specific cases. With the rise of
waist corsets on the market, systematic binding of
the abdomen in postpartum women is questioned by
the participants of this study. To date, no randomized
controlled trials have investigated the effectiveness of
abdominal binding postpartum to address DRA.
The recommendations for the intrapartum phase
are currently unsupported by evidence in the scientific
literature. Although some of these recommendations
were determined by our participants to be of second-
ary priority, they were possibly established on the
basis of the theory of motor coactivation patterns
between the PFMs and the abdominal muscles.34,35
Further research is needed to determine whether there
is a relationship between the birthing position, the
degree of injury to the PFMs and endopelvic fascia
from delivery (tear, avulsion, episiotomy, etc), and
abdominal and LA function during postpartum recov-
ery, which currently remains theoretical. Yet, experts
were in agreement that these concepts are indirectly
connected and need to be considered holistically when
addressing DRA as articulated in Table 3.
Finally, an interesting and unexpected finding was
that the experts in this study did not agree on the role
of health promotion in the conservative management
of pregnancy-related DRA. Activity counseling,
nutrition counseling, and sleep counseling were all
left as inconclusive statements at the end of phase III.
It has been proposed for more than a decade that
physiotherapists need to demonstrate and enact clini-
cal competencies that include assessments of health,
lifestyle health behaviors, and lifestyle risk factors.36
Furthermore, this perspective has been substantiated
through a recent systematic review confirming that
physiotherapists can effectively counsel patients with
respect to lifestyle behavior change.37 Knowledge
translation related to the importance of integrating
health promotion strategies into physiotherapy con-
servative management strategies is needed.
The 28 recommendations established by a con-
sensus process among Canadian experts in women’s
health corroborate many findings presented by Keeler
et al.13 Importantly, our results extend these findings by
addressing DRA from additional perspectives and by
the different perinatal stages. Interestingly, our expert
panel was enthusiastic and in agreement that women’s
health physiotherapists have a clear advocacy role
during the intrapartum stage, which was not identified
in the study by Keeler et al.13 Finally, an overreaching
sentiment reflected within the recommendations high-
lights our participants’ unanimous perspective related
to avoiding any language within a recommendation
that could potentially prompt fear of movement.
Overall, this study is the first to commence bridging
the current evidence-practice gap through a systematic
mode of practice-based inquiry. The major limitation
of this study relates to the fact that it yields level 5
evidence (expert opinion) and is dependable on the
reliability of the participating experts.38 All established
consensus-based recommendations require further
testing in appropriate research designs to determine
efficacy.38 Another potential limitation relates to the
relatively low participation rate for phase II. Although
phases I and III garnered a high response rate, in phase
II, only 11 participants contributed. However, it most
likely did not impact the final results as the partici-
pants were able to reflect on these items again in phase
III. Finally, although we applied methodological pro-
cedures to mitigate participant bias, we acknowledge
that it was not possible to eliminate all potential bias.
CONCLUSION
This study generated 28 Canadian expert-based recom-
mendations for conservative care of pregnancy-related
DRA. Nationally recognized expert physiotherapists
Copyright © 2019 Section on Women’s Health, American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
Research Report
Journal of Women’s Health Physical Therapy © 2019 Section on Women’s Health, American Physical Therapy Association 81
in women’s health agree that the impairments and
dysfunctions related to DRA are multidimensional and
multifactorial and accentuate the need for a global, yet
individually tailored care approach of this condition.
Some of these consensus-based recommendations cor-
roborate with the scientific literature, and some do
not. Our findings point to research-practice gaps that
require further study.
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... However, further investigation is needed to verify these relationships because of the weak methodological quality of the existing studies and their heterogenicity regarding study design and population [31,32]. Numerous studies have investigated the impact of specific therapeutic exercises or other physiotherapy methods on pregnancy-related DRA [8,[33][34][35][36][37]. Physiotherapy has been shown to improve the condition [38][39][40]. However, according to a recent systematic review and meta-analysis, there is currently no high-quality scientific evidence on the most effective exercise programs in the treatment of postpartum DRA [41]. ...
