12/16/2013
Background
MIND THE GAP:
A COMPREHENSIVE APPROACH FOR
THE EVALUATION OF AND
INTERVENTION OF DIASTASIS RECTI
ABDOMINIS
What is a diastasis rectus abdominis?
Cynthia M. Chiarello, PT, PhD
Adrienne McAuley, PT, DPT, MEd, OCS, FAAOMPT
CSM 2014, Las Vegas, Nevada
SECTION ON WOMEN’S HEALTH
Diastasis Rectus Abdominis (DRA)
The “abnormal” midline
separation of the right and left
rectus abdominis muscles along
the linea alba.
Appears as a visible increase in
the width of the linea alba or
Inter-Recti Distance (IRD).
Connective tissue alterations of
the linea alba (Szczesny, 2006)
Damage of the fixation of the
rectus muscles (Axer, 2001)




The Abdominal Wall

Diastasis Rectus Abdominis (DRA)

What is normal?


While there is agreement that a DRA is abnormal,
there is no consensus in the literature as to what the
optimal IRD is for all adults
What is functional?


Optimal support and force distribution
Pain free
The Abdominal Wall
Abdominal Muscles
Abdominal Wall
 Abdominal
 Connective
Hernández-Gascón, 2012)
 Linea
Muscles
Tissue Mechanical Stability (Axer, 2001,
alba
 Aponeuroses
Rectus
abdominis
Neumann. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation, 2nd Edi. Mosby, 2010.
Obliquus
externus
abdominis
Obliquus
internus
abdominis
Transversus
abdominis
Muscolino. The Muscular System Manual: The Skeletal Muscles of the Human Body, 3rd Edition. Mosby, 2010. VitalBook file.
1
12/16/2013
The Abdominal Wall
The Abdominal Wall
Rectus Sheaths & Linea Alba

Linea Alba is composed of tendinous fibers of the
abdominal muscles
 Variable composition 3
dimensional meshwork of
fibers
 Anterior
A t i rectus
t Sheath
Sh th
(oblique fibers)
 from Aponeurosis of EO,
IO, TrA, RA
 Posterior Rectus Sheath
(transverse fibers)
 from Aponeurosis of EO,
IO, TrA
Architecture of Linea Alba (Axer, 2002)

Ext Oblique
Int Oblique
TA
The Abdominal Wall
Architecture of Linea Alba (Axer, 2002)


Distinct Craniocaudal regions
 Supraumbilical
 Umbilical
 Transition zone
 Infra-arcuate
Connective tissue is the
stabilizing part of the
abdominal wall

Collagen fibers - 3-D
meshwork in the same
orientation as the
muscle fibers of the
ventrolateral abdominal
wall
1.
2.
3.
Oblique Fiber Layer
Transverse Fiber Layer
Irregular Fiber Layer
The Abdominal Wall
Linea alba: Gender differences

Size & Location (Axer, 2002)
 Thickness ♂ > ♀
 Infraumbilical
Fiber diameter & thickness - Infraumbilical > supraumbilical
Thickness ♂ > ♀
 Width ♀ > ♂
 ♀ more transverse (relative to oblique) bundles



Compliance (Grassel, 2005)
For both sexes - highest longitudinally & smallest in the
transverse direction
 Supra & Infraumbilical, transverse compliance smaller in
♀ than ♂

collagen fibers in the LA
show the same orientation
as the muscle fibers
DRA : what is normal?
Interrecti Distance: Age
To

date there is no agreed upon size
and location for measuring the normal
width of the linea alba
IRD is relative to




Age
Gender
Location along the linea alba
Measurement tool
Rath (1996) Often sited as the normal range of IRD
Cadavers
CT scan > 45 yo
CT scan > 45 yo
1.72 cm Supraumbilical
10mm Supraumbilical
27mm Umbilicus
9mm Infraumbilical
15mm Supraumbilical
27mm Umbilicus
14mm Infraumbilical
2.25 cm Umbilicus
.66 cm Infraumbilical
2
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12/16/2013
Inter-recti Distance: Gender
Nulliparous Women
Interrecti Distance: Location
Study
N
Beer et al., 2009
Coldron et al.,



