Abdominal Separation In Post-Partum Women

By: Gema Sanchez, PT (Edited by Bradley Brown)

Diastasis rectus abdominis (DRA) is a structural impairment of the muscular and connective tissue of the abdominal wall which presents as a separation of the abdominal muscles along their midline. It is measured as the distance between the right and left sides of the abdominal muscle grid (the “six-pack”), and is referred to as the inter-recti distance (IRD). Measurement of IRD in the clinic is generally made by hand or with calipers. Criteria for the diagnosis of DRA vary, but IRD is generally considered abnormal if it exceeds 2 fingers width at rest, measured at or just above the navel. DRA has been linked to support-related pelvic floor dysfunction and lumbopelvic pain.  One study in 2009 found that 74% of women seeking physical therapy for abdominal or lumbopelvic symptoms exhibited increased IRD and had significantly greater pain than those without DRA.

Risk of pregnancy-related DRA is about 27% during the second trimester and peaks in the third trimester at 66-100% due to the baby’s increase in size. Luckily, there is some research which suggests that exercise during pregnancy may mitigate the occurrence of DRA. In 2005, one such study looked at the effect of abdominal strengthening on the presence and size of DRA in pregnant women. Eight women who participated in a prenatal exercise program of abdominal muscle strengthening, pelvic floor exercises and education were compared to 10 non-exercising women. They found that only 12.5% of the exercising women exhibited a DRA as compared to 90% of the non-exercising women.

Incidence of DRA decreases postpartum but is still present in as many as 39% of women six months postpartum, and some women still have not fully recovered one year postpartum. DRA-related abdominal instability can be especially limiting during this time, as women return to previous normal activity in addition to the load of caring for their child.

Integrity of the anterior abdominal wall is essential to stability, posture, breathing, trunk movement and support of internal organs.  Specific abdominal exercises are used to narrow the IRD and help prevent future separation. In two recent studies, ultrasound measurements were used to assess the effect of active abdominal contraction on DRA in post-partum women. Both studies concluded that IRD was reduced with regular, static abdominal contraction. In another study, researchers used ultrasound to measure IRD at rest and during abdominal exercises in 84 women during and after their pregnancy. Their results support the notion that conservative abdominal exercises consistently produced a significant narrowing of the IRD.

It is important that women with DRA receive individual supervision and assessment so that adjustments can be made based on each patient’s reaction to exercise as well as rate of improvement.

New Heights Physical Therapy Plus has physical therapists with the training, skill, and knowledge to assist your clients with DRA during and after their pregnancy.

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Pregnancy Related Low Back and Pelvic Pain

By: Gema Sanchez, PT

Prevalence of low back and pelvic pain during pregnancy has been estimated to be as high as 90%. It is so common that many obstetricians consider it a normal finding in pregnancy. Many women also consider pain to be an inevitable and normal part of pregnancy and do not seek treatment, despite significant limitations in day to day activities. As many as 80% of pregnant women report that back pain affects daily activities such as walking, rolling over in bed, getting out of a chair and getting out of bed.

Low back and pelvic pain during pregnancy also has significant repercussions post-partum. Risk of return of pain in a subsequent pregnancy has been estimated at 85%. One study found 20% of women with back pain during pregnancy reported residual pain three years later and 10% of women with chronic low back pain link the onset of their pain to pregnancy. This is unfortunate, since several studies have shown that simple interventions for pain during pregnancy such as exercise, education and manual therapy techniques can significantly improve pain and function during pregnancy and prevent persisting and chronic pain post-partum.

Exercise combined with education (in anatomy and physiology, posture, pain, normal pelvic changes, self help management, ADL modifications) has been found to be an effective treatment for pregnancy related lumbar, pelvic, and symphysis pubis pain. In 2014, Van Benten et al reviewed 22 randomized controlled trials on the effectiveness of physical therapy interventions in treating lumbopelvic pain during pregnancy.  They concluded that exercise combined with education had a positive effect on pain, disability and/or sick leave. In one of the reviewed studies, Shim et al provided education and an exercise program to a group of 56 women with pregnancy related lumbar and pelvic pain. After 12 weeks, the women in the intervention group reported an almost three point decrease in pain. Education and exercise were also provided to late pregnancy subjects with symphysis pubis pain and dysfunction in the study by Depledge, et al. They found that after only one week of education and exercise, average pain decreased by 31.8% and disability decreased by 38.6%.

Osteopathic manual techniques, practiced by osteopathic physicians and physical therapists, have also been shown to be effective for pregnancy related back pain. Licciardone et al compared the effect of the addition of 5-7 sessions of osteopathic manual techniques (soft tissue, myofascial release, muscle energy and range of motion mobilization) to usual obstetric care in 146 women with late pregnancy back pain. They found that back pain decreased and back specific functioning deteriorated less in those women who received the manual techniques.

Low back pain, pelvic pain and functional limitations because of pain should not be considered an inevitable or normal part of pregnancy. Intervention during pregnancy can decrease pain, improve function and reduce the risk of persisting and chronic pain. Physical therapy at New Heights Physical Therapy Plus provides safe and effective customized assessments and interventions in all stages of pregnancy and post-partum.

In June, we will be welcoming a new physical therapist, Julie Burtis. Julie specializes in women’s health and will be splitting her time between the West and East clinics. She will be giving a lecture on Postpartum Rehab at New Heights (East Clinic) on June 29th from 6-7PM.