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Journal of Physiotherapy Jul 2023What is the effect of a 12-week, home-based, abdominal exercise program containing head lifts and abdominal curl-ups on inter-recti distance (IRD) in women with... (Randomized Controlled Trial)
Randomized Controlled Trial
Curl-up exercises improve abdominal muscle strength without worsening inter-recti distance in women with diastasis recti abdominis postpartum: a randomised controlled trial.
QUESTION
What is the effect of a 12-week, home-based, abdominal exercise program containing head lifts and abdominal curl-ups on inter-recti distance (IRD) in women with diastasis recti abdominis (DRA) 6 to 12 months postpartum? What is the effect of the program on: observed abdominal movement during a curl-up; global perceived change; rectus abdominis thickness; abdominal muscle strength and endurance; pelvic floor disorders; and low back, pelvic girdle and abdominal pain?
DESIGN
This was a two-arm, parallel-group, randomised controlled trial with concealed allocation, assessor blinding and intention-to-treat analysis.
PARTICIPANTS
Seventy primiparous or multiparous women 6 to 12 months postpartum, having a single or multiple pregnancy following any mode of delivery, with a diagnosis of DRA (IRD > 28 mm at rest or > 25 mm during a curl-up).
INTERVENTION
The experimental group was prescribed a 12-week standardised exercise program including head lifts, abdominal curl-ups and twisted abdominal curl-ups 5 days a week. The control group received no intervention.
OUTCOME MEASURES
The primary outcome measure was change in IRD measured with ultrasonography. Secondary outcomes were: observed abdominal movement during a curl-up; global perceived change; rectus abdominis thickness; abdominal muscle strength and endurance; pelvic floor disorders; and low back, pelvic girdle and abdominal pain.
RESULTS
The exercise program did not improve or worsen IRD (eg, MD 1 mm at rest 2 cm above the umbilicus, 95% CI -1 to 4). The program improved rectus abdominis thickness (MD 0.7 mm, 95% CI 0.1 to 1.3) and strength (MD 9 Nm, 95% CI 3 to 16) at 10 deg; its effects on other secondary outcomes were trivial or unclear.
CONCLUSION
An exercise program containing curl-ups for women with DRA did not worsen IRD or change the severity of pelvic floor disorders or low back, pelvic girdle or abdominal pain, but it did increase abdominal muscle strength and thickness.
REGISTRATION
NCT04122924.
Topics: Pregnancy; Female; Humans; Rectus Abdominis; Pelvic Floor Disorders; Abdominal Muscles; Postpartum Period; Exercise Therapy; Diastasis, Muscle; Abdominal Pain
PubMed: 37286390
DOI: 10.1016/j.jphys.2023.05.017 -
Arthroscopy : the Journal of... Dec 2020Often referred to as a "sports hernia" or "core muscle injury," athletic pubalgia is a common yet poorly defined athletic injury. It is characterized by abdominal and...
Often referred to as a "sports hernia" or "core muscle injury," athletic pubalgia is a common yet poorly defined athletic injury. It is characterized by abdominal and groin pain likely from weakening or tearing of the abdominal wall without evidence of a true hernia. Symptoms can appear acutely or insidiously, primarily as groin and lower abdominal pain that can radiate toward the perineum and proximal adductors. Pain is exacerbated by athletic activity such as kicking, cutting, and sprinting. The pubis acts as a pivot point between the abdominal musculature and lower-extremity adductors, and therefore, pain with palpation over the symphysis or its surrounding structures is typical in athletic pubalgia. Symptoms can be reproduced during a resisted sit-up or with a forced cough or sneeze. Clinical examination should include an evaluation of articular hip pathology to identify underlying femoroacetabular impingement syndrome. Magnetic resonance imaging can aid in ruling out other pathologies and identify specific findings including tears or strains of the ipsilateral rectus abdominis or adductor tendons. Lidocaine injections can be used to localize the source of the pain. First-line treatment consists of a period of rest and anti-inflammatories, followed by a course of focused physical therapy. If conservative therapy fails to allow an athlete to return to activity, a variety of open or laparoscopic surgical techniques can be used. The surgical principles include reattachment of the rectus abdominis and repair or reinforcement of the abdominal musculature in layers to re-create the inguinal ligament anatomy. At times, variations of pelvic floor repair are performed or the addition of an adductor tenotomy or repair is used concomitantly. Numerous studies report a high rate of return to play after surgical management. Diagnosis and appropriate treatment of coexisting femoroacetabular impingement syndrome are crucial to a successful return to athletic activity.