Location varies in the literature
Consider height, tool and gender
Clinically note location where IRD appears widest
Inter-recti Distance: Gender
Males
2008
Chiarello,
McAuley, 2013
N
Moesbergen et al,
Mean Age
Chiarello,
McAuley, 2013
(yrs)
Method
75
71
CT
Supraumbilical
Subumbilical
11
37.5
USI
4.5cm ↑ umb
4.5cm ↓ umb
16.2 ± 1.0
7.4 ± 8.9
Caliper
4.5cm ↑ umb
4.5cm ↓ umb
16.3 ± 6.9
16.8 ± 5.4
Location
69
27
22
28
Size (mm)
7±5
13 ± 7 8 ± 6
USI
just ↑ umb
11.2 ± 3.6
USI
4.5cm ↑ umb
4.5cm ↓ umb
7.5 ± 4.3
2.2 ± 2.9
Caliper
4.5cm ↑ umb
4.5cm ↓ umb
8.1 ± 5.3
16.9 ± 6.8
N
Mean Age
Measurement
(yrs)
Method
32
USI
20.7 ± 12.5
4.3 ± 5.8
Parker et al, 2009
53
41.4
Liaw et al., 2011
30
Chiarello,
McAuley, 2013
23
Location
Size (mm)
just ↑ umb
23.3 ± 8.4
Caliper
4.5cm ↑ umb
umbilicus
4.5cm ↓ umb
16.6 ± 8.0
19.2
19
2 ± 5.7 57
15.9 ± 8.3
32.1
USI
2.5cm ↑ umb
upper umb
Lower umb
2.5cm ↓ umb
18.0 ± 7.2
21.3 ± 6.5
18.1 ± 4.1
14.0 ± 4.0
39.6
USI
4.5cm ↑ umb
4.5cm ↓ umb
20.3 ± 10.2
10.5 ± 6.5
Caliper
4.5cm ↑ umb
4.5cm ↓ umb
20.4 ± 16.1
23.6 ± 14.3
Characteristics Associated With DRA

Abdominal Muscle Function Chiarello et al., 2006)
Increased RA length and angle of insertion (Gilleard & Brown, 1996)
Decreased strength and endurance (Gilleard & Brown, 1996, Liaw et al., 2011)
 Negative relationship between IRD and abdominal
muscle function postpartum (Liaw et al., 2011)
 Reduction in IRD size postpartum associated with
improved trunk flexor strength (Liaw et al., 2011)
IRD is smaller in nulliparous♀ than parous ♀
 Parous females→ 1.5-2 cm above & below the
umbilicus
 Nulliparous females→ 1 cm or less above & below
the umbilicus
 Males → More study is needed
umbilicus → 1.5 cm
umbilicus → <1 cm
Location
Xyphoid
yp
3 cm ↑ umb
2 cm ↓ umb
115


 Below
USI
Coldron et al, 2008
Clinical Relevance
 Above
29
150
Size (mm)
Inter-recti Distance: Gender

Method
Measurement
2009
Measurement
(yrs)
Inter-recti Distance: Gender
Parous Women
Study
Study
Mean Age


Abdominal Circumference

(Chiarello et al., 2012)
for each cm > 102 cm, IRD increased by 1.44mm


Subcutaneous adipose not a factor
Implications for pregnancy & obesity
3
12/16/2013
Characteristics Associated With DRA

Pregnancy

Characteristics Associated With DRA

IRD increases during gestation

Second trimester→ 27%; third → 66% (Boissonnault & Blaschak 1988,)

No DRA at 14 weeks, seen at 30 weeks (Gilleard & Brown, 1996)

Estimated fetal size moderately related to IRD
Parity


Does not fully resolve postpartum (Coldron et al., 2006, Liaw et al., 2011)
 At 12 months postpartum, 48% of women have larger IRD than
nulliparous (Coldron et al., 2006)
 39% of 1,738 women undergoing a hysterectomy several years
postpartum exhibited a DRA (Ranney,1990)
DRA: Associated Disorders

Lumbo-pelvic pain (Wade 2005, Sheppard et al., 1996, Toranto, 1990)



Older = larger IRD
Rath (1996) defined normal IRD increase with age
Gender


Nulliparous females have the smallest IRD (Beer, et al., 2009)
Males similar to nulliparous females (Chiarello & McAuley, 2013)
DRA: Associated Disorders

