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Case Reflection
Submitted to demonstrate competence as a Women’s Health Clinical Specialist (WCS)
Megan Cordes, PT, DPT, CLT, ARTIC
Case Rationale
Diastasis recti abdominis (DRA) is defined as a separation and thinning of the recti abdominis muscles and stretching of the linea alba1. This separation can occur anywhere along the linea alba and in some individuals has been found to span the entire length2-3. A DRA may jeopardize the function of the abdominal wall and lead to low back pain, altered posture and body mechanics, pelvic girdle pain, urinary incontinence as well as cosmetic defects2-4. Severity of DRA ranges from mild which measures 2.5 to 3.4 cm wide, to severe, greater than 5 cm wide.This condition occurs most commonly during pregnancy1. Successful treatment for DRA has been researched and documented in individuals from the second trimester of pregnancy until 1 year post partum5-8; however research is deficient for those that are more than one year post partum and still experiencing complications associated with DRA.
The abdominal wall primarily consists of four paired muscles; the transverse abdominis (TA), the internal oblique, the external oblique, and the rectus abdominis (RA). Muscle fibers are oriented vertically, horizontally, and obliquely and are all connected to the thoracic cage superiorly, pelvis inferiorly, the linea alba aponeurosis anteriorly and the thoracolumbar fascia and spinal column posteriorly9-11. The linea alba is a fibrous raphe of connective tissue that extends from the xiphoid process to the pubic symphysis. It produces a basket-weave like effect which occurs when the abdominal muscles’ aponeuroses travel from one side of the abdomen to the other3,11-12. The abdominal wall serves to: protect the abdominal viscera; maintain the visceral position against changing gravitational forces; increase compartmental pressure; provide lumbopelvic stability and mobility; and assist with delivery of the fetus3 8,11,13.
As pregnancy progresses, multiple factors affect maternal trunk morphology and thus the abdominal wall and its function. Elevated levels of estrogen and progesterone contribute to increased vascularization of the uterus. This allows it to increase in size as the baby grows inside. The growth of the uterus adds additional internal abdominal pressure, thus increases the stress load to the abdominal musculature. As a result, this results in elongation of the RA as it stretches and curves around the abdominal wall. Likewise, increased relaxin, progesterone and estrogen levels allow for laxity and relaxation of the ligaments and connective tissue in the body. As a connective tissue, the linea alba is susceptible to these hormonal changes and this laxity can ultimately contribute to a weakened abdominal musculature1-4.
Boissinault reported that 27 percent of pregnant women demonstrate DRA in the second trimester and up to 66 percent will experience DRA by the end of the third trimester. In the immediate postpartum stage, 53 percent continue to demonstrate DRA and 36 percent demonstrate DRA up to seven weeks postpartum. The RA has been shown to be significantly thinner, wider, and to have a larger inter-rectus distance up to 12 months post-partum when compared to a nulliparous control group2,4,9,14. Although DRA has been observed after one year post-partum, current research lacks in successful treatment for this condition 1-3.
The purpose of this case report is to describe the physical therapy management of a patient with DRA two years post partum. Physical therapy has been shown as a conservative treatment, although the specifics of such treatment are not well defined in the literature. A successful intervention should specifically address the TA muscle and avoid the RA until the patient is able to recruit the TA properly2. Common treatments utilized by physical therapists include general TA muscle re-education, pelvic floor strength, and progression to functional tasks15.
Examination
Patient History:
The patient was a 34 year old Caucasian female referred by her OB-GYN for DRA and low back pain. The pain had begun 2 years prior during the second trimester of her second pregnancy and had decreased since delivery but not resolved completely. She also noted a “bulge” in her abdomen that had begun around the same time as her low back pain and not reduced since delivery.
