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Home , Abdominal fascia, Diastasis recti, Levator ani, Linea alba (abdomen), Rectus sheath, Thoracolumbar fascia

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 Recti Abdominus Association Spring Conference 2018

Objective Case study #1 complaints

1. Understand anatomy of and deep motor control • Mrs. H is 37 year old who is 6 months post-partum system • Back since late and . 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 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 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 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 (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 , attaches to deep levels of • Pelvic floor muscles thoracolumbar 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

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Erector Spinae mm Quadratus lumborum • 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. • Lateral fibers attach to medial half • 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

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Diaphragm Diaphragmatic assistance with trunk control • Contributes to trunk control • Note how far into the • Resting tone increased prior to peripheral movements 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, 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

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Pelvic Floor 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 , ileum, and • Tension is transmitted to ligamentus 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 • 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 , • Lateral Sling and contralateral hip • Attaches to glut med, glut adductors. min, TFL and lateral thoraco-pelvic stabilizers.

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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 , 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, , , urethra rectus abdominus and 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 • 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

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External oblique Internal and external oblique mm

• Largest abdominal muscle • Hyperactivity of internal oblique pulls ribs down and out—will have • Arises from lower 8 ribs widened sternal angle • Interdigitates with serratus anterior and • External oblique hyperactivity will have narrowed infrasternal angle latissimus dorsi, possible attachments onto with ribs being pulled in and down thoracolumbar fascia • Attach onto anterior iliac crest • With hyperactivity or with imbalance between IO, EO and TrA, will • Blend to rectus fascia and into linea alba pull linea alba down and apart • Fibers run generally inferomedially • TrA smallest at level inferior to umbilicus • Over activity presents with rigidity of rib cage or • IO is responsible for inferior section of linea alba closure acute inferior rib angle

Rectus abdominus Linea alba anatomy

• Arises from pubic crest and ligaments of pubic • TrA fibers form the posterior section of the symphysis • TrA pulls across rectus sheath • Inserts into 5-7 costal cartilage and xyphoid • EO and IO fibers form anterior section of rectus sheath. process • Highest compliance of linea alba is longitudinal • Enclosed in fascial sheath formed by • Lowest compliance is in transverse plane of TrA, EO and IO • Inferior to umbilicus compliance is smaller transversely • Medial borders of RA connect via the linea alba, compared to oblique direction a strong fascial sheath

Note fascial envelope formed by obliques and Optimal abdominal wall function TrA requirements • Intact anatomy that is able to generate force closure • or DRA are inability to complete force closure • Optimal timing of muscle activation, relaxation and elongation • Adequate strength and endurance to complete task

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Normal width of linea alba Prevalence of DRA

• Using ultrasound Beer et all 2009, measured 150 nulliparous women • 66% of women with DRA have (UI, POP, pain) aged 20-45 years Spitznagle et al 2007 • Mean width was highly variable at inferior, superior and level of • 100% of women have DRA of 2.7 cm during 3rd trimester Mota 2014 umbilicus • Many DRA do not close at 8 weeks and remain unchanged at 1 year • 7 mm +/- 5 mm at xyphoid post-partum Coldron et al 2008, Liaw et al 2011 • 13 mm +/- 7.3 cm at just superior to umbilicus • 8 mm +/- 6.2 cm inferior to umbilicus • DRA can change up to 4 months after discontinuation of breastfeeding • Some women have diastasis of other fascial planes as well

Risk factors for DRA Causes of DRA • Research definition of 16 mm at 2 cm below umbilicus • Prevalence of 100% at 35 weeks gestation with mean IRD 65 mm • Caused by variable changes that differ from patient to with range from 22-126 mm. patient • Prevalence at 6 months postpartum 35-39% • Knowns: • No statistical difference found between women with/without DRA • 1) Deep stability system muscles are often compromised at 6 months postpartum. • 2) Superficial muscles are often overactive • Pre-pregnancy BMI • 3) Recruitment strategies are suboptimal for task at hand • Pregnancy weight gain • Baby’s birth weight • Abdominal circumference during pregnancy • Fascial hypermobility

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Co-morbidities with DRA Behavior of linea alba with DRA

• Inter-recti distance (IRD) greater at rest • In urogynecological population, 52% found to have DRA Spitznagle with subjects with DRA vs those without 2007 • Distortion index (seen on real time ultrasound) greater in those with DRA • Of this population, 66% had at least one pelvic fascial support related • Linea alba became wrinkly, domed, or dysfunction sagged • IRD increased with curl up without cues to • Stress urinary incontinence engage TrA • • Many subjects with DRA could reduce • distortion index with cues to activate TrA Pelvic prolapse prior to curl up. • However, this strategy sometimes increased the IRD but improved function of patient