Support –related Pelvic Floor Dysfunction - females
(Spitznagle et al., 2007)
Rationale: Abdominal musculature supports and stabilizes the

pelvis anteriorly through its aponeurotic attachments at midline LA
and posteriorly through attachments of the thoracolumbar fascia.
DRA disrupts the integrity of this encircling fascial corset.
74% of women with some type of lumbopelvic
dysfunction exhibited a DRA (Parker et al., 2008)
 Chronic lumbopelvic pain ameliorated with surgical
correction of a DRA at abdominoplasty (Toranto, 1990, Oneal et al., 2011)
 LPP cohort had a wider IRD (Whittaker et al, 2013)
Multiple vs singleton pregnancy (Lo 1999)
Age


Multiparous > primiparous>nulliparous (Candito et al, 2005, Beer et al,
2009, Coldron et al, 2008)

Rational: Synergistic function of pelvic floor and
abdominal wall



Abdominal Aortic Aneurism - males

Rational: Connective tissue disorder



66% had 1 or more → stress urinary incontinence, fecal
incontinence, pelvic organ prolapse
67% of AAA pts had a DRA, 16.9% DRA with PAD (McPhail, 2009)
High prevalence of supraumbilical DRA found in both AAA (67%) &
controls (64%) (Moesbergen et al., 2009)
HIV associated lipodistrophy syndrome
(Blanchard, 2005)
DRA Measurement: Technique
Direct
Measurement of DRA



Surgical
(Kostarinos, 1991, Mendez et al., 2007)
Cadaver (Rath et al. 1996, Axer et al. 2001 & 2002, Chiarello et al. 2012)
Relevance - compare LA size and location in
various populations and conditions
Determination & Pinning of IRD
IRD
Site 2
4.5 cm
Umbilicus
Site 1
4.5 cm
Site 3
IRD
4
2014 CONTINUING
EDUCATION COURSES
The Section on Women’s Health is proud to announce the course schedule for 2014.
We hope you will be able to take advantage of the variety of course options and locations throughout the country.
Registration for 2014 educational courses and the 2014 Fall Conference is now open on our website.
www.womenshealthapta.org/education/regional_courses/index.cfm
For updates on courses and registration openings, please follow the Section’s Twitter and Facebook pages.
Pelvic Physical
Therapy 1
January 17-19, 2014 (Fri-Sun) <<<
Speakers: Lori Mize, PT, DPT, WCS
Carina Siracusa Majzun, PT, DPT
Greenville, SC
March 21-23, 2014 (Fri-Sun) <<<
Speaker: Lori Mize, PT, DPT, WCS
Houston, TX
June 20-22, 2014 (Fri-Sun) <<<
Speakers: Lori Mize, PT, DPT, WCS
MJ Strauhal, PT, BCB-PMD
Baton Rouge, LA
July 11-13, 2014 (Fri-Sun) <<<
Speakers: Lori Mize, PT, DPT, WCS
Barb Settles-Huge, PT
Des Moines, IA
October 10-12, 2014 (Fri-Sun) <<<
Speaker: Carina Siracusa Majzun, PT, DPT
East Lansing, MI
November 14-16, 2014 (Fri-Sun) <<<
Speaker: Barb Settles Huge, PT
Boca Raton, FL
Gynecologic
Visceral
Manipulation
LEVEL 1-2
October 2-5, 2014 (Thurs-Sun) <<<
Speaker: Gail Wetzler, PT
Bethlehem, PA
Pelvic Physical
Therapy 2
Pelvic Physical
Therapy 3
February 28-March 2, 2014 (Fri-Sun) <<<
Speaker: MJ Strauhal, PT, BCB-PMD
Portland, OR
June 27-29, 2014 (Fri-Sun) <<<
Speakers: MJ Strahaul, PT, BCIA-PMDB
Carina Siracusa Majzun, PT, DPT
Rochester, NY
September 12-14, 2014 (Fri-Sun) <<<
Speaker: MJ Strahaul, PT, BCIA-PMDB
Portland, OR
April 25-27, 2014 (Fri-Sun) <<<
Speaker: Barb Settles Huge, PT
Madison, WI
August 1-3, 2014 (Fri-Sun) <<<
Speakers: Carina Siracusa Majzun, PT, DPT
Towson, MD
Fundamental Topics
in Pregnancy and
Postpartum Physical
Therapy
March 28-30, 2014 (Fri-Sun) <<<
Speakers: Suzanne Badillo, PT, WCS
Susan Giglio, PT, RYT
Baton Rouge, LA
May 16-18, 2014 (Fri-Sun) <<<
Speakers: Karen Litos, PT, MPT
Valerie Bobb, PT, MPT, WCS, ATC
East Lansing, MI
July 25-27, 2014 (Fri-Sun) <<<
Speaker: Suzanne Badillo, PT, WCS
Edina, MN
August 22-24, 2014 (Fri-Sun) <<<
Speakers: Susan Giglio, PT, RYT
Karen Litos, PT, MPT
Longmont, CO
(Hybrid Course – details coming soon!)
November 7-9,2014 (Fri-Sun) <<<
Speaker: MJ Strahaul, PT, BCIA-PMDB
Madison, WI
Advanced Topics in
Pregnancy and
Postpartum Physical
Therapy
February 21-23, 2014 (Fri-Sun) <<<
Speaker: Susan Giglio, PT, RYT
St. Louis, MO
May 4-6, 2014 (note Sun-Tues) <<<
Speakers: Susan Giglio, PT, RYT
Susan Steffes, PT
Baltimore, MD
NE
The Physical Therapist in W
Labor & Delivery: Advanced
Techniques in Labor Support
October 24-26, 2014 (Fri-Sun) <<<
Speaker: Susan Steffes, PT, CD (DONA)
Austin, TX
Check website for new courses throughout the year!
This course is part of the Section on Women's Health Certificate
of Achievement in Pelvic Physical Therapy (CAPP-Pelvic) Program.
This course is part of the Section on Women's Health Certificate of Achievement
in Pregnancy and Postpartum Physical Therapy (CAPP-OB) Program.
For more details on CAPP, go to http://www.womenshealthapta.org/capp.cfm
For more information on Section on Women's Health sponsored courses go to
http://www.womenshealthapta.org/education/education.cfm or contact
the SOWH at sowh@apta.org, or 703-610-0224.
APTA
American Physical Therapy Association
N
EW
12/16/2013
DRA Measurement: Technique
DRA Measurement: Technique
Palpation
Palpation