Current Condition:
Her pain level reported was 4 out of 10 and worsened with increased activities such as lifting her daughters, running marathons, and participating in work-out classes. She also noted her pain was more intense in the evenings. She described the pain as a centralized, dull ache in her low back; she denied any radicular symptoms. She was avoiding activities that made the pain worse. She had previously been squatting 35 pounds during her Body Pump® class and running full marathons. She currently denied any urinary leaking with coughing, sneezing, or laughing; likewise she denied any leaking with increased urge to void or full bladder.
The patient reported that she had recently purchased a DVD workout series called MuTu® and had been doing this program for six weeks but noted no change in the pain or bulge. She had voiced her concern at her recent OB-GYN yearly appointment regarding the bulge and pain as well as the fact that there had been no change in her symptoms despite the 6 weeks of MuTu® exercises. Additionally, she told her OB-GYN that she was considering having another child, however did not want to worsen the back pain or increase the abdominal bulge. Based on her lack of progress on her own with exercise attempts as well as concerns regarding issues with an additional pregnancy, she was referred to physical therapy.
Medications:
She was not currently taking any medications other than ibuprofen occasionally for the back pain.
Medical/Surgical History:
She had progressed through full gestation for two pregnancies and delivered her first daughter via unplanned caesarian section on July 1, 2010. According to the patient, her first labor was not progressing and she developed a high fever contributing to fetal distress and thus lower uterine segment caesarian section was performed. She denied any other complications with this pregnancy or delivery. She underwent planned caesarian section on September 27, 2012 scheduled secondary to previous caesarian. Other past medical history was unremarkable.
Social History/Employment/Work:
The patient was married with a 2 year old and 4 year old daughter at home. Her 4 year old daughter weighed 23 pounds at the time of the evaluation. She was not employed outside the home and prior to her pregnancies had enjoyed running marathons and exercise classes such as Body Pump® and Body Combat®.
Personal Goals:
Her personal goals for physical therapy included:
1. Return to running marathons without pain in the back
2. Be able to lift at least 23# (weight of her youngest daughter) without pain
3. Return to work out regime including Body Pump® and Body Combat ®
4. Be instructed in comprehensive home program and educated on what “not to do”
5. Reduce anxiety regarding getting pregnant again without complications of back pain and more severe diastasis
REFLECTION
This case is good illustration of a women’s health specialty practice in physical therapy for a variety of reasons. First, the patient presented with low back pain, present for well over 2 years, which was likely due to a condition directly related to one or more of her pregnancies. Interestingly, 18.6% of patients that have undergone Caesarean section continue to have pain more than 3 months after delivery and 12.3% still have pain up to 10 months after surgery. This suggests that Caesarean section can contribute to chronic pain, especially considering that chronic pain has been defined as pain lasting more than a three month duration 16. It is likely that persistent pain post caesarian may occur as the incision can compromise the integrity of the abdominal wall and its functions of mobility and stability and thus contribute to increased incidence of DRA as well as other diagnosis such as pelvic girdle pain, urinary incontinence and sacro-iliac dysfunction1,9,16.
The patient had also enjoyed working out in a class setting lifting heavy weights repeatedly. This has also been shown to increase likelihood of DRA as a result of increased load on the RA in combination with increased intra-abdominal pressure1. Thus it was important to determine if her past exercise regime might be playing a role either in the development, worsening, or lack of improvement of both the DRA and subsequently her lower back pain. I was already familiar with the Les Mills Body® classes that she had previously been participating in. Body Pump® is an hour long exercise class targeting eight major muscle groups designed with weight lifting. Body Combat® is also an hour long class that utilizes a combination of karate, kick boxing, taekwondo, muay thai, and street fighting.
I was not familiar with the MuTU workout program the patient had been performing the 6 weeks prior to the therapy referral. More questioning of the patient regarding the MuTu® program would have been helpful in determining specifically what she had already been attempting to remedy her problem. Additionally, observation of her performing these activities in order to note any compensations she may have been utilizing that might be contributing to her chief complaints would have been appropriate. In preparation of this case study, I could not find any published research for this program, but did find information on its website. It is a 12 week DVD program with emphasis on TA in the post-partum individual and was developed by a fitness trainer who is also a mother 17. The website did not show the exercises that are provided in the DVD. Based on the information I discovered about this program, I further realize how important it is to familiarize myself as a therapist with the exercise program a patient is performing and how it might relate specifically to her condition.
