Diastasis Recti

Picture from Lamaze.org

I saw a patient this week who had given birth to her second child about 3 months ago. Her friend told her that her belly was sticking out and the bulge may remain for months or years post partpartum. 

She has diastasis recti of about 2 fingers width. She was afraid that she would have low back pain and incontinence if the diastasis recti was not corrected.

Diastasis recti (DR) is the separation of the rectus abdominis (or 6-pack ab) muscles during and after pregnancy. The rectus abdominis runs in a straight line along the front of your stomach. A band of connective tissue called the linea alba divides the rectus abdominis into left and right sides. In simple terms it is the separation of the six-pack muscles into 2 halves.

It happens when the rectus abdominis muscles separate during pregnancy after being stretched. The linea alba becomes thinner and gets wider as it gets pushed by the uterus when it expands. The criteria for the diagnosis of DR is a gap or separation of more than 1.5 cm at one or more points of the linea alba.

Here is how I measure/check for the tummy gap. I get my patient to lie supine with knees bent and hip width apart. I place 2 fingers above her belly button. Then I get her to slowly lift her head, neck and shoulders off the bed like a low level sit-up. I then move my fingers below and above the belly button length wise and feel for any gaps and whether I can fit more than 2 fingers width wise. It's easy to feel for the gap this way.

After the baby is delivered, the linea alba can retract as the connective tissue is highly elastic. It can retract (like a rubber band). This usually happens for some new mums, the linea alba repairs itself within 10-12 weeks. However, when the linea alba loses its elasticity from being overstretched (larger babies) and/ or from a second and third pregnancy, the gap widens in the rectus abdominis.

Many patients have been told (by healthcare practitioners) that if DR continues after 10-12 weeks, their stomach/ core muscles cannot function efficiently and cannot properly support the lumbar spine (low back) or stomach contents. 

These same healthcare practitioners that treat diastasis recti will NOT be happy reading what I write next. Yes, women with DR may have weaker abdominal muscles (and perhaps more abdominal pain) BUT no higher prevalence of pelvic floor disorders (or incontinence), low back pain and pelvic girdle (hip) pain than women without DR (Gluppe et al, 2021). 

In fact, subgroup analyses comparing women with severe and moderate DR to women without DR showed no difference in abdominal strength, pelvic floor disorders (incontinence), low back pain, pelvic girdle and abdominal pain (Gluppe et al, 2021). This is actually the first study to investigate possible consequences of DR in a subgroup of women with moderate to severe diastasis.

I did not come up with that. There are many published research contrasting all that BS (excuse my language) about getting low back pain if you don't 'fix' your diastasis recti (Benjamin et al, 2019).

These studies contradict the common belief there there is an association between diastasis recti and pelvic floor disorders.  It does not mean that you definitely need treatment if you have a gap in your tummy after giving birth. Do not allow others to frighten you by saying that you will have back aches/ pain, weak core, hip, pelvic girdle pain and even incontinence if you don't 'fix' it.

So did I manage to reduce the tummy gap in my patient? I did and that may have to be a different post.

References

Benjamin DR, Frawlwy HC, Shields N et al (2019). Relationship Between Diastasis Of The Rectus Abdominis Muscle And Musculoskeletal Dysfunctions, Pain And Quality Of Life: A Systematic Review. 105(1): 24-34. DOI: 10.1016/j.physio.2018.07.002

Giuppe S, Engh ME and Bo K (2021). Women With Diastasis Recti Abdominis Might Have Weaker Abdominal Muscles And More Abdominal Pain, But No Higher Prevalence Of Pelvic Floor Disorders, Low Back And Pelvic Girdle Pain Than Women Without Diastasis Recti Abdominis. Physiotherapy. 111:57-65. DOI: 10.1016/j.physio.2021.01.008

*Thanks to Kaylee and Vean for getting me the articles

Is Yoga Helpful For Low Back Pain?

Please let me be clear, I have nothing against anyone doing yoga or any yoga instructors. I'm just sharing what I read from a published Cochrane review.

This latest Cochrane review that was just published 2 days ago, evaluated whether yoga was beneficial or harmful for treatment of non specific low back pain. Review articles from the Cochrane Database of Systematic Reviews are highly respected and trusted.

The review wanted to find out if yoga helps improve function (getting dressed, walking or housework), quality of life and pain associated with low back pain. Medical databases searched for randomized controlled trials of yoga compared to sham (fake) yoga, no treatment, any other treatment and yoga added to other treatment.

Altogether 21 trials with 2223 participants (mostly women in their 40's or 50's) were found. 10 trials from USA, 5 from India, 2 form UK and 1 each from Crotia, Germany, Sweden and Turkey.

10 studies compared yoga to no exercise control group which received usual education and were put on a waiting list for yoga. 6 studies compared yoga to back-focused exercise or similar core exercise programs.  5 studies compared yoga, no exercise and qigong.