Method





Clinical Relevance
Useful as a quick screen or when
USI is contraindicated
 Errors
 identification of medial edges of
rectus
 Variation in depth
Hook-lying, partial curl-up
Palpating finger-tips identify
medial edges of the right & left
RA, perpendicular to the LA
Size - number of fingers placed
medially between the two recti
Location –relative to umbilicus

Reliability – unreliable for clinical

Validity – clinical palpation of DRA

assessment (Burch, 1987)
not associated with presence at
surgery (Kostorinos, 1991)
Beer, et al, 2009
Chiarello, McAuley, 2013
DRA Measurement: Technique
DRA Measurement: Technique
Caliper
Caliper

Method






Method
Hook-lying
Mark location along LA
Water soluble pen
Tape measure
Palpate medial borders of RA
Mark measurement positions
Palpate medial borders of RA
 Position inside caliper jaw
b
between
muscle
l b
belly
ll at
palpating finger
perpendicular to the surface
 Adjust caliper to perceived
IRD width
 Condition


Nylon Digital Caliper
(Mitutoyo American Corporation)


DRA Measurement: Technique
Caliper

Reliability

Dial Calipers

High Intra and Inter-rater at rest & active (ICC .90-.95) (Boxer & Jones,
1997; Hitchman et al., 1997)

Digital Calipers

High Intra-rater with muscles contracting and at rest (ICC .94-.99)
(Chiarello McAuley, 2013)


High Inter-rater (ICC .87) (Chiarello et al. 2005)
Validity

Concurrent validity of calipers compared to USI (Chiarello McAuley, 2013)


Good above the umbilicus with muscles contracting and at rest
(ICC .71-.79)
Below the umbilicus calipers measured IRD significantly larger
than USI with muscles at rest and contracted
Passive - Muscles at rest
Active – Partial curl-up
DRA Measurement: Technique
Caliper

Clinical Relevance
Inexpensive, valid and reliable tool in the hands of a
trained clinician
 Calipers may measure IRD width larger than direct
measurement or imaging, particularly below the
umbilicus
 Allows for documentation of change
 Preferable to finger-tip width when imaging is not
available.