The patient was a stay at home mother of two young daughters that she lifted repeatedly throughout the day. Repetitive lifting has been shown to increase intra-abdominal pressure placing more stress on the linea alba. This can contribute to increased spreading of the rectus abdominis muscles at the linea alba, progressing DRA18.Further questioning regarding how high she was lifting them and for what reason could have given better insight into the nature of her daily routine. Since the daughters were two and four, there is likelihood that they still used high chairs or booster seats for meals. The two year old could have possibly been still sleeping in a crib. Also, she should have still been using car seats for both children. The type of vehicle she drove and the make of car seat would make a difference on how high she was required to lift them. Questioning her regarding other daily activities she participated in would have been useful as well such as: number of outings daily, how many times the children ate and how many naps, or times of day the children were in bed. This would have determined how much, how high, and how often she was lifting.
Differential diagnosis for the patient should include disk herniation, nerve entrapment, pelvic girdle dysfunction, or spondylolisthesis19. Other systems should be cleared as well including gallbladder, appendix, ovarian cyst, or endometriosis. All of these diagnoses have been shown to refer pain to the low back and are possible considering her age and reports of back pain20. As she had been referred by her OB-GYN following her last yearly checkup, questioning and screening should have been done at that time to rule out ovarian cysts, cervical cancer or endometriosis; however I did not inquire about this information and in retrospect, should have as all of those pathologies can contribute to pain or refer to the low back19-20.
This patient reported several risk factors contributing to DRA including: multiple caesarian sections, heavy weight lifting, reports of abdominal “bulge”, and back pain towards the end of the day with repetitive lifting. Based on this, my working hypothesis was that the patient presents with DRA causing weakened abdominal support and observable bulge contributing to back pain with repetitive demanding daily activities.
Functional Outcomes Measure:
The Modified Oswestry was issued as a functional outcomes measure in order to measure disability associated with low back pain. She scored 4 out of 100 on it, indicating minimal dysfunction at the time of the initial evaluation. This measure indicated that the patient was able to lift heavy weights causing increased pain; however all other activities in this outcome measure were not problematic according to this patient.
REFLECTION
The most common complaint noted by patients presenting to the clinic with DRA is low back pain18. The Modified Oswestry has presented as the “gold standard” to examine dysfunction resulting from back pain21. Prior to the examination, the patient was administered the Modified Oswestry based on the referral of “low back pain”. She scored a very low score indicating minimal dysfunction. Scores that range from 1-20 indicate that the patient can cope with most daily activities and the suggested intervention is recommendations on lifting, exercise, and transitional movements. However, after listening to her chief complaints, I should have administered a more appropriate outcome measure. The Patient Specific Functional Scale (PSFS) has been found to be reliable and valid and would have been more fitting for her and likely shown more of a significant dysfunction22.
Objective Data/Evaluation
Postural Assessment:
The patient was observed to have an anterior pelvic tilt posture in stance.
REFLECTION
Weakness and elongation in the abdominals and gluteal musculature as well as limited flexibility in the hip flexors and lumbar extensors may contribute to anterior pelvic tilt posture10. Tight hip flexors contributing to anterior pelvic tilt can alter the mechanics of the RA leading to a decrease in leverage making it more difficult for this muscle to deal with load and promoting DRA10. The Thomas test could have been performed to confirm tightness in the hip flexors. This test is performed by having the patient sit on the edge of a plinth, then rolling back while holding both knees to the chest; one limb is lowered towards the floor while continuing to hold the opposite limb. Goniometric measurements are taken at the hip and knee joints and normal values required for pelvic and hip movement are 0 hip flexion and 90 knee flexion. Although reliability of the Modified Thomas test has been debatable, goniometric measurements have shown good inter-rater (0.86-0.93) and intra-rater (0.89-0.93) reliability for this test. This can provide important objective information regarding the flexibility of the ilio-psoas and allow the clinician to monitor progression23-26. `
Manual Muscle Testing:
Manual muscle testing of the RA and internal and external obliques all tested at 5/5 strength. Strength of hip adbducation, adduction, flexion and internal rotation were also graded at 5/5. Hip extension and external rotation were graded at 4/5.
