Association Among Pelvic Girdle Pain, Diastasis Recti Abdominis, Pubic Symphysis Width, and Pain Catastrophizing: A Matched Case-Control Study

Low back pain, ultrasonographic muscle thickness measurements and biopsychosocial factors at different trimesters of pregnancy

BACKGROUND

Pregnancy-related low back pain is a multifactorial problem and its assosiation with pain intensity and biopsycosocial factors can not be fully explained. This study aimed to determine the psychosocial as well as biological/physical risk factors associated with self-reported low back pain (LBP) intensity during different trimesters of pregnancy.

METHODS

This cross-sectional study comprised 107 pregnant women. An introductory information form for physical and medical characteristics, Visual Analog Scale (VAS) for low back pain intensity and Oswestry Disability Index (ODI) for degree of loss of functionality, Short Form-36 (SF-36) for quality of life and Pregnancy Physical Activity Questionnaire (PPAQ) for physical activity were applied. Abdominal muscle thicknesses and diastasis recti were measured by ultrasonography. Univariate regression was used to analyse associations between each plausible independent variable and low back pain intensity.

RESULTS

Mean LBP intensity during 1st, 2nd ve 3rd trimesters were 26.8 ± 20.9, 27.3 ± 19.8, 21.6 ± 20.1 mm, respectively. ODI scores were associated with LBP intensity, explaining 11%, 13% and 26% of LBP severity during the 1st, 2nd ve 3rd trimesters, respectively. Other biological/physical variables like age, body mass index, muscle thickness and diastasis recti were not associated with pain intensity. SF-36 emotional role limitation (coef = -0.03, R2 = 0.20, p = 0.01) in the 3rd trimester and SF-36 pain score in the 1st (coef = -0.04, R2 = 0.12, p = 0.02) and 3rd (coef = -0.05, R2 = 0.26, p = 0.004) trimesters and PPAQ-sedentary was associated during the 2nd trimester (coef = 0.17, R2 = 0.17, p = 0.02) with pain intensity.

CONCLUSION

ODI scores were associated with LBP intensity in all three trimesters, with SF-36 pain domain in the 1st and 3rd trimesters, with SF-36 emotional role limitation only in the 3rd trimester and with sedentary activity level only in the 2nd trimester. İncreased pain intensity was surprisingly associated with a small number of biopsychosocial factors in all the trimesters. There is need for further large-sample studies.

Intra- and Interimage Reliability of Inter-Rectus Distance Measurements Determined via Ultrasound Imaging by the Same or Different Testers in Women in the Early Postpartum Period

OBJECTIVES

No consensus regarding the optimal position and location for the measurement of the inter-rectus distance (IRD) via ultrasound (US) has been reached. By investigating the intra- and interimage reliability of IRD measurements taken in different positions and at different locations within and between testers, this study provides a theoretical basis for the current situation.

METHODS

The IRD was measured via US in 46 women at 42-60 days after delivery at the superior margin of the umbilicus and 3 cm above, 5 cm above and 3 cm below the umbilicus while the women were in the supine, crunch and standing positions. In the interimage test, every participant was tested 2 times by Physician X and 1 time by Physician Y; in the intraimage test, the images collected by Physician X during the first test were saved in the machines, and two measurements were performed by Physician X and one measurement was performed by Physician Y. Paired t tests and intraclass correlation coefficients (ICCs) were calculated.

RESULTS

Only the first IRD measurements by tester X and tester Y at 3 cm below the umbilicus in the crunch position were significantly different (9.56 ± 6.00 versus 11.00 ± 5.55) (P < .05). All the ICCs were greater than .75, and the intratester ICCs were greater than or equal to the corresponding intertester ICCs. The ICCs at 3 cm below the umbilicus were the smallest in the supine and crunch positions and the largest in the standing position due to the increased frequency of IRD values of 0. The ICCs for the crunch position were greatest according to the intraimage test but smallest according to the interimage test. The interimage ICCs between the two testers in the supine position at the superior margin, 3 cm above, 5 cm above, and 3 cm below the umbilicus were .972, .974, .975, and .956, respectively.

CONCLUSIONS

Ultrasound imaging (USI) is a reliable method for measuring the IRD in women in the early postpartum period. The dynamic measurement of the IRD at or above the umbilicus in the supine position by different testers in real time showed the highest reliability.

Rehabilitations for maternal diastasis recti abdominis: An update on therapeutic directions

Diastasis recti abdominis (DRA) affects a significant number of postpartum women, while its treatments are still under debate. This study aimed to systematically evaluate the effectiveness of rehabilitation training programs for postpartum DRA treatment. Four databases were systematically searched to identify eligible studies published up to February 1, 2023. We followed the PRISMA for scoping reviews guideline in this study. The characteristics and the main findings of the included studies were extracted. Sixteen studies enrolling 1129 women during the ante- and/or postnatal period were included. The common rehabilitation training for DRA included physical exercise, non-exercise physical therapy, acupuncture, and electrotherapy. The presence of DRA could be diagnosed by ultrasound, caliper, or palpation, of which ultrasound had the best reliability. Besides, these assessments could also be used for evaluating the therapeutic efficacy after the rehabilitation training programs. Several studies concluded that patients with DRA could be effectively improved by specific interventions. But a few included studies revealed rehabilitation training might be not more effective than no interventions when treating DRA. For example, some investigators did not recommend physical exercise for DRA patients due to this intervention during pregnancy kept the linea alba less stressed by maintaining abdominal tone, strength, and control, and therefore might aggravate DRA. However, it should be noted that this evidence was derived from limited studies (16/60, 27 % papers) with small samples. To some extent, women with postpartum DRA can benefit from the specific rehabilitation regimen by alleviating postpartum inter-rectus distance. Further research is still warranted to propose strategies for improving postpartum DRA.