Topics: Abdominal Pain; Athletes; Athletic Injuries; Femoracetabular Impingement; Groin; Hernia, Abdominal; Herniorrhaphy; Humans; Magnetic Resonance Imaging; Male; Physical Examination; Pubic Bone; Rectus Abdominis; Tendons; Tenotomy
PubMed: 33276883
DOI: 10.1016/j.arthro.2020.09.022 -
Journal of Cachexia, Sarcopenia and... Feb 2023Muscle ultrasound is an emerging tool for diagnosing sarcopenia. This review aims to summarize the current knowledge on the diagnostic test accuracy of ultrasound for... (Meta-Analysis)
Meta-Analysis Review
Muscle ultrasound is an emerging tool for diagnosing sarcopenia. This review aims to summarize the current knowledge on the diagnostic test accuracy of ultrasound for the diagnosis of sarcopenia. We collected data from Ovid Medline, Embase and the Cochrane Central Register of Controlled Trials. Diagnostic test accuracy studies using muscle ultrasound to detect sarcopenia were included. Bivariate random-effects models based on sensitivity and specificity pairs were used to calculate the pooled estimates of sensitivity, specificity and the area under the curves (AUCs) of summary receiver operating characteristic (SROC), if possible. We screened 7332 publications and included 17 studies with 2143 participants (mean age range: 52.6-82.8 years). All included studies had a high risk of bias. The study populations, reference standards and ultrasound measurement methods varied across the studies. Lower extremity muscles were commonly studied, whereas muscle thickness (MT) was the most widely measured parameter, followed by the cross-sectional area (CSA). The MTs of the gastrocnemius, rectus femoris, tibialis anterior, soleus, rectus abdominis and geniohyoid muscles showed a moderate diagnostic accuracy for sarcopenia (SROC-AUC 0.83, 8 studies; SROC-AUC 0.78, 5 studies; AUC 0.82, 1 study; AUC 0.76-0.78, 2 studies; AUC 0.76, 1 study; and AUC 0.79, 1 study, respectively), whereas the MTs of vastus intermedius, quadriceps femoris and transversus abdominis muscles showed a low diagnostic accuracy (AUC 0.67-0.71, 3 studies; SROC-AUC 0.64, 4 studies; and AUC 0.68, 1 study, respectively). The CSA of rectus femoris, biceps brachii muscles and gastrocnemius fascicle length also showed a moderate diagnostic accuracy (AUC 0.70-0.90, 3 studies; 0.81, 1 study; and 0.78-0.80, 1 study, respectively), whereas the echo intensity (EI) of rectus femoris, vastus intermedius, quadriceps femoris and biceps brachii muscles showed a low diagnostic accuracy (AUC 0.52-0.67, 2 studies; 0.48-0.50, 1 study; 0.43-0.49, 1 study; and 0.69, 1 study, respectively). The combination of CSA and EI of biceps brachii or rectus femoris muscles was better than either CSA or EI alone for diagnosing sarcopenia. Muscle ultrasound shows a low-to-moderate diagnostic test accuracy for sarcopenia diagnosis depending on different ultrasound parameters, measured muscles, reference standards and study populations. The combination of muscle quality indicators (e.g., EI) and muscle quantity indicators (e.g., MT) might provide better diagnostic test accuracy.
Topics: Humans; Middle Aged; Aged; Aged, 80 and over; Sarcopenia; Quadriceps Muscle; Ultrasonography; Rectus Abdominis; Diagnostic Tests, Routine
PubMed: 36513380
DOI: 10.1002/jcsm.13149 -
Brazilian Journal of Physical Therapy 2021Diastasis recti abdominis (DRA) affects a significant number of women in the postpartum period. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Diastasis recti abdominis (DRA) affects a significant number of women in the postpartum period.
OBJECTIVE
To systematically review whether abdominal and pelvic floor muscle (PFM) exercise programs are effective in the treatment of DRA postpartum.