... In physiotherapy research involving IRD measurement, musculoskeletal USI has been widely used owing to its high reliability [7,18,[47][48][49][50]. However, review studies have indicated that IRD measurement procedure has not been standardized [39,40]. The main discrepancies between the study protocols concern measurement sites (supraumbilical and infraumbilical) and diagnostic criteria for DRA [14,[38][39][40]. ...
... However, review studies have indicated that IRD measurement procedure has not been standardized [39,40]. The main discrepancies between the study protocols concern measurement sites (supraumbilical and infraumbilical) and diagnostic criteria for DRA [14,[38][39][40]. They also apply to the examinee's body position, way of abdominal muscle activation, or breathing phase during image capturing. ...
Article
Full-text available
Background Inter-recti distance (IRD) measurement using musculoskeletal USI has been used in physiotherapy research, in particular, to investigate pregnancy-related diastasis recti abdominis (DRA) and to seek its effective treatment methods. Severe and untreated diastasis may result in the formation of umbilical or epigastric hernias. Objective This study aimed to systematically map physiotherapy-related research articles that included descriptions of IRD measurement procedures using USI to present their similarities and differences, and formulate recommendations on the procedure. Design A scoping review was conducted according to PRISMA-ScR guidelines, including 49 of 511 publications from three major databases. Publications were selected and screened by two independent reviewers whose decisions were consulted with a third reviewer. The main synthesized data items were: the examinees’ body position, breathing phase, measurement sites, and DRA screening methods. The final conclusions and recommendations were the result of a consensus between seven reviewers from four research centers. Results Studies used 1–5 measurement sites that were differently determined. IRD was measured at the umbilicus ( n = 3), at its superior ( n = 16) and/or inferior border ( n = 9), and at different levels: between 2 and 12 cm above the umbilicus, or a third of the distance and halfway between the umbilicus and xiphoid ( n = 37); between 2 and 4.5 cm below the umbilicus or halfway between the umbilicus and pubis ( n = 27). Different approaches were used to screen subjects for DRA. Conclusions The discrepancies between the measurement procedures prevent between-study comparisons. The DRA screening method should be standardized. IRD measurement protocol standardization has been proposed. Critical relevance statement This scoping review indicates that the inter-recti distance measurement procedures using ultrasound imaging differ between studies, preventing between-study comparisons. Based on the results synthesis, the measurement protocol standardization has been proposed. Key points The inter-recti distance measurement procedures using USI differ between studies. Proposed standardization concerns body position, breathing phase, measurements number per location. Determination of measurement locations considering individual linea alba length is suggested. Recommended locations: umbilical top, ½ of umbilical top-xiphoid, ¼ of umbilical top-xiphoid/pubis distances. Diastasis recti abdominis diagnostic criteria are needed for proposed measurement locations. Graphical Abstract
... The Delphi technique (three rounds)-which is commonly used for decision making and forecasting studies-was used to determine consensus of clinical and exercise professionals on postpartum return-to-run topics. [24][25][26][27][28][29][30][31] Experienced professionals (respondent group) were asked their opinion on key musculoskeletal assessments, milestones and screening that should be used when determining run-readiness postpartum. Consensus statement media (ie, Twitter, Instagram and Facebook) and word-of-mouth via a purposeful and snowball sampling approach. ...
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... Besides the lack of standardization regarding values to characterize RAM distance as diastasis and the tools used for measurement 30 , there are also differences in the literature on the exact time at which this distance should be measured. We found studies that measured RAM distance during the 21 st week of pregnancy, six and eight weeks after delivery, and 12 months after delivery 6,23 . ...