REFLECTION
RA strength was tested with her in supine. I anchored her feet to the plinth manually and asked her to perform a sit up; she was able to rise without difficulty or struggle. Oblique muscles were graded similarly with her rising while performing a twist. These both graded as a 5/5 strength. Since she was noting pain with prolonged activity and lifting, testing of muscle endurance could have possibly shown more deficits here and provided a better overall picture of this patient. To evaluate trunk flexor endurance, the patient is positioned in a supine position with lower extremities raised to 90 hip and knee flexion. The patient is then measured on how long she can maintain this position with maximal cervical flexion and neutral pelvis; testing time not to exceed 5 minutes 27. This test was not performed in the initial evaluation, however could have potentially demonstrated deficits in muscle endurance contributing to this patients complaints of pain with prolonged activities.
A Trendelenburg stance or gait pattern was not assessed for at the initial evaluation, however with the weakness noted in hip external rotation; this should have been formally tested and documented if present. This test is performed in the standing position; the patient is asked to flex one hip to 30 while standing on the other leg. The pelvis should not tilt or rotate as the weight is shifted onto the supporting leg. Failure to maintain this position indicates a positive test and functional weakness in the gluteus medius and gluteus minimus. This has been proven both and accurate and reliable test28. The gluteus medius and minimus act together to abduct the hip and prevent external rotation during the single leg stance phase of gait. Excessive external rotation can contribute to back pain and dysfunctional load transfer through the pelvis during functional movements. These muscles work in combination with the TA and RA and provide support and stability during movement 29. Other patients I have treated with pelvic girdle pain, low back pain or DRA have also presented with weakness in the hip external rotators and a Trendelenburg stance.
Special Tests:
Table 1 reports all other testing that was performed, the reason the test was performed and the result of the test.
TABLE 1
Pathology Test Finding
Herniation of Disk Repeated Flexion Negative
Repeated Extension Negative
Nerve Entrapment/Dysfunction Straight Leg Raise Negative
Slump Test Negative
Load Transfer Tests Active Straight Leg Raise Negative
Stork Test Negative
Gillets Negative
Sacro-illiac Dysfunction Patrick’s FABERS Test Negative
Thigh Thrust Test Negative
Gaenslen’s Test Negative
REFLECTION
I quickly screened and ruled out disk herniation, Si dysfunction, load transfer dysfunction, and nerve root involvement. Based on her age and history, these diagnoses could not be dismissed and were required to be ruled out; however this group of testing performed is done in approximately 5 min collectively and has been shown to be reliable and valid30-31.
Diastasis Rectus Measurements:
DRA was measured with patient in hooklying supine position. The patient was asked to lift her shoulders and head from the mat and the linea alba was palpated and measured with a tape measure. Measurements were taken 4.5 cm above the umbilicus, at the umbilicus and 4.5 cm below the umbilicus. The findings are listed in table 2.
TABLE 2
Location Measurement
4.5 cm above the umbilicus 3.5 cm
Umbilicus 3.0 cm
4.5 cm below the umbilicus 1.5 cm
REFLECTION
Computed tomography and ultrasound are considered the gold standard for measurement of DRA; however these were unavailable for use in the clinic1,19,32. The most common measurement performed by clinicians is finger width; however, differing finger size amongst clinicians contributes to poor reliability of this method. Tape measurement is a practical and accurate means for measuring DRA in the clinic32. Boissonnault reported measure at 3 specific locations in order to maintain accuracy: 4.5 cm above the umbilicus, at the umbilicus and 4.5 cm below the umbilicus; consequently the reasoning for my measurements at these locations2,5.