METHODS
Electronic search was conducted from inception to March 2020. Randomized controlled trials (RCT) or pilot RCTs that compared abdominal training, PFM training, or a combination of both in at least one arm of the trial were included. The primary outcome was presence of DRA (numbers/percentage) or inter-recti distance (IRD) change. GRADE was used to rate the overall quality of evidence. Pooled effect sizes were expressed as mean difference (MD) with 95% confidence intervals (CI).
RESULTS
Seven RCTs totaling 381 women were included. Two studies comparing transversus abdominis (TrA) training with minimal intervention provided data to be included in a meta-analysis. The results provided very low level quality evidence that TrA training reduced IRD (MD = -0.63 cm, 95% confidence interval: -1.25, -0.01, I = 0%). Two studies included curl-up exercises as part of their intervention. Level of evidence based on single trials of high risk of bias show very low evidence that curl-up training is more effective than minimal intervention for treating DRA. Similarly, analyses based on single trials provided low to very low quality evidence that PFM training is not more effective than minimal intervention for treating DRA.
CONCLUSION
There is currently very low-quality scientific evidence to recommend specific exercise programs in the treatment of DRA postpartum.
Topics: Diastasis, Muscle; Exercise Therapy; Female; Humans; Pelvic Floor; Postpartum Period; Randomized Controlled Trials as Topic; Rectus Abdominis
PubMed: 34391661
DOI: 10.1016/j.bjpt.2021.06.006 -
The British Journal of Surgery Oct 2021The definition, classification and management of rectus diastasis (RD) are controversial in the literature and a variety of different surgical treatments have been...
BACKGROUND
The definition, classification and management of rectus diastasis (RD) are controversial in the literature and a variety of different surgical treatments have been described. This article reports on the European Hernia Society (EHS) Clinical Practice Guideline for RD.
METHOD
The Guideline group consisted of eight surgeons. The Grading of Recommendation, Assessment, Development and Evaluation (GRADE) approach and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument were used. A systematic literature search was done in November 2018 and updated in November 2019 and October 2020. Nine Key Questions (KQs) were formulated.
RESULTS
Literature reporting on the definition, classification, symptoms, outcomes and treatments was limited in quality, leading to weak recommendations for the majority of the KQs. The main recommendation is to define RD as a separation between rectus muscles wider than 2 cm. A new classification system is suggested based on the width of muscle separation, postpregnancy status and whether or not there is a concomitant hernia. Impaired body image and core instability appear to be the most relevant symptoms. Physiotherapy may be considered before surgical management. It is suggested to use linea alba plication in patients without concomitant hernia and a mesh-based repair of RD with concomitant midline hernias.
CONCLUSION
RD should be defined as a separation of rectus muscles wider than 2 cm and a new classification system is suggested.
Topics: Hernia, Umbilical; Hernia, Ventral; Herniorrhaphy; Humans; Physical Therapy Modalities; Postoperative Care; Rectus Abdominis; Surgical Mesh
PubMed: 34595502
DOI: 10.1093/bjs/znab128 -
The American Journal of Sports Medicine Mar 2023Pain in the groin region, where the abdominal musculature attaches to the pubis, is referred to as a "sports hernia,""athletic pubalgia," or "core muscle injury" and has... (Review)
Review
BACKGROUND
Pain in the groin region, where the abdominal musculature attaches to the pubis, is referred to as a "sports hernia,""athletic pubalgia," or "core muscle injury" and has become a topic of increased interest due to its challenging diagnosis. Identifying the cause of chronic groin pain is complicated because significant symptom overlap exists between disorders of the proximal thigh musculature, intra-articular hip pathology, and disorders of the abdominal musculature.
PURPOSE
To present a comprehensive review of the pathoanatomic features, history and physical examination, and imaging modalities used to make the diagnosis of core muscle injury.
STUDY DESIGN
Narrative and literature review; Level of evidence, 4.
METHODS
A comprehensive literature search was performed. Studies involving the diagnosis, treatment, and rehabilitation of athletes with core muscle injury were identified. In addition, the senior author's extensive experience with the care of professional, collegiate, and elite athletes was analyzed and compared with established treatment algorithms.