Technical aspects of inter-recti distance measurement with ultrasonographic imaging for physiotherapy purposes: the scoping review

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.

A bibliometric and visualized research on global trends of abdominoplasty, 2011-2021

OBJECTIVES

Patients with multiple pregnancies, multiple pregnancies, and a history of severe obesity, the abdominal wall muscles, and skin exhibit rectus abdominis separation and skin laxity due to prolonged overstretching, which causes damage to both the patient's appearance and health. Abdominoplasty is a surgical solution to the problems of separation of the rectus abdominis muscle and laxity of the skin of the abdominal wall under direct vision, which is important for patients with the above problems. Currently, many studies have been reported on abdominoplasty, however, no reverent bibliometric analyses of abdominoplasty have been published.

METHODS

In this study, we screened 1,119 studies on abdominoplasty between 2011 and 2021 based on the Web of Science Core Collection (WOSCC) database and performed a bibliometric analysis.

RESULTS

We found that high-quality research related to abdominoplasty has increased in the last decade, and the United States was the leading country in the field of abdominoplasty. Stanford university ranked first in number of publications and citations. Aesthetic surgery journal was the most productive journal, followed by the Plastic and reconstructive surgery and Aesthetic plastic surgery. In addition, bariatric surgery, venous thromboembolism, rectus diastasis, breast reconstruction and umbilicoplasty are the keywords of recent publications that are the focus of current research.

CONCLUSION

This study provides a comprehensive analysis and visualization of global research trends on abdominoplasty from 2011 to 2021, and improvements in abdominoplasty to reduce the incidence of postoperative complications will remain a focus of future research.

Dynamic Evaluation of the Rectus Abdominis Muscle before and after Delivery by Ultrasonography

Objective. To evaluate the changes of rectus abdominis thickness and inter-rectus distance before and after delivery with high-frequency ultrasound. Methods. A total of 148 pregnant women at 12 weeks of gestation who underwent prenatal examination in our hospital from January 2019 to March 2020 were selected, and 140 of them cooperated with rectus abdominis examination. According to the results of rectus abdominis examination 42 days after delivery, 97 patients were divided into the DRA group with rectus abdominis isolated and 43 patients were divided into the normal group with rectus abdominis not isolated. At 12 weeks, 24 weeks, and 37 weeks of pregnancy, 3 days and 42 days after delivery, the thickness and spacing of the left and right rectus abdominis muscle were measured by high-frequency ultrasound along the white linea at three positions: 5 cm above the navel, 3 cm below the umbilical edge, and 3 cm below the navel. Results. The thickness of rectus abdominis at 5 cm above the navel, 3 cm below the navel, and at the navel margin of the abdominal white line in the pregnant women of the two groups was gradually decreased with the increase of the pregnancy cycle and gradually recovered after delivery. At 42 days after delivery, the thickness of rectus abdominis in the DRA group was significantly lower than that in the normal group, which was 5 cm above the umbilicus, 3 cm below the umbilicus, and the umbilical margin of the abdominal white line ( $P<0.05$ ). The space between rectus abdominis 5 cm above the navel, 3 cm below the navel, and the navel margin of the abdominal white line in the pregnant women of the two groups was gradually increased with the increase of the pregnancy cycle and gradually recovered after delivery. At 37 weeks of pregnancy, 3 days after delivery, and 42 days after delivery, the space of rectus abdominis along the umbilicus 5 cm above, 3 cm below the umbilicus, and the umbilicus border of the abdominal white line in the DRA group was significantly larger than that of the normal group ( $P<0.05$ ). Conclusion. Ultrasound can accurately measure the inter-rectus distance and rectus thickness, accurately evaluate the degree of DRA, and realize the one-stop evaluation from prenatal diagnosis and prediction to postpartum rehabilitation monitoring, so as to intervene during pregnancy and reduce the risk of postpartum DRA.

The Association between Postpartum Pelvic Girdle Pain and Pelvic Floor Muscle Function, Diastasis Recti and Psychological Factors-A Matched Case-Control Study

There is uncertainty regarding the association between abdominal morphology, pelvic floor function, and psychological factors in women with postpartum pelvic girdle pain (PGP). The aim of this case-control study was to evaluate the differences between women with and without persistent PGP regarding pelvic floor function, diastasis recti, and psychological factors 6−24 weeks postpartum. Pelvic floor manometry, palpation examination of abdominal muscles, the International Consultation on Incontinence Questionnaire Short Form, The Depression, Anxiety and Stress Scale—21, and the Pain Catastrophizing Scale were used. The PGP group presented with lower vaginal resting pressure (p < 0.001), more tenderness (p = 0.018) and impaired voluntary activation of pelvic floor muscles (p ≤ 0.001). Women with pain also had more distortion on the level of the anterior abdominal wall (p = 0.001) and more severe diastasis recti (p = 0.046) when compared to pain-free controls. Lower vaginal resting pressure was the strongest factor explaining PGP (OR 0.702, 95%CI 0.502−0.981). There were no differences in terms of the pelvic floor strength, endurance, severity of urinary incontinence and reported distress between the groups. Women with PGP 6−24 weeks postpartum differ in pelvic floor and abdominal muscle function from the pain-free controls. Vaginal resting pressure may be an important factor in pelvic girdle pain shortly postpartum. Further studies are needed to see a trend in changes over time.