Anterior and posterior rectus abdominis sheath stiffness in relation to diastasis recti: Abdominal wall training or not?

Gender Equality in Diastasis Rectus Abdominis in Chronic Back Pain: A Model of M. Transversus Abdominis Motor Control Impairment

Introduction: Diastasis rectus abdominis (DRA) is defined as an increased distance between the left and right muscle of the m. rectus abdominis. Pregnancy-related factors are assumed to be dominant factors in the occurrence of DRA. However DRA is not only found in peri-partum women but also in men and nulliparous women with back or pelvic pain. This study provides an inventory of the incidence of DRA in subjects with chronic back and pelvic pain. If DRA is common in both men and women then other factors besides pregnancy, like impaired motor control, should be explored as cause for DRA. Material and Methods: This study was conducted with data from 849 back pain patients. Results from ultrasound assessment of the abdominal wall were combined with anamnestic data on age, gender, medical history and pregnancies (in women). Results: There was no difference in Inter Rectus Distance cranial of the umbilicus (IRD above umbilicus) between men and women. Almost half of all women and men (45% and 43%, respectively) exhibit an increased IRD above umbilicus. The incidence of an increased IRD above umbilicus is twice as high in women below 30 years, compared to men below 30 years old. This difference is not observed for men and women above 30 years old. Discussion: DRA occurs in women during pregnancy and increases with an increasing number of pregnancies. However, this condition does not affect significantly more women than men. Increased IRD above umbilicus already occurs in young men (mean age 30). Over 30 years of age, cranial of the umbilicus there is no difference in IRD between women and men. An alternative etiological mechanism is suggested.

Intra- and inter-session reliability of electrical detection and pain thresholds of cutaneous and muscle primary afferents in the lower back of healthy individuals

To advance evidence-based practice and targeted treatments of low back pain (LBP), a better pathophysiological understanding and reliable outcome measures are required. The processing of nociceptive information from deeper somatic structures (e.g., muscle, fascia) might play an essential role in the pathophysiology of LBP. In this study, we measured the intra- and inter-session reliability of electrical detection and pain thresholds of cutaneous and muscle primary afferents of the lower back. Twenty healthy participants attended two study visits separated by 27.7 ± 1.7 days. To determine the location-specific electrical detection threshold (EDT) and pain threshold (EPT), needle electrodes were inserted in the epidermal layer over, and in the lumbar erector spinae muscle. Additionally, established quantitative sensory testing (QST) parameters were assessed. Reliability was determined by differences between measurements, intraclass correlation coefficients (ICC2,1), Bland-Altman plots, and standard error of measurement (SEM). Correspondence between QST parameters and electrical thresholds was assessed using Pearson's correlation. Except for cutaneous EPT, no significant (p ≤ 0.05) intra- and inter-session differences were observed. Excellent intra-session reliability was shown for cutaneous and intramuscular electrical stimulations and all QST parameters (ICC: 0.76-0.93). Inter-session reliabilities were good (ICC: 0.74-0.75) except for electrical stimulations (ICC: 0.08-0.36). Limits of agreement and SEM were higher for inter-session than intra-session. A medium to strong relationship was found between electrical and mechanical/pressure pain thresholds. In conclusion, cutaneous and intramuscular electrical stimulation will potentially close an important diagnostic gap regarding the selective examination of deep tissue afferents and provide location-specific information for the excitability of non-nociceptive and nociceptive afferents.

The TOR concept (training, operation, and rehabilitation) applied to a cohort of postpartum women with training-resistant symptomatic rectus diastasis: evaluation 1 year after surgery

BACKGROUND

Rectus diastasis is a common sequela of pregnancy and is associated with functional disabilities such as back pain, abdominal core instability, abdominal muscle weakness, urinary incontinence, and psychological issues such as a negative body image. The aim of this study was to evaluate the effect of the TOR concept (training, operation, and rehabilitation), a novel concept for treating abdominal wall insufficiency combined with rectus diastasis, after pregnancy. TOR consists of preoperative evaluation of symptoms and custom-designed abdominal core training, tailored rectus diastasis repair, and individual progressive postoperative rehabilitation.

METHODS

A consecutive series of women diagnosed with rectus diastasis and core dysfunction resistant to training, underwent plication of the linea alba between 2018 and 2020. After surgery, all patients participated in an individually designed rehabilitation programme over a 4-month interval. Physical function was recorded before surgery and 1 year after surgery using the disability rating index questionnaire. Symptoms associated with core instability were recorded before and 1 year after surgery. Quality of life was assessed using the SF-36. The abdominal wall anatomy was assessed with ultrasound before and 1 year after surgery.

RESULTS

Seventy-one women were included and all attended 1-year follow-up. Response rate was 81.7 per cent (58) for the disability rating index, and 59.2 per cent (42) for SF-36. Self-reported physical function (disability rating index) improved in 54 of 58 patients (93.1 per cent), with a median score reduction of 91.3 per cent. Core instability symptoms decreased significantly. All SF-36 subscales improved significantly compared with preoperative scores, reaching levels similar to or higher than the normative Swedish female population. No recurrence of rectus diastasis was seen at the 1-year follow-up.