RESULTS
The differential diagnosis of groin pain in the athlete should include core muscle injury with or without adductor longus tendinopathy. Current scientific evidence is lacking in this field; however, consensus regarding terms and treatment algorithms was facilitated with the publication of the Doha agreement in 2015. Pain localized proximal to the inguinal ligament, especially in conjunction with tenderness at the rectus abdominis insertion, is highly suggestive of core muscle injury. Concomitant adductor longus tendinopathy is not uncommon in these athletes and should be investigated. The diagnosis of core muscle injury is a clinical one, although dynamic ultrasonography is becoming increasingly used as a diagnostic modality. Magnetic resonance imaging is not always diagnostic and may underestimate the true extent of a core muscle injury. Functional rehabilitation programs can often return athletes to the same level of play. If an athlete has been diagnosed with athletic pubalgia and has persistent symptoms despite 12 weeks of nonoperative treatment, a surgical repair using mesh and a relaxing myotomy of the conjoined tendon should be considered. The most common intraoperative finding is a deficient posterior wall of the inguinal canal with injury to the distal rectus abdominis. Return to play after surgery for an isolated sports hernia is typically allowed at 4 weeks; however, if an adductor release is performed as well, return to play occurs at 12 weeks.
CONCLUSION
Core muscle injury is a diagnosis that requires a high level of clinical suspicion and should be considered in any athlete with pain in the inguinal region. Concurrent adductor pathology is not uncommon.
Topics: Humans; Athletic Injuries; Hernia; Chronic Pain; Magnetic Resonance Imaging; Groin; Tendinopathy; Athletes; Rectus Abdominis
PubMed: 35234538
DOI: 10.1177/03635465211063890 -
Hernia : the Journal of Hernias and... Aug 2021Diastasis recti abdominis (DRA) or rectus diastasis is an acquired condition in which the rectus muscles are separated by an abnormal distance along their length, but... (Review)
Review
PURPOSE
Diastasis recti abdominis (DRA) or rectus diastasis is an acquired condition in which the rectus muscles are separated by an abnormal distance along their length, but with no fascia defect. To data there is no consensus about risk factors for DRA. The aim of this article is to critically review the literature about prevalence and risk factor of DRA.
METHOD
A total of 13 papers were identified.
RESULTS
The real prevalence of DRA is unknown because the prevalence rate varies with measurement method, measurement site and judgment criteria, but it is certainly an extremely frequent condition. Numbers of parity, BMI, diabetes are the most plausible risk factors. We identified a new anatomical variation in cadaveric dissection and in abdominal CT image evaluation: along the semilunar line the internal oblique aponeurosis could join the rectus sheath with only a posterior layer, so without a double layer (anterior and posterior) as usually described. We conducted a retrospective review of abdominal CT images and the presence of the posterior insertion only could be considered as a risk factor for DRA.
CONCLUSION
Further studies with large sample size, including nulliparous, primiparous, pluriparous and men too, are necessary for identify the real prevalence.
Topics: Female; Herniorrhaphy; Humans; Male; Pregnancy; Prevalence; Rectus Abdominis; Retrospective Studies; Risk Factors
PubMed: 34363190
DOI: 10.1007/s10029-021-02468-8 -
Scandinavian Journal of Surgery : SJS :... Sep 2021Diastasis of the rectus abdominis muscle is a common condition. There are no generally accepted criteria for diagnosis or treatment of diastasis of the rectus abdominis...
BACKGROUND
Diastasis of the rectus abdominis muscle is a common condition. There are no generally accepted criteria for diagnosis or treatment of diastasis of the rectus abdominis muscle, which causes uncertainty for the patient and healthcare providers alike.
METHODS
The consensus document was created by a group of Swedish surgeons and based on a structured literature review and practical experience.
RESULTS
The proposed criteria for diagnosis and treatment of diastasis of the rectus abdominis muscle are as follows: (1) Diastasis diagnosed at clinical examination using a caliper or ruler for measurement. Diagnostic imaging by ultrasound or other imaging modality, should be performed when concurrent umbilical or epigastric hernia or other cause of the patient's symptoms cannot be excluded. (2) Physiotherapy is the firsthand treatment for diastasis of the rectus abdominis muscle. Surgery should only be considered in diastasis of the rectus abdominis muscle patients with functional impairment, and not until the patient has undergone a standardized 6-month abdominal core training program. (3) The largest width of the diastasis should be at least 5 cm before surgical treatment is considered. In case of pronounced abdominal bulging or concomitant ventral hernia, surgery may be considered in patients with a smaller diastasis. (4) When surgery is undertaken, at least 2 years should have elapsed since last childbirth and future pregnancy should not be planned. (5) Plication of the linea alba is the firsthand surgical technique. Other techniques may be used but have not been found superior.