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Maternal organism suffers physiological and biomechanical changes during pregnancy, including the separation of rectus abdominis muscles (RAM). This cross-sectional study aimed to compare the distance between the RAM among sedentary and active primiparous women who had vaginal childbirth and cesarean section, to correlate RAM separation with maternal and child variables and to compare these variables between primiparous women with and without RAM diastasis. In total, 56 women were evaluated in their ninth postpartum week, divided into four groups according to the mode of delivery and the practice of resistance exercises. RAM distance was calipered in the supraumbilical, umbilical, and infraumbilical regions. The values obtained were verified via analysis of variance (ANOVA), Pearson’s correlation, and independent t-test. We found no main effect between mode of delivery and practice of resistance exercises or interaction between mode of delivery and practice of resistance exercises (p≥0.118) for RAM distance. We found significant correlation between body weight before pregnancy and RAM distance (p<0.001). There was no association between body weight gain during pregnancy and the newborn’s weight with RAM distance (p≥0.132). We observed significant difference in body weight before pregnancy between primiparous women with and without RAM diastasis (p<0.005). We found no differences between groups regarding body weight gain during pregnancy and the newborn’s weight (p≥0.122). It was concluded that the practice of resistance exercises and the mode of delivery have no impact on the separation of supraumbilical, umbilical, and infraumbilical regions of RAM in primiparous women. Keywords| Diastasis Muscle; Physical Exercise; Physical Therapy; Pregnancy; Postpartum Period
... Além da ausência de padronização em relação aos valores considerados para caracterização da distância entre os MRAs como diástase e aos instrumentos utilizados para mensuração 30 , também não existe um consenso na literatura quanto ao tempo exato em que se deve mensurar essa distância. Existem estudos que realizaram a mensuração da distância entre os MRAs durante a 21ª semana de gestação, seis e oito semanas após o parto, e 12 meses após o parto 6,23 . ...
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Maternal organism suffers physiological and biomechanical changes during pregnancy, including the separation of rectus abdominis muscles (RAM). This cross-sectional study aimed to compare the distance between the RAM among sedentary and active primiparous women who had vaginal childbirth and cesarean section, to correlate RAM separation with maternal and child variables and to compare these variables between primiparous women with and without RAM diastasis. In total, 56 women were evaluated in their ninth postpartum week, divided into four groups according to the mode of delivery and the practice of resistance exercises. RAM distance was calipered in the supraumbilical, umbilical, and infraumbilical regions. The values obtained were verified via analysis of variance (ANOVA), Pearson’s correlation, and independent t-test. We found no main effect between mode of delivery and practice of resistance exercises or interaction between mode of delivery and practice of resistance exercises (p≥0.118) for RAM distance. We found significant correlation between body weight before pregnancy and RAM distance (p<0.001). There was no association between body weight gain during pregnancy and the newborn’s weight with RAM distance (p≥0.132). We observed significant difference in body weight before pregnancy between primiparous women with and without RAM diastasis (p<0.005). We found no differences between groups regarding body weight gain during pregnancy and the newborn’s weight (p≥0.122). It was concluded that the practice of resistance exercises and the mode of delivery have no impact on the separation of supraumbilical, umbilical, and infraumbilical regions of RAM in primiparous women. Keywords| Diastasis Muscle; Physical Exercise; Physical Therapy; Pregnancy; Postpartum Period
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Background : This study investigates the physical activity and apparel choices of perinatal women. The perinatal period involves significant anatomical, physiological, and biomechanical changes as the body prepares to carry and deliver a child, and the recovery process which follows. Despite the recognized benefits of physical activity, returning to physical activity postpartum can be difficult. Methods : One hundred and six postpartum women completed an online questionnaire exploring women’s physical activity habits before, during, and after pregnancy, along with their use of activewear/compression garments during this time. Statistical analyses, including chi-squared tests, investigated the relationship between initiation of physical activity postpartum (by and after 12 weeks) and: delivery method (vaginal, c-section, and assisted), perineal trauma, activewear purchase, and prepregnancy activity level. Thematic analysis was applied to identify themes from participant’s answers. Results : A vaginal delivery correlated with a higher likelihood of resuming physical activity within 12 weeks postpartum. Moreover, a high level of activity prepregnancy was associated with a high level of physical activity postpartum. The study identified key reasons for the cessation of physical activity during pregnancy including discomfort, tiredness, and misinformation. Barriers hindering the return to physical activity postpartum included discomfort, misinformation, and time constraints. Few participants used compression garments in the postpartum period, with the majority leveraging them to alleviate pain (71%). Conclusions : This study highlights a crucial gap in utilization of compression garments during the postpartum period. Understanding these factors is pivotal in enhancing support for postpartum women in their pursuit of resuming physical activity.