The majority of DRA’s are noted at or above the umbilicus1-3. This patient presented with distal measures of 1.5 cm and considered “not significant” according to literature. The rectus sheath is strongest below the umbilicus because the aponeurosis of all the abdominal muscles crosses in front of the RA below the arcuate line. Normally, distal to the umbilicus, the RA is roughly only 1 cm apart, whereas at the umbilicus and proximally, the RA is roughly 2 cm apart. DRA’s are considered significant when greater than 2 cm anywhere along the entire linea alba; however this increased distal support should be taken into consideration when taking measurements and considering dysfunction2.
Functional Mobility:
The patient was also observed to perform supine to sit in RA dominate pattern of long sitting.
REFLECTION
Lack of TA activation with transitional movements places increased stress on the linea alba and promotes increased inter-rectus distance. I did not observe her perform lifting mechanics during the initial evaluation. Improper lifting mechanics can contribute to increased DRA and back pain1. This can be a combination of several contributing factors such as lack of core activation and support, improper center of gravity with lifting, muscle weakness or spasm29. Observation of her lifting to and from high chairs, lifting into and out of a crib or bed, and lifting into a car seat could have also given a better picture of dysfunctional body mechanics. While these exact items are not available in the clinic, setting up a scenario could have provided some evidence as to body mechanics with her lifting and any dysfunction that could be occurring as a result.
Integument
Scar tissue was noted just proximal to the mons pubis, 5 inches in length; no evidence of keloid, however distal ends demonstrate significant tissue restrictions.
REFLECTION
I did not perform a pelvic floor examination on this patient as she did not report any leaking or pelvic pain. Had she presented with these complaints, I would have. Since many patients that present to the clinic with DRA do have complaints of urinary incontinence, this is another objective measure that could be performed19. She did present with weakness in the hip external rotators; the obturator internus, one of the hip external rotators, provides direct support for the levator ani group of the pelvic floor. The noted weakness in the external rotators could potentially contribute to dysfunction of the pelvic floor. Based on time for the evaluation with this patient, and lack of her complaints of dysfunction in this region, I chose to not perform this at the time of the initial evaluation. If her noted complaints do not resolve then it is an aspect I could re-address in the future.
Evaluation/Physical Therapy Diagnosis
The patient presented with signs and symptoms of mild DRA. The limitations are noted in Table 3.
TABLE 3
Medical Diagnosis Low Back Pain
Diastasis Rectus
Physical Therapy Diagnosis Impaired muscle performance
Lack of coordination
Impairments Lack of motor control of TA
Dysfunctional muscle performance
Dysfunctional coordination of core muscles
Pain in the Low Back
Hip muscle weakness
Functional Limitations Lifting daughters
Running
Lifting weights
Clinical Goals:
The clinical goals were set to be achieved in and were as follows:
1. Patient will be able to demonstrate correct lifting techniques for at least 30# in order to lift children without pain or risk of injury in 6 weeks.
2. Patient will be able to demonstrate decreased DRA to < 2 cm throughout linea alba in order to prevent further complications with future pregnancy in 6 weeks.
3. Pt will be able to demonstrate supine to sit with correct mechanics in order to decrease overuse of rectus abdominis and thus abolish back pain when caring for her daughters in 3 weeks.
4. Patient will be complaint with home exercise program in order to resume running and doing Les Mills work out routines in 6 weeks.
REFLECTION
She did have what is considered a mild pathologic DRA at and above the umbilicus based on her measurements1. In combination with her anterior pelvic tilt posture, scar tissue restrictions and hip weakness, this could likely be the reason behind her back pain. This affirms the working hypothesis that her presentation of DRA is contributing to her back pain and abdominal bulge.