At 3 months, there was low to moderate evidence that yoga was slightly better than no exercise in improving back function and pain, although the difference were not sufficiently important to the person with low back pain. 

There was low quality evidence for better clinical improvement with yoga while there was moderate quality evidence for a slight improvement in both physical (able to be active) and mental (emotional problems) quality of life.  Evidence was of very low quality for helping depression. In addition there was moderate quality evidence that there was little or no difference between yoga and other types of exercise in improving back function and pain.

Increased low back pain was the most commonly reported 'harmful' reaction and there were no reported cases of serious side effects. There was low quality evidence that the risk of harm was higher with yoga than no exercise and back-focused exercise.

No studies comparing yoga to sham yoga were found, so there is no evidence how yoga would affect low back pain if people did not know they were doing yoga. All the participants knew they were doing yoga and this may influence their interpretation of whether their back pain has changed.

There you have it, quite different from what you have been told, heard or read. Our goal is to help patients confidently take up different movement, postures, physical activity, social and work engagement so you can can a healthy and pain free life.

There are free educational resources to support these processes if you do have low back pain and have not seen us in our clinics.

You can watch this Youtube video or visit this site for more details. This will help reduce stress and build self sufficiency for you to better self manage your LBP and make better informed choices about your care.

Our spine is strong, robust and adaptable. A campaign to change this may encounter resistance even in the physiotherapy and ergonomic professions as their business model may not be in line with what we now know to be best practice for managing low back pain.

So here's my take, whether it's yoga, pilates, stationary cycling or any exercise, it is your choice, as long as you keep doing it consistently, it will help your low back pain. Find an exercise you enjoy and keep at it. 

Reference

Wieland LS, Skoetz N, Pilkington K et al (2022). Yoga For Chronic Non-specific Low Back Pain. Cochrane Database of Systematic Reviews. Issue 11. Art. No : CD010671. DOI: 10.1002/1465.CD010671

Stationary Cycling Just As Good As Pilates For Chronic Low Back Pain?

The Pilates instructors reading this post along with those of you who do Pilates aren't gonna like me a lot, not with a heading like the one above. But before you get upset, please let me be clear, I have nothing against anyone doing Pilates or any Pilates instructors. I'm just sharing what I read from a published study.

This study compared the effects of specific trunk exercises (or Pilates) versus stationary cycling on subjects with chronic non specific low back pain. 

One group was randomized to undergo specific trunk exercises (SEG) for 8 weeks while the other group did stationary cycling (CEG). The SEG group performed Pilates with attention to muscle control, posture and breathing. 

THE CEG group were informed that they were performing a style of cycling called Pilates Pedal. This is to reduce bias so that their group will not wonder why their exercise program did not include trunk specific exercises. Look at the diagram below, you will see that the CEG group just did a mixture of mixed resistance cycling and no core exercises.

Pain was reduced in both groups after exercises compared to the start of the study. Even though disability was significantly lower in the SEG group compared to the CEG group after 8 weeks, the overall data pattern suggested no long term differences between both groups 6 months later.

Fear-avoidance beliefs (FAB) or activity avoidance behavior scores were lower in the SEG group at 8 weeks only, the CEG group had lower FAB scores at 6 months.

The authors concluded that an 8-week supervised group of Pilates had only better short term but not long term clinically meaningful improvements compared to stationary bike cycling.  

If a patient with chronic non specific low back pain stick to either Pilates or stationary cycling (or any exercise program  for that matter), similar improvements will be achieved as long as a minimal level of adherence is maintained.

If you look in detail at the baseline scores for pain and disability, you will notice they were mild to moderate. Hence, results from this study may not be transferable to those with severe back pain and disability.

Pilates or stationary bike cycling (or any general exercise), your choice really, as along as you stick to it, will help with your recurrent low back pain. Find exercises you enjoy and keep at it.

Reference

Marshall PWM, Kennedy S, Brooks C et al (2013). Pilates Exercise Or Stationary Cycling For Chronic Nonspecific Low Back Pain. Does It Matter? A Randomized Controlled Trial With 6-Month Follow-up. Spine. 38(15): 952-959. DOI: 10.1097/BRS.0b013e318297c1c5.

*thanks to Byron Tan who got me the article. Email me if you like to have a look at the article

Transverse Abdominis and Low Back Pain

I remember being a second year physiotherapy student in the early 90's when we had a special tutorial on how to assess and strengthen the Transverse Abdominis (TA). While in crook lying, you move your leg (bent knee fall out), leg straightening etc and had to maintain the TA contraction.

This was just before a young Paul Hodges and his supervisor Carolyn Richardson (both very famous physiotherapists) published his article on the TA. His research compared the timing of TA and Multifidus in people with low back pain (LBP) for 18 months or more against healthy subjects with no LBP.

Using fine wire and surface EMG, the participants had to move their leg or shoulder and their timing of TA and Multifidus muscles measured. Those with LBP had delayed activation of their TA/ Multifidus.

