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Diastasis Recti Abdominus Association Spring Conference 2018

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Diastasis Recti Abdominus Association Spring Conference 2018 Diagnosis and treatment of DRA. 4/13/18 MPTA Spring Conference 2018. Kansas City Jennifer Cumming, PT, MSPT, Diagnosis and treatment of CLT, WCS Missouri Physical Therapy No disclosures Diastasis Recti Abdominus Association Spring Conference 2018 Objective Case study #1 complaints 1. Understand anatomy of abdominal wall and deep motor control • Mrs. H is 37 year old who is 6 months post-partum system • Back pain since late pregnancy and postpartum period. 2. Understand the causes and prevalence of diastasis rectus • Pain not responding to traditional physical therapy abdominus (DRA) • Pain with transition movements and bending 3. Understand how to assess for DRA • Also c/o stress urinary incontinence and pain with intercourse 4. Understand basic treatment strategies for improving functionality of abdominal wall and deep motor control system Case study #1 orthopedic assessment Case study #2 complaints • 1 ½ finger diastasis rectus abdominus just inferior to umbilicus • Ms. S is a 20 year old elite college level athlete • Active straight leg raise (ASLR) with best correction at PSIS indicating • History of DRA developing with high level athletic training involvement of posterior deep motor control system • Complains of LBP with prolonged sitting, bending, and lifting activities • L3 right rotation at level of DRA • Hypertonicity B internal oblique muscles Property of J Cumming, PT, MSPT, CLT, WCS. Do not copy without permission. 1 Diagnosis and treatment of DRA. 4/13/18 MPTA Spring Conference 2018. Kansas City Case study #2 orthopedic assessment Case study #3 complaints • L SI joint unlocks with weight shift L • During pregnancy: • L rib translation with weight shift L • Severe pubic symphysis pain with all activities • L external oblique and erector spinae hypertonicity • Seen Webster trained chiropractor for pubic symphysis alignment with no success • 1 finger DRA just superior to umbilicus • Unable to complete home or work activities due to pubic pain • ASLR best correction at pubic symphysis indicating involvement of anterior pelvic floor muscles Case study #3 orthopedic assessment • During pregnancy • B SI joint unlocking with weight shift to either leg • 4 finger DRA at umbilicus and 3 finger DRA superior to umbilicus Anatomy • Postpartum • B SI joint unlocking with single leg stance L and 75% weight shift on R • 1 ½ finger DRA superior to umbilicus and 2 fingers at umbilicus • PFM weakness (2/5) with increased tone deep transverse perineal, levator plate, and obturator internus Trunk Multifidus mm components • Superficial fibers • Deep muscles • Insert 3 vertebral levels below insertion • Superficial muscles • Deep fibers • Diaphragm • In pelvis, attaches to deep levels of • Pelvic floor muscles thoracolumbar fascia of raphe of glut max • Lumbar spine • Connect into capsule of SIJ • Pelvis • Blends with Sacrotuberous ligament • Lower ribs • More Type I fibers than Type II Property of J Cumming, PT, MSPT, CLT, WCS. Do not copy without permission. 2 Diagnosis and treatment of DRA. 4/13/18 MPTA Spring Conference 2018. Kansas City Erector Spinae mm Quadratus lumborum • Longissimus thoracis pars lumborum • Runs L1-L5 from transverse processes to medial aspect of PSIS • Deep to erector spinae and lateral • Longissimus thoracis pars thoracis to psoas • Runs from T1-12 ribs and transverse processes and • Arises from transverse processes attaches to transverse processes of lumbar spine and of L5 and iliac crest. sacrum • Lateral fibers attach to medial half • Iliocostalis lumborum pars lumborum of 12th rib • Runs from transverse processes of L1-L4 to iliac crest lateral to PSIS • Medial fibers attach to anterior surfaces of transverse processes • Iliocostalis lumborus pars thoracis superior to L5 • Runs from inferior borders of lower 7 ribs to ilium and sacrum Psoas attachments Iliacus • Attachments along iliac crest to • T12-L1 and L4-L5 anterior fibers lesser tubercle • L1-L5 posterior fibers • Blends with Psoas • Provides lumbar and hip segmental • Hip flexor control • Important role as hip flexor • Optimally recruits prior to superficial hip flexors or adductors Contributors to lumbar stability Diaphragm attachments • Muscle activation for vertebral form closure • Xyphoid process • Fascial tension • Internal surfaces of lower 6 ribs • Increased intra-abdominal pressure • Lumbar spine • Static stability and maintenance of neutral spine requires minimal co- contractions of trunk muscles • Arcuate ligament arch over psoas and quadratus lumborum Property of J Cumming, PT, MSPT, CLT, WCS. Do not copy without permission. 