CONCLUSIONS

Surgical reconstruction within the TOR concept resulted in significant improvements in physical function and quality of life as well as a significant decrease in symptoms of core instability.

An Algorithmic Approach for the MIS Repair of Ventral Midline Hernias Associated With Diastasis of the Rectus Abdominis Muscle

Purpose: We present our algorithmic approach for symptomatic ventral hernias with Diastasis of the Rectus Abdominis Muscle (DRAM). Methods: Retrospective analysis of patients with symptomatic ventral hernias and DRAM undergoing hernia repair and plication of DRAM from July 2018-March 2021 was conducted. Based on our algorithm, patients were selected for an Endoscopic Onlay Repair (ENDOR) or a Robotic Extended Totally Extraperitoneal Ventral Repair (R-eTEP). Results: We performed a R-eTEP in fifty-seven patients and an ENDOR in twenty-four patients. In the R-eTEP group, thirty-seven (65%) patients were female, the mean age was 54.8 (±10.6), and the mean BMI was 32 (±4.8). Fifty patients (87.7%) had multiple defects, of which 19 (38%) were recurrent hernias and 31 (62%) were incisional hernias. The mean operative time was 200 (±62.4) minutes, with two cases requiring a hybrid approach. The median length of stay was 1 day (0-12), and the median follow-up was 103 days. Twenty-four patients underwent an ENDOR, 19 females (79.2%), the mean age was 45.7 years (±11.7) and the mean BMI was 28 (±3.6). 13 patients had isolated umbilical or epigastric hernias. The mean operative time was 146.2 min (±51.1). Fibrin sealant and suture was the predominant method for mesh fixation, and most cases were performed in an ambulatory setting. Four patients developed post-operative seromas; one requiring drainage due to infection. The Median follow-up was 48.5 days (10-523), with two reported hernia recurrences. Conclusion: An algorithmic approach for adequate patient selection was shown to be safe for treating ventral hernias with DRAM.

Association Between Inter-Recti Distance and Impaired Abdominal Core Function in Post-Partum Women With Diastasis Recti Abdominis

Background and Aim: The definition and management of Diastasis Recti Abdominis (DRA) is under debate. This study aimed to understand the correlation between the post-partum inter-recti distance (IRD) and functional impairments associated with core instability, with the hypothesis that IRD could serve as a proxy for core instability symptoms and constitute a tool in decision-making for DRA treatment. Material and Methods: A cohort of post-partum women with abdominal core instability symptoms combined with DRA were studied. The size of IRD was measured with ultrasonography and cross-sectionally analysed against functional impairments registered with the self-report Disability Rating Index (DRI), which grades the ability to perform 12 different daily activities. Results: A total of 224 women were included in the study. In univariable analysis, IRD was associated with impairment of the activities running (p = 0.007), heavy work (p = 0.036) and exercise/sports (p = 0.047), but not with dressing, walking, sitting for long periods, standing bent over a sink, carrying a suitcase, making a bed, light manual labour or heavy lifting. No significant correlations were seen in the multivariable analysis when adjustments were made for BMI and parity. Conclusion: IRD and post-partum functional impairments had no significant correlation in multivariable analysis. The post-partum core instability condition is complex and probably associated with more factors than solely the IRD. The IRD alone does not seem to be a sufficient proxy for decision-making regarding optimal treatment. A more complete instrument to assess the post-partum abdominal core is warranted.

Efficacy of electro-acupuncture in postpartum with diastasis recti abdominis: A randomized controlled clinical trial

Background

Electro-acupuncture (EA) has promising effects on diastasis rectus abdominis (DRA), defined as a separation of the two muscle bellies of rectus abdominis. To study, there is scant knowledge or scarce high-quality evidence.

Objective

We aimed to evaluate the long-term efficacy and safety of EA in treating DRA during postpartum. It was assumed that the improvement of DRA was more obvious in the EA group than in the control group.

Design

Randomized, controlled, blinded trial (Clinical Trial Registration: ChiCTR2100041891).

Setting

Hangzhou Hospital of Traditional Chinese Medicine in China.

Participants

Females aged 20-45 years without a past medical history of pathological rectus abdominal dissection were recruited from DRA inclusion criteria from 42 days to 1 year postpartum.

Intervention

110 participants were randomly assigned in a 1:1 ratio to a control group with no EA intervention (n = 55), and EA group (n = 55). The EA group received ten sessions of EA combined with physical exercise or only physical exercise for 2 weeks with a 26-week follow-up.

Measurements

Outcomes were assessed at baseline, week 2, and week 26. The primary outcome was the change of the inter recti distance (IRD) and electromyographic evaluation of the pelvic floor. Secondary outcomes included elasticity of linea alba (LA), paraumbilical subcutaneous adipose tissue (SAT) measurement, body mass index (BMI), percentage body fat (F%), dyspepsia symptoms, menstrual symptoms, quality of life (QoL), pain performance of patients with lower back pain, postnatal depression symptoms (PDS), postpartum self-image, and DRA-related symptom assessment including urine leakage, frequency, and urgency, constipation, sexual dysfunction, and chronic pelvic pain.