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Introduction and hypothesis Despite exercise being the standard approach to diastasis recti abdominis (DRA) rehabilitation, there is no consensus on the most effective exercise routine and adjunct modalities for reducing DRA and improving functional parameters. The present study is aimed at investigating evidence for DRA rehabilitation in postpartum women, as well as knowledge gaps and areas for future research. Methods For this scoping review a systematic search was conducted in MEDLINE, AMED, CINAHL, Embase, ScienceDirect, Scopus, and PEDro up to November 2022. Selection criteria included studies investigating exercise therapy interventions both with and without adjunct modalities for postpartum DRA. Sample characteristics, diagnostic criteria, program design, and outcome measures were recorded. Critical appraisal of clinical trials was performed using PEDro classification. Results Twenty-eight studies were included: 14 clinical trials, 3 case series, and 11 observational studies. DRA exercises that focused on deep and superficial muscles, pelvic floor muscles, respiratory maneuvers, functional exercises, or alternative interventions (yoga, suspension training, hypopressive exercise) and adjunct modalities showed promising results in reducing the inter-recti distance and related dysfunction. However, there was great variability in diagnostic criteria and methods, DRA severity, time post-birth, and exercise program design. Conclusions Reviewed studies provide valuable insights into exercise therapy, but it is important to recognize their limitations, as variability in diagnostic criteria, sample characteristics, and exercise program design hinder the generalizability of the findings. Further high-quality research is needed to strengthen the evidence in this area and provide reliable recommendations for clinical practice.
Article
Background: With the increased interest in inter-recti distance measurement using ultrasound imaging in physiotherapy, there is a question of measurement reliability, and the importance of the examiner's experience. Purpose: The study aimed to investigate the reliability of inter-recti distance measurement in a DICOM viewer software by an experienced radiologist. For the measurement, the radiologist used linea alba images captured by two physiotherapists who were novice examiners. Methods: Ultrasound images were acquired by two novice examiners on repeated occasions 7 days apart (sessions A and B) in 28 nulliparous women at supraumbilical, umbilical, and infraumbilical locations along linea alba. Results: Excellent intra-examiner reliability of inter-recti distance measurements was shown at the supraumbilical and umbilical levels (ICC2,k = 0.941-0.983) with minimal detectable change (MDC95) ranging from 1.31 mm to 2.29 mm. Infraumbilical measurements had good to excellent reliability (ICC2,k = 0.894-0.972) with MDC95 ranging from 0.33 mm to 0.72 mm. Session A inter-examiner reliability was excellent for the mean measurements of two, three, four, and five images taken at each location (ICC2,k = 0.913-0.954) with MDC95 ranging from 0.47 mm to 2.96 mm. Session B inter-examiner reliability was excellent for the mean measurements of two, three, four, and five images taken at the supraumbilical and umbilical (ICC2,k = 0.94-0.98), MDC95 ranging from 1.38 mm to 2.58 mm and good (ICC2,k ≥ 0.81) with MDC95 ranging from 0.72 mm to 0.80 mm at the infraumbilical locations. Conclusion: Novice examiners were able to capture good-quality ultrasound images of the linea alba that allowed for good to excellent intra- and inter-examiner reliability.