Inter-rectus distance with functional tasks Findings from Lee and Hodges 2016

• Found that with patients with minimal distortion index at rest • Lee and Hodges 2016 measured distance between rectus (minimal sagging or doming of linea alba) did not have increased abdominus mm at rest and with curl up task with and without cues distortion index with functional tasks to activate deep core • Linea alba tension was maintained at rest and with functional tasks • From this information able to determine distortion index with real time ultrasound of linea alba with all three tasks • Infrasternal angle should stay the same and inter-rectus distance should not change with proper activation of TrA and functional linea • Rated the quality of abdominal muscle activation regarding: alba • Optimal activation of TrA • Inconsistent activation between tasks or from left to right • No TrA co-activation with dominance of superficial mm

Correlation of width and load transfer failure Curl up task

• Some women with DRA are able to produce enough force closure of • Requires co-activation of all abdominal muscles lumbar and pelvis to have functional load transference with DRA • Is automatic strategy patient to patient • Other women with same IRD fail to regain ability to transfer forces • When TrA is activated, a hollowing of the abdominal wall is noted for lumbar and pelvic stability • Poor TrA activation can cause doming or sagging of abdominal wall • Factor of difference is not width of linea alba but tension that can • When TrA activation is cued, the patient is often unable to sustain the be generated across linea alba to left and right recuts abdominus contraction mm • Endurance deficit • As long as forces are sufficient to stabilize the lumbar, pelvis and thoracic spine, patient demonstrate good load transfer regardless of width of linea alba

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What if we look at function instead of solely Using IRD only for DRA assessment at IRD? • Body of research has focused on use of IRD to assess DRA changes in • Strategies that focus solely on IRD narrowing allows for increased postpartum women. distortion index of linea alba • Focus noted that curl up task narrowed IRD while cues for activating • Increased distortion of linea alba affects abdominal pressure, pelvic TrA increased IRD in some women floor control, function of thoracic and lumbar spine, and pelvic • Suggested that post-partum women with DRA should perform curl ups stability instead of TrA activation • Abdominal wall activation strategies that decrease distortion of linea • Sole goal to narrow IRD alba but may increase the IRD • This theory did not look at function or load transference strategies. • Individual assessment is required to assess linea alba behavior with • Pascoal, Dionisio, Cordeiro, Moto 2014 TrA activation and curl up tasks

Our goal is not to close the DRA but to generate tension across it to restore function. Assessment

TrA assessment

• Must be palpated to assess activity accurately • Without deep palpation, assessment will be of IO or EO activity or hypertonicity and TrA activity will be missed • Best assessment is to palpate through layers to reach TrA • Slowly palpate and assess through EO and IO and surrounding fascial layers • Once you reach the TrA, gently abduct palpating hands to take up slack of surrounding fascial tissue and linea alba • TrA co-contracts with PFM • Cues should include PFM and TrA visualizations for best TrA contraction

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Assessment of deep fibers of multifidus Active straight leg raise

• Patient lies prone. • Assesses load transfer strategies between trunk and LE in patients • Palpate multifidus lateral to spinous process with pelvic pain Mens 1999, 2001, 2002 • Pressing firmly, compare fibers of opposite sides at same lumbar level • Ideally, LE raises with little to no effort and no movement of pelvis in relation to ribs or LEs. • Hypertonicity in erector spinae mm must be released before able to fully assess deep multifidi • Compression on pelvis can decrease effort in patients with poor load transfer strategies or pelvic girdle pain • With proper synergy of PFM and TrA, multifidi will co-contract with deep system with cuing. • Provider can vary location of compression for more information on load transfer deficits Lee and Lee 2004 • Proper activation will feel like swelling into palpating finger • Common substitutions include ES and QL activation

Compression anterior pelvis Compression of posterior pelvis

Level of ASIS Pubic symphysis Level of PSIS Ischial tuberosities • Simulates: • Simulates: • Simulates • Simulates • Lower fibers of TrA • Anterior pelvic floor muscles • L5-S1 multifidus • Posterior pelvic floor muscles • IO • Endopelvic fascia • Thoracolumbar fascia • Endopelvic fascia • Abdominal fascial planes • Lowest fibers of TrA • Lowest fibers of IO

Activating TrA and differentiating from IO and Observe ASLR assessment EO • Observe left vs right for ease of lift and ask patient’s assessment of • Note degree of infrasternal angle ease of movement • Widened angle indicates increased IO activation • Narrowed angle indicates increased EO activation • Flexion should occur at hip joint without pelvic movement • Best cue per research includes phrases focusing on deep core • Ribs should be stable without drawing in or flaring • Palpate abdominal wall and give following cues to feel difference • Ribs should not be braced and there should be some lateral rib in mm activation expansion with breath • Make rib cage heavy • Flatten your back to the mat • Should not be thoracic spine extension or shift from left->right • Pull your belly button up and in • Draw your hip bones closer together like they are connected by a wire