3 Diagnosis and treatment of DRA. 4/13/18 MPTA Spring Conference 2018. Kansas City Diaphragm Diaphragmatic assistance with trunk control • Contributes to trunk control • Note how far into the • Resting tone increased prior to peripheral movements thoracic cavity the diaphragm goes. The • Tonically active with sustained activity core really starts in • Modulates activity with respiration during peripheral activities mid-thoracic range and runs to pelvic floor. Coordination of diaphragm and TrA Pelvic floor function in breathing Inhale: • TrA and diaphragm activity • Diaphragm actively contracts, linked with opposing patterns and pulls down, expanding rib • TrA activity increases with cage and belly expiration while diaphragm activity decreases • Pelvic Floor relaxes and • TrA activity decreases with descends inspiration while diaphragm Exhale: activity increases burrelleducation.com • Diaphragm relaxes up, rib cage contracts, abdominals contract • Pelvic floor contracts and lifts Diaphragm restrictions Pelvic Floor Superficial layers • Hypertonicity of EO, IO, RA or ES often restrict movement of lower • Ischiocavernosus, ribs and prevent proper diaphragmatic excursion bulbospongiosus, transverse • Minimal expansion of rib cage will occur during inspiration with EO, perineal, deep transverse IO, RA or ES hypertonicity perineal, urethral sphincter, • With decreased diaphragmatic excursion, inspiration will occur urethrovaginalis primarily in upper anterior chest • Share common attachments at perineal body • Provide more sphincteric action Property of J Cumming, PT, MSPT, CLT, WCS. Do not copy without permission. 4 Diagnosis and treatment of DRA. 4/13/18 MPTA Spring Conference 2018. Kansas City Pelvic Floor Levator ani group Thoracolumbar fascia • Deepest layer of the pelvic floor muscles • Iliococcygeus, ischiococcygeus, • Critical structure for load transfer puborectalis, pubococcygeus, between trunk and lower extremities • Share tendinous attachments with • Contains alpha-smooth muscle actin called myoblasts with contractile obturator internus capability • Attach at coccyx, ileum, ischium and • Tension is transmitted to ligamentus pubis flavum and assists with lumbar alignment Bony and fibrous attachments of Muscle attachments of thoracolumbar fascia thoracolumbar fascia Bony attachments Fibrous attachments • Transverse abdominus • Biceps femoris • • • Iliac crest • Ligamentus flavum Internal oblique Quadratus lumborum • • • PSIS • Iliolumbar ligament External oblique Lower trap • • • Posterior sacrum • Supraspinous ligament Glut max Multifidus • • • Sacrotuberous ligament Latissimus dorsi Erector spinae Four fascial slings for trunk Fascial Slings • Posterior oblique sling • Longitudinal sling Posterior Oblique Sling Anterior Oblique Sling • Attaches to latissimus dorsi • Attaches to peronei, and glut max via the biceps femoris, thoracolumbar fascial plane Sacrotuberous ligament, • Anterior oblique sling thoracolumbar fascia and erector spinae • Attaches to external oblique, anterior abdominal fascia, • Lateral Sling and contralateral hip • Attaches to glut med, glut adductors. min, TFL and lateral thoraco-pelvic stabilizers. Property of J Cumming, PT, MSPT, CLT, WCS. Do not copy without permission. 5 Diagnosis and treatment of DRA. 4/13/18 MPTA Spring Conference 2018. Kansas City Normal abdominal wall anatomy Posterior Fascial support Note the connections from the pelvic floor, pelvis and sacrum, hip adductors, lumbar spine, and circumventing around the abdominal wall. Transversus Abdominus Functions of abdominal wall • Deepest abdominal muscle • Arises from inguinal ligament, iliac crest, thoracolumbar fascia, and • Abdominal and pelvic support inner surfaces of lower 6 ribs • Orifice closure • Attaches into fascial plane of • Esophagus, inferior vena cava, aorta, rectum, vagina, urethra rectus abdominus and linea alba and midline • Breathing • Fibers of upper, middle, and lower • Movement control and stability sections of TrA lay at different • Work synergistically with diaphragm and pelvic floor orientations • Superior fibers lay superiomedially • Provide joint control of pelvis, lumbar spine, lower thorax • Middle and inferior fibers lay • Cresswell et al 1993, Hodges et al 1996, 2014 inferiomedially at slightly different angles Functions of TrA Internal oblique • Lies between TrA and EO • Arises from iliac crest, inguinal • Generally increases intra-abdominal pressure for improved ligament, and thoracolumbar fascia spinal stability inferior to L3 • Attach to 7-10th ribs at costochondral • Superior portion joints and tips of 11-12th ribs • Assists in stabilizing rib cage • Blend into to rectus fascia and into • Middle linea alba to pubic crest • Fibers are generally oriented in • Contributes to spinal stability via connections into thoracolumbar superiomedial plane fascia • Over activity of IO presents with increased inferior rib angle or rib • Inferior flaring • Contributes to pelvic stability Property
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