Chapter
It has been only recently that female endurance athletes have been deemed capable of training and being successful in endurance sports. This unfortunate attitude has resulted in limited research regarding female endurance over the life course. In this chapter we overview the impact of key life events over the life span of female endurance athletes, the menstrual cycle, pregnancy, postpartum, and menopause, and discuss key considerations during these important times. Scientific literature can be scarce for the endurance athlete who participates in high-level training or sport, especially at the national team level, and thus we focus on exercise (moderate to vigorous) that encompasses the recreational endurance athlete and where possible include reference to elite sporting activities. We provide guidance for pregnant athletes and their healthcare providers.KeywordsPregnancyExerciseRelative energy deficiency in sportMenstrual cyclePostpartumMenopauseBone healthPelvic floor
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Background: With the increased interest in inter-recti distance measurement using ultrasound imaging, there is a question of measurement reliability, and the importance of the examiner’s experience. Methods: The study aimed to investigate the reliability of the inter-recti distance measurement performed offline by an experienced radiologist on linea alba images captured by two novice examiners. Additionally, it was aimed to determinethe number of image repetitions that provide an acceptable measurement reliability level. Ultrasound images were acquired by two novice examiners on repeated occasions (sessions A and B) in twenty-eight nulliparous women of reproductive age. Five images were captured at supraumbilical, umbilical, and infraumbilical points during each session. Results: The excellent intra-examiner reliability of inter-recti distance measurements was shown at the supraumbilical and umbilical levels (ICC=0.894-0.983). Infraumbilical measurements had good to excellent reliability (ICC=0.894-0.972). Session A inter-examiner reliability was excellent for the mean measurements of two, three, four, and five images taken at each location (ICC=0.913-0.954). Session B inter-examiner reliability was excellent for the mean measurements of two, three, four, and five images taken at the supraumbilical and umbilical (ICC=0.94-0.98) and good (ICC≥0.81) at the infraumbilical locations. Some images were unusable (1.6% of images of Examiner 1 and 2.2% of Examiner 2). Conclusions:Novice examiners were able to capture good-quality ultrasound images of the linea alba that allowed for excellent intra- and inter-examiner reliability of supraumbilical and umbilical measurements, and good to excellent reliability of inframbilical measurements in nulliparas.
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Purpose: An increased inter-rectus distance (IRD) can persist after a pregnancy and may be associated with lumbopelvic dysfunction. Ultrasound imaging (USI) is currently the gold standard for measuring IRD; however, no study has explored the need to standardize the transducer angle during these evaluations. The purpose of this study was to determine whether the angle of the ultrasound transducer relative to the underlying abdominal wall has an effect on measurements of IRD in parous women. Method: Ultrasound images of the linea alba (LA) were captured from 15 women, at rest and during a head lift, beginning with images acquired perpendicular to the LA at the midline, then tilted in 5° increments to 15° in both the cranial and the caudal directions. Repeated-measures analyses of variance were used to test for systematic differences in IRD measurements among the transducer angles in both the rest and the head-lift conditions. An α of 0.05 was used for all tests. Results: No significant effect of transducer angle was found in IRD measurements acquired with participants at rest (F2.24,31.3=1.814;p=0.18) or during a head lift (F3.15,44.1=1.315;p=0.28). Conclusion: When using USI, cranial or caudal tilt errors in transducer angle do not appear to pose a problem when measuring IRD.
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Background/aim Diastasis recti abdominis (DRA) is defined as a separation of the 2 muscle bellies of rectus abdominis. To date there is scant knowledge on prevalence, risk factors, and consequences of the condition. The present study aimed to investigate the prevalence of DRA during pregnancy and post partum, presence of possible risk factors, and the occurrence of lumbopelvic pain among women with and without DRA. Methods This prospective cohort study followed 300 first-time pregnant women from pregnancy till 12 months post partum. Data were collected by electronic questionnaire and clinical examinations. DRA was defined as a palpated separation of ≥2 fingerbreadths either 4.5 cm above, at or 4.5 cm below the umbilicus. Women with and without DRA were compared with independent samples Student's t-test and χ2/Fisher exact test, and OR with significance level >0.05. Results Prevalence of DRA was 33.1%, 60.0%, 45.4%, and 32.6% at gestation week 21, 6 weeks, 6 months and 12 months post partum, respectively. No difference in risk factors was found when comparing women with and without DRA. OR showed a greater likelihood for DRA among women reporting heavy lifting ≥20 times weekly (OR 2.18 95% CI 1.05 to 4.52). There was no difference in reported lumbopelvic pain (p=0.10) in women with and without DRA. Conclusions Prevalence of mild DRA was high both during pregnancy and after childbirth. Women with and without DRA reported the same amount of lumbopelvic pain 12 months post partum.