5
12/16/2013
DRA Measurement: Technique
DRA Measurement: Technique
Ultrasound Imaging (USI)

Ultrasound Imaging (USI)
Method
Method

Examiner determines
hyperechoic connective
tissue (rectus sheaths, LA) and
margins of hypoechoic RA.
 Mark distance with
automatic ruler.
Position and mark as with other
methods
 Place transducer perpendicular to LA
 Adjust focus and depth or image
according to individual patient
 Adjust transducer to visualize medial
aspect of right and left RA
 Condition



Reliability


Passive - Muscles at rest
 Active – Partial curl-up
 Breathing
Coldron et al., 2008
Very high intra-rater (ICC .90-.98) (Liaw et al., 2011, Chiarello McAuley, 2013)
Validity (Mendes et al., 2007)



Supraumbilical – No difference in IRD USI compared to
surgical measurement
Infraumbilical - values higher at surgery
DRA Measurement: Technique
Ultrasound Imaging (USI)

Clinical Relevance



Case Examples
Improved accuracy over palpation
methods
Useful tool to use when ever possible
Extensive examiner training
necessary for image interpretation
1.
2.
3.
Post-partum mother
Middl
Middle-aged
d man
Exercise enthusiast
Beer et al., 2009
Post-partum mother - Intro



34-year-old woman who
gave birth to her 3rd
child 4-months ago & is
weaning breastfeeding
All 3 were vaginal births
Largest baby weighed 9
lbs, 2 oz.
Post-partum mother - Subjective

Left low back pain
approximately 50% of
day
Worse when carrying
child/ren
 NPRS 4/10
 Difficulty with
transitional
movements




“Lifelong” tendency
toward constipation
Occasional SUI
Hasn’t resumed
sexual intimacy since
birth of 3rd child
6
TRY OUR
HOME STUDY MODULES
Now Available!
• Physical Therapist Management of Patients with Chronic Pelvic Pain
• Medical Management and Physical Therapy Management of High-Risk Pregnancy
• EMG Homestudy
• Physical Therapy in Obstetrics
• Physical Therapy for Osteoporosis: Prevention and Management
• Anatomy and Physiology of Intra-abdominal Pressure
For more information, go to
the Section on Women's Health
website at
www.womenshealthapta.org
or call 703-610-0224.
Women’s Health
Section on
APTA
American Physical Therapy Association
Women’s Health
Section on
2014 Women’s Health Resource Directory
• A great resource to learn about products for your patients
• Learn about upcoming courses and conferences
• New Directory is updated throughout the year, adding new information for you!
Professional Continuing Education
Exercise Videos/Programs
Orhopedic Products/Orthotics
Patient Education Resources
Maternity Products and Supports
Pelvic Floor Biofeedback & E Stim
Business Planning & Marketing
Health Organizations
Pelvic Floor Therapy Products
For more information about advertising in the Section on Women’s Health Resource Directory
go to http://goo.gl/65bI9
or contact Sarah Haag, PT, DPT, WCS' • (815) 274-2073 • financialdev@womenshealthapta.org
APTA
American Physical Therapy Association
12/16/2013
Post-partum mother - Objective

Posture



Anterior pelvic sway
Widest point was 2.5
cm above umbilicus
 3.2 cm at rest
 2.8
2 8 cm active
ti

Pelvis

No obliquities or
asymmetries noted


IRD
ASLR
Pelvic floor

Poor contraction
 MMT 2/5, 4 sec hold


Right 3/5
Left 3/5
Active Straight Leg Raise – Load transfer test
Mens et al, 1999, 2001, 2002. 2010; Liebenson et al, 2009
Post-partum mother - Considerations
Post-partum mother - Summary
Examination
Treatment

Treatment
Pregnancy &
breastfeeding info


Binder /belt / tape
“Best” exercises


Pelvic floor function
Role in stability
 Bladder function
 Bowel function
 Sexual function

Taping
(Irion, p. 218)