DISCUSSION
The level of evidence behind these statements varies, but they are intended to lay down a standard strategy for treatment of diastasis of the rectus abdominis muscle and to enable uniformity of management.
Topics: Abdominal Core; Abdominal Wall; Female; Hernia, Ventral; Humans; Pregnancy; Rectus Abdominis; Sweden
PubMed: 32988320
DOI: 10.1177/1457496920961000 -
Physical Therapy May 2022The objectives of this Perspective paper are to educate physical therapists on their important role in assessing and treating common pregnancy- and delivery-related... (Review)
Review
ABSTRACT
The objectives of this Perspective paper are to educate physical therapists on their important role in assessing and treating common pregnancy- and delivery-related health conditions and to advocate for their routine inclusion in postpartum care during the fourth trimester. Pelvic floor dysfunction (PFD) and diastasis recti abdominis (DRA) are 2 examples of musculoskeletal disorders associated with pregnancy and childbirth that can have negative physical, social, and psychological consequences. This paper reviews evidence from 2010 through 2021 to discuss the efficacy of physical therapist intervention in the fourth trimester for PFD and DRA. The role of physical therapy in the United States is compared with its role in other developed nations, with the intent of illustrating the potential importance of physical therapy in postpartum care. Evidence shows physical therapy is an effective, low-risk, therapeutic approach for PFD and DRA; however, physical therapists in the United States currently have a peripheral role in providing postpartum care. Lack of awareness, social stigma, and policy barriers prevent women from receiving physical therapist care. Recommendations are made regarding ways in which physical therapists can increase their involvement in the fourth trimester within their community, stimulate policy change, and promote improved postpartum care practices.
IMPACT
This Perspective highlights the valuable role of physical therapist assessment and treatment during the postpartum period for some common musculoskeletal conditions associated with pregnancy and delivery.
Topics: Diastasis, Muscle; Female; Humans; Physical Therapy Modalities; Postnatal Care; Postpartum Period; Pregnancy; Rectus Abdominis
PubMed: 35225339
DOI: 10.1093/ptj/pzac021 -
International Journal of Environmental... Sep 2019Most of the studies evaluating core muscle activity during exercises have been conducted with healthy participants. The objective of this study was to compare core...
Most of the studies evaluating core muscle activity during exercises have been conducted with healthy participants. The objective of this study was to compare core muscle activity and tolerability of a variety of dynamic and isometric exercises in patients with non-specific low back pain (NSLBP). 13 outpatients (average age 52 years; all with standing or walking work in their current or latest job) performed 3 consecutive repetitions at 15-repetition maximum during different exercises in random order. Surface electromyography was recorded for the rectus abdominis; external oblique and lumbar erector spinae. Patients rated tolerability of each exercise on a 5-point scale. The front plank with brace; front plank and modified curl-up can be considered the most effective exercises in activating the rectus abdominis; with a median normalized EMG (nEMG) value of 48% (34-61%), 46% (26-61%) and 50% (28-65%), respectively. The front plank with brace can be considered the most effective exercise in activating the external oblique; with a nEMG of 77% (60-97%). The squat and bird-dog exercises are especially effective in activing the lumbar erector spinae; with nEMG of 40% (24-87%) and 29% (27-46%), respectively. All the exercises were well tolerated; except for the lateral plank that was mostly non-tolerated. In conclusion; the present study provides a variety of dynamic and isometric exercises; where muscle activity values and tolerability can be used as guide to design evidence-based exercise programs for outpatients with NSCLBP.
Topics: Adult; Back Muscles; Chronic Pain; Cross-Sectional Studies; Electromyography; Exercise Therapy; Female; Humans; Low Back Pain; Male; Middle Aged; Rectus Abdominis; Spain
PubMed: 31547140
DOI: 10.3390/ijerph16193509