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Purpose: To investigate the interrater reliability of inter-rectus distance (IRD) measured from ultrasound images acquired at rest and during a head-lift task in parous women and to establish the standard error of measurement (SEM) and minimal detectable change (MDC) between two raters. Methods: Two physiotherapists independently acquired ultrasound images of the anterior abdominal wall from 17 parous women and measured IRD at four locations along the linea alba: at the superior border of the umbilicus, at 3 cm and 5 cm above the superior border of the umbilicus, and at 3 cm below the inferior border of the umbilicus. The interrater reliability of the IRD measurements was determined using intra-class correlation coefficients (ICCs). Bland-Altman analyses were used to detect bias between the raters, and SEM and MDC values were established for each measurement site. Results: When the two raters performed their own image acquisition and processing, ICCs(3,5)ranged from 0.72 to 0.91 at rest and from 0.63 to 0.96 during head lift, depending on the anatomical measurement site. Bland-Altman analyses revealed no systematic bias between the raters. SEM values ranged from 0.23 cm to 0.71 cm, and MDC values ranged from 0.64 cm to 1.97 cm. Conclusion: When using ultrasound imaging to measure IRD in women, it is acceptable for different therapists to compare IRDs between patients and within patients over time if IRD is measured above or below the umbilicus. Interrater reliability of IRD measurement is poorest at the level of the superior border of the umbilicus.
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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.
Article
Background: A separation of the abdominal muscles at the linea alba, known as diastasis recti abdominis (DRA), can occur after childbirth. However, the impact of DRA on abdominal muscle function is not clear. Objective: The objective was to determine if differences exist in trunk muscle function and self-reported pain and low back dysfunction between women with and without DRA at 12 to 14 months postpartum and if differences that emerge from the data are associated with the magnitude of the interrectus distance (IRD). Design: This study was a prospective observational case-control study. Methods: Women with (IRD ≥ 2.2 cm; n = 18) and without DRA (IRD < 2.2 cm; n = 22) participated. Maximal trunk flexion, extension, and rotation torque-generating capacity (Newton-meters), The Sit Up test (0-3 points), and the Sitting-Rising Test (0-10 points), and trunk flexion, extension, and lateral flexion endurance (seconds) were measured. Pain and disability were assessed using numerical pain rating scales (0-100) and the Roland Morris Low Back Pain Questionnaire (0-24 points). Women were compared using independent t tests and Mann-Whitney U-Tests. Pearson's product-moment and Spearman's rank correlation coefficients were used to determine associations; α = .05 was used for all tests. Results: Women with DRA demonstrated significantly lower trunk muscle rotation torque and scored lower on the sit-up test than those without DRA. IRD was negatively correlated with both trunk rotation torque (rho = -0.367) and sit-up test score (rho = -0.514). Limitations: The results of this study should not be generalized to women who present with moderate-to-severe IRDs or to multiparous women. Conclusion: The presence of DRA in primiparous women at 1 year postpartum is associated with trunk rotation strength and ability to perform a sit-up.
Article
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
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The linea alba is a complex structure commonly involved in hernia formation. Knowledge of its mechanical behavior is essential to design suitable meshes and reduce the risk of recurrence. The aim of this study was to investigate the relationships between the mechanical properties of the linea alba and the organization of collagen and elastin fibers. For that purpose, longitudinal and transversal samples were removed from four porcine and three human linea alba, to perform tensile tests under a biphotonic confocal microscope, in each direction. Microscopic observation revealed a tissue composed of two layers, made of transversal collagen fibers in the dorsal side and oblique collagen fibers in the ventral side. This particular architecture led to an anisotropic mechanical behavior, with higher stress in the transversal direction. During loading, oblique fibers of the ventral layer reoriented toward the tensile axis in both directions, while fibers of the dorsal layer remained in the transversal direction. This rotation of oblique fibers progressively increased the stiffness of the tissue and induced a non-linear stress-stretch relation. Elastin fibers formed a layer covering the collagen fibers and followed their movement, suggesting that they ensure their elastic recoil. All of these results demonstrated the strong relationships between the microstructure and the mechanical behavior of the linea alba.
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