TrA
Keeler et al. 2012
Education
Posture
 Body mechanics
 Bowel / bladder







Outcomes
5 weeks (7 sessions)
DRA taping
Education



Posture / mechanics
bowel / bladder function
Neuro re-ed


TrA
PFM
Sahrmann’s abdominal
progression & BKFO
Toileting





Pain free 90% of time
ASLR 0/5 each LE
Resolution of SUI
Pain free intercourse
Constipation managed
PFMC 4/5 MMT x 10seconds
IRD?
www.thewomens.org.au
7
12/16/2013
Middle-aged man - Intro


47-year-old man
Middle-aged man - Subjective

Pronounced abdominal
distention


Current complaint is
back & left leg pain x3-4
months


PSH includes fusion
L4/5 and inguinal hernia
repair on the right
Middle-aged man - Objective

Posture



Wide base of support
Excessive lordosis
Neuro screen



Trunk ROM


Grossly 50%; no curve
reversal with flexion
Segmental



Excessive motion L5/S1
Hypomobile thoracic spine

Reflexes, myotomes,
dermatomes normal
Passive SLR +60° L



IRD 3.6 cm at umbilicus
Inability to recruit TrA
No signs of AAA
Waist girth 118 cm at
umbilicus
Hip PROM


Flexion L 95°, R 110°
IR L 10°, R 23° (90/90)
Middle-aged man - Summary
Treatment: 10 sessions in 12 weeks



Outcomes
Visceral work to help reduce abdominal
distention

Oswestry 12%
Manual work to facilitate thoracic
mobility

Passive SLR 80°
Hip dissociation & neural flossing
exercises

Hip PROM L = R

Waist girth 112 cm

IRD?

Postural awareness

Stability training



Drawing in maneuver
Sidelying & quadruped positions favored
Transition to functional positions for work
Left leg pain worse
with walking
No complaints
related to bowel or
bladder function



Works as school
janitor &
groundskeeper
Has missed 3 days
work due to pain
Oswestry 46%
Middle-aged man - Considerations
Examination

Surgical history

Waist girth
Abd
Abdomen

Back pain worse with
sitting


Treatment



> 102 cm Chiarello et al, 2012
Screen for aortic
aneurysm Mechelli et al, 2008
Excessive intraabdominal pressure

Contributors
Interventions
Mobility thoracic
spine & hips
Exercise enthusiast - Intro



22-year-old gym
enthusiast
Training for a
marathon
c/o right sided groin
pain
8
12/16/2013
Exercise enthusiast - Subjective
Right sided groin pain
after run; lasts 2 days

When it
it’ss present,
present
will feel it more with
sitting


Upon questioning,
“small bladder” and
frequent urination
Exercise enthusiast - Objective


Abdomen

Sahrmann


Findings consistent with
anterior femoral glide
syndrome
Pain with intercourse,
but nothing that isn’t
“normal”

Infrasternal angle

100°

PFM


Femoral Anterior Glide Syndrome
IRD at rest 1.9 cm
throughout length of linea
alba above umbilicus
Active contraction
INCREASES IRD to
t 2.6
2 6 cm
Hypertonic; inability to
contract or relax well
1-finger insertion without
difficulty, but unable to
insert 2
Femoral Anterior Glide Syndrome
Described by Sahrmann


Movement Impairment Syndrome

Groin pain with flexion


Altered PICR

Inadequate posterior glide
Path of the instant
center of rotation
Groin pain with extension


Excessive anterior glide

Muscle Imbalances

TFL : Ilipsoas

Hamstring : GMax
Sahrmann, 2001. p. 145-146
Sahrmann, 2001. p. 149
Exercise enthusiast - Considerations
Exercise Enthusiast - Summary
Examination
Treatment: 1x / week, 6 weeks

Infrasternal angle

Treatment

Wide angle
Diaphragmatic
breathing

Manual soft tissue
work & HEP

Lateral margins of recti
abdominis mm
 Internal PFM / OI



Increased IRD with
active contraction
Oblique dominance?
 Soft tissue
restrictions?


Soft tissue work


Outcomes
Neuro re-ed Sahrmann
& Kinetic Control
exercises
Education – healthy
bladder habits



Infrasternal angle
decreased to 90°
IRD no longer increases
with active contraction;
IRD at rest unchanged
Ran marathon; no pain
with running by doing
pre / post exercises
Bladder emptying every
3 hours
Pain free intercourse
9
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