Results

A total of 110 maternal (55 in each group) were recruited. The mean difference in IRD from baseline to week 2 and week 26 in all states of the two groups were reduced compared with those before treatment, with statistical significance (P < 0.05). The mean of IRD at the horizontal line of the umbilicus in the end-expiratory state was smaller in the EA group than in the control group, but the difference was not statistically significant (P > 0.05) at week 2. The mean of IRD at the horizontal line of the umbilicus in head-up and flexed knee state was smaller in the EA group than in the control group, and the difference was statistically significant (P < 0.05) at week 26. Five (9.1%) and thirteen (23.64%) adverse events were reported in EA and control groups, respectively. No serious adverse events were reported.

Limitation

The frequency intensity of EA parameters was selected between 4 and 6 because of individual tolerance differences.

Conclusion

EA is an effective approach to improve IRD, electromyographic evaluation of the pelvic floor, BMI, the elasticity of LA, paraumbilical SAT, and symptoms of DRA, with durable effects at 26 weeks.

Primary funding source

The Construction Fund of Medical Key Disciplines of Hangzhou (Project Number: OO20200097), Hangzhou Medical and Health Science and Technology Project No. A20200483, and Zhejiang Traditional Chinese Medicine Science and Technology Plan Project (Project Number: 2021ZQ065).

Clinical trial registration

http://www.chictr.org.cn/index.aspx, identifier: ChiCTR2100041891.

The male rectus diastasis: a different concept?

PURPOSE

More interest in the treatment of rectus diastasis has been evoked lately. Following the postpartum females from a great distance, the middle-aged males living with obesity are the second most common group of rectus diastasis patients. Although gender differences are considered frequently in regard to cosmetic appearance and symptoms, it is less obvious in classifications and subsequent treatment strategies. Is a unisex approach of rectus diastasis still applicable? The lack of a firm answer warrants this review of the current literature.

METHODS

An explorative free-text multi-database bibliographic search (Pubmed/CENTRAL/EMBASE/PEDro/Scholar) was performed with the focus on the rectus diastasis in males. Anticipating the limited references, the design was a non-systematic review. All studies, regardless of study type, language or time period, describing etiology, symptoms, classification and/or treatment options were eligible for inclusion. From the articles retrieved out of this search, additional references were identified by a manual search among the cited references.

RESULTS

The multi-database search resulted in a total of 7633 records. Based on the title and abstract 95 records were full text assessed for eligibility. Eleven studies were identified as relevant, six by cross-reference and another four by hand-search were added to provide an insight in gender-specific aspects in rectus diastase. Hereditary causes are differences in collagen-like composition of types and concomitant abdominal aneurysm as well as gender differences in the linea alba architecture. Acquired etiology is distributed into both absolute pressure by visceral obesity and relative pressure caused by weight lifting or improper exercises. Furthermore, the impact of muscle thickness and age are considered as influencers of biomechanics. Gender differences can also play a role in symptoms of body image and core stability. It is known that there are anatomical differences between male and female persons; more transverse fibers are found in infra-umbilical region in women. In classifications the awareness of male rectus diastasis is limited, treatment outcome studies are scarce on males.

CONCLUSION

An overview of male-specific aspects of rectus diastasis is provided, underlining that key aspects surrounding rectus diastasis in males differ from females. Although males are the minority of rectus diastasis patients, we recommend that the male rectus diastasis as a concept should be specifically acknowledged in classifications systems and study outcome reporting to evaluate this subgroup more accurately in the future.

Muscle elasticity is different in individuals with diastasis recti abdominis than healthy volunteers

Objective

To determine the value of shear wave elastography (SWE) in assessing abdominal wall muscles, including rectus abdominis (RA), external oblique muscle (EO), internal oblique muscle, and transversus abdominis (TrA) in patients with diastasis recti abdominis (DRA) and healthy controls.

Methods

From October 2018 to December 2019, 36 postpartum DRA patients and 24 nulliparous healthy women were identified. Inter-rectus distance (IRD) measurements were taken by B-mode ultrasound. Shear wave speed (SWS) values were acquired by one operator at ten specific locations. Clinical and ultrasound variables, including demographics, IRD, muscle thickness, and muscle SWS, were compared between the two groups using Student’s t test or Fisher's exact test. Pearson correlation analyses were conducted for the variables of IRD, muscle thickness, and SWS in the 36 DRA patients.

Results

The maximum diameter of recti abdominus separation was located at the umbilicus in DRA patients (4.59 ± 1.14 cm). The SWS value was significantly lower in the RA (p = 0.003) and higher in the TrA muscle (p < 0.001) in DRA patients compared with the age-matched controls. However, SWS in both muscles (RA and TrA) showed a statistically positive correlation with IRD (p < 0.05). In addition, the SWS value in EO statistically decreased in DRA patients compared with the healthy controls (1.65 ± 0.15 vs. 1.79 ± 0.14, p = 0.001).

Conclusions

The application of SWE to abdominal wall muscles in DRA patients is feasible. The correlation between SWS value and IRD in RA should be interpreted with caution.