Hodges suggested that the TA was the likely to be the main cause of LBP as it is the most important and deepest muscle in the abdomen. It looks and works like a corset to stabilise the back.

This article made the allied healthcare/ fitness industry conclude that the TA was a trunk stabilising muscle that was very important to strengthen for those with LBP. Patients who had LBP had weaknesses in their TA which led to instability in the spine.

Because of Hodges' research, many other research on LBP went in that direction. However, out of the seven systematic reviews found, six of them now showed no increase in benefit in such TA based exercises over general exercises. Further research is probably not going to significantly alter this.

As I wrote last week, this early work by Hodges, Richardson and Gwen Jull was quickly adopted by the fitness industry (though Joseph Pilates never intended this). The Allied Health/ Physiotherapy community started assessing the TA via palpation, ultrasound etc and coming up with various rehabilitation exercises for it as well. There are various continuing education courses teaching this approach still.

Although research says this may help, it is no better than general graded exercise and we know that LBP is also associated with obesity and mental health (Maher et al, 2016).

There is even research advising those who have been trained to brace/ hollow their 'core' should be discouraged from doing this as this may create abnormal movement patterns creating more stress on the spine (Lederman et al, 2010).

Brace or hollow your core?

So rather than getting our patients to feel for a deep muscle (like the TA and Multifidus) in a low load movement, it would make more sense for us to get patients to do an exercise/ activity they enjoy that gives them similar benefits.


References

Hodges PA and Richardson CA (1998). Delayed Postural Contraction Of Transversus Abdominis In Low Back Pain Associated With Movement Of The Lower Limb. J Sp Disorders. 11(1): 46-56.

May S and Johnson R (2006). Stabilisation Exercises For Low Back Pain: A Systematic Review. Physiotherapy. 94(3): 179-189. DOI: 10.1016/j.physio.2007.08.010

Maher CG, Underwood M et al (2016). Non-specific Low Back Pain. The Lancet. 389(10070): 736-747. DOI: 10.1016/S0140-6736(16)30970-9

Lederman E (2010). The Myth Of Core Stability. J of Bodywork, Mvt Ther. 14(1); 84-98. DOI: 10.1016/jbmt.2009.08.001

Saragitto B, Maher CG et al (2016). Motor Control Exercise For Nonspecific Low Back Pain. A Cochrane Review. Spine 41(16): 1288-1295. DOI: 10.1097/BRS.0000000000001645

10 Helpful Facts About Low Back Pain

Favia Dubyk on her hangboard

Last week I discussed the myths about low back pain (LBP). This week I will write about 10 helpful facts about LBP once anything sinister and serious pathology are excluded. A positive mindset regarding LBP definitely helps with lower pain levels, disability and seeking healthcare.

Fact 1: LBP is not a serious life-threatening condition.

Fact 2: Most episodes of LBP improve and LBP does not get worse as we age.

Fact 3: A negative mindset, fear-avoidance behavior, negative recovery expectations, and poor pain coping behaviors are more strongly associated with persistent pain than is tissue damage.

Fact 4: Scans do not determine prognosis of LBP, the likelihood of future LBP disability, and do not improve LBP clinical outcomes.

Fact 5: Graduated exercise and movement in all directions is safe and healthy for the spine.

Fact 6: Spine posture during sitting, standing and lifting does not predict LBP or its persistence.

Fact 7: A weak core does not cause LBP, and some people with LBP tend to overtense their core muscles. while it is good to keep the trunk muscles strong, it is also helpful to relax them when they aren't needed.

Fact 8: Spine movement and loading is safe and builds structural resilience when it is graded.

Fact 9: Pain flare-ups are more related to changes in activity, stress and mood rather than structural damage.

Fact 10: Effective care for LBP is relatively cheap and safe. This includes: education that is patient-centered and fosters a positive mindset, and coaching people to optimize their physical and mental health (such as engaging in physical activity and exercise, social activities, healthy sleep habits and body weight, and remaining in employment.

There you have it. Quite different from what you have been told, read or heard. We seek to help patients confidently take up different postures, movement, graded loading physical activity, social and work engagement so you can live healthily. There are free educational resources to support these processes if you do have low back pain and have not seen us in our clinics.

You can watch this Youtube video or visit this site for more details. This will help reduce stress and build self sufficiency for you to better self mange your LBP and make better informed choices about your care.

In my next post, I will address how strengthening your 'core' (Transverse Abdominis and Multifidus) muscles was rapidly adopted by the Pilates, Physiotherapy and fitness community and if we should continue down that path.


References

Lin I, Wiles L, Waller R et al (2019). What does Best Practice care for Musculoskeletal Pain Look Like? Eleven Consistent Recommendations From High-quality Clinical Practice Guidelines: Systematic Review. BJSM. DOI: 10.1136/bjsports-2018-099878

O' Sullivan PB, Caneiro JP et al (2019). Back To Basics: 10 Facts Every Person Should Know About Back Pain. BJSM. DOI: 10.1136/bjsports-2019-101611.