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Curl up task Observe ASLR assessment

• Observe the task • Observe left vs right for ease of lift and ask patient’s assessment of • Is there a hollowing or doming along linea alba ease of movement • Palpate linea alba and note inter-recti distance • Flexion should occur at hip joint without pelvic movement • Note tissue at bottom of linea alba and if it is firm or soft • Ribs should be stable without drawing in or flaring • Give cues for TrA activation • Ribs should not be braced and there should be some lateral rib • Repeat curl up task and note changes in quality of task and firmness of linea expansion with breath alba • Should not be thoracic spine extension or shift from left->right

Support for pelvic ring and thorax

• Use a Serola SI belt for pelvic ring support as needed • Kinesiotape for stability • SI stability: Can tape across SI joint with external support or a * over SI joints individually Treatment strategies

Kinesiotape options for DRA Where to start with exercises

• With firm base: Pt engage deep motor control system. Anchor tape • With necessary support at linea alba, activate TrA and deep motor lateral to one side of rectus abdominus and tape to other side. control system at appropriate level for patient and for goal task Repeat in opposite direction. • Start with symmetrical activation • Hashtag: Tape along B RA muscles. Then tape across to opposite side • Pelvic brace in # • Dead bug or single knee fall out or Saurman levels • Bridges • Squats • Multifidus activation

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Case study #1 treatment and outcomes Advancing to task Post-partum 7 months with back pain • Advance to unilateral exercises when patient able to transfer load • Cues and HEP for multifidus activation with focus on L3 level across linea alba without a breakdown in the • Manual STM internal oblique to decrease pull on linea alba functional system • • Lunge Ther ex for TrA, multifidus, diaphragm, and PFM activation for deep • Single leg standing motor control • Single leg squat • Train to task with simulated exercises, assessing • After treatment, able to complete childcare activities with good patient’s ability to transfer load across linea motor control of L3 vertebrae alba without breakdown • Able to transfer loads across linea alba at level of DRA

Case study #2 treatment and outcomes Case study #3 treatment and outcomes Athlete Pregnant and newly post-partum with pubic pain • Ther ex with focus on PFM activation prior to deep motor control • During pregnancy system challenges • Stability through pelvic ring with Serola SI belt • K-tape across linea alba for improved load transference during pregnancy • Multifidus and TrA HEP • Postpartum • External oblique and erector spinae mm releases • Serola belt for SI joint stability • TrA, multifidus and PFM muscle activation for functional deep motor stability • Motor control challenges with functional activities in varied positions—supine, • Return to sport without pain sitting, standing, standing in stride, step ups • • Improved deep motor control with bending and lifting activities with Outcomes • DRA closed and able to transfer loads across linea alba good SI joint force closure • Functional motor control system strength with increasing strength of TrA, multifidus, • Good load transference across linea alba and PFM muscles

Resources

• Spitznagle TM, Leong FC, Van Dillen LR (2007) Prevelence of abdominus in a urogynecological patient population. Int Urogynecology. 18(3), 321-328. • Liaw LJ et al. (2011) The relationships between inter-recti distance measured by ultrasound imaging and abdominal muscle function in post-partum women: A 6-month follow-up study. JOSPT. 41(6), 435-443. • Beer GM, et al. (2009) The normal width of the linea alba in nulliparous women. Clinical Anatomy. 22(6), 706-711. • Mendes DA, et al. (2007) Ultrasonography for measuring rectus abdominus muscles diastasis. Acta Cirurgica Brasileira. 22(3), 182-186. • Lee D, Hodges PW. (2016) Behavior of the linea alba during curl-up task in diastasis rectus abdominus: An observational study. JOSPT. 46(7), 580-589. • Pascoal AG et al. (2014). Inter-rectus distance in postpartum women can be reduced by isometric contraction of the abdominal muscles: A preliminary case-control study. Physiotherapy. 100(4), 344-348. Jennifer Cumming, PT, MSPT, CLT, WCS • Lee DG, Lee LJ, McLaughlin. (2008) Stability, continence and breathing: The role of fascia following pregnancy and delivery. J Bodywork Move Ther. 12, 333-348. [email protected] • Mens JMA, et al. (1999) The active straight leg raising test and mobility of the pelvic joints. European Spine. 8, 468. foundationalconcepts.com 816-569-2802

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