Prognosis:
It was anticipated that the patient be seen one time a week for six weeks with treatments lasting approximately sixty minutes and focus on home exercise program. Her only barrier to rehab was having two young children at home to find childcare for during her treatment times. She did not have any barriers to learning and was very motivated to participate in therapy. Her rehab potential was excellent based on this.
REFLECTION
This patient had been attempting to educate herself regarding DRA and treatments; however this had been unsuccessful according to the patient. Her exercise routines prior to pregnancy had promoted stronger musculature; however, because of her weight lifting and kickboxing activities with emphasis on the rectus abdominis she could have potentially had DRA prior to first pregnancy or even following first caesarean section. She may have never noticed it or it had not progressed to the point of back pain.
Intervention
During her initial evaluation, the patient was educated regarding anatomy of abdominal and core musculature and proper coordination of these muscles during functional movements. She was also trained on proper body mechanics with transitional movements and utilization of TA with functional activities (See appendix 1). She was instructed in the Elizabeth Nobel technique, otherwise known as DRA curl-up. This technique involves manual approximation of the RA while performing a partial sit up. She was instructed to lift her head and chin onto her chest while using a sheet to assist with RA closure (See Appendix 2); 10 repetitions above the umbilicus, 10 repetitions at the umbilicus and 10 repetitions below the umbilicus, three times a day. She was advised to avoid the Les Mills workouts at this time and focus on instructed home program. Additionally, she was instructed in scar massage with emphasis on the lateral edges where more restrictions were noted.
REFLECTION
Research demonstrates that a patient can gradually close DRA over 6 weeks with daily contractions, thus my rationale for duration of treatment. Abdominal work until the DRA demonstrates significant closure can contribute to further separating15. For this reason, I advised her to avoid the Les Mills work outs until she was able to properly utilize these core muscles as a functional unit. After demonstrating significant closure the patient can progress further abdominal work. I chose to see her once a week, because she was already body conscious and was able to isolate TA during the initial evaluation. Had she been unable to do so, I may have chosen to see her more frequently until this was demonstrated. She was also a stay at home mother and had to get child care during her appointment times. The less I had to have her come into the clinic, the easier it would be on her and her family, promoting better continuity and compliance. I chose to have her perform these three times a day. This helped prevent muscle fatigue and promote re-education of the TA musculature. Although this patient had been utilizing the MuTu® workouts, she demonstrated an anterior pelvic tilt posture and she was unable to differentiate TA contractions from pelvic tilting. Tactile cuing and visual imagery allowed her to perform TA contraction without utilizing pelvic tilts.
Visit One:
On her first visit back into the clinic, one week later, she reported that the pain had reduced overall; however, did increase as a result of wearing heels and standing up in a wedding over the weekend. Pain level reported this date was 2/10. She did report having a gym ball at home that she could utilize in her home exercise program. In addition to her approximation exercises and transitional activities stability ball exercises were added to her home program. Emphasis was placed on postural positioning and core activation including deep diaphragmatic breathing and pelvic floor contractions (Appendix 3). She was able to demonstrate supine to sit and sit to stand with appropriate body mechanics this date.
REFLECTION
Wearing high heels caused her to shift more into anterior pelvic tilt than she was already presenting with. This increased pressure on the RA as well as the increased lordosis in the low back contributed to her increased pain at this visit.
The stability ball was chosen as a base for her home program because she reported that she already had one and was interested in using it. Secondly, research has proven reliable for better activation of the TA on a stability ball as opposed to stable surface33-34. I began her with basic exercises so she could emphasize and self correct posture while performing them. I only gave her 6 exercises because she was already performing the DRA curl-up 3 times a day as well as self correcting postures using the biomechanics education and handout that was provided in her first visit. Six exercises was not overwhelming for her or difficult for her to find time to do with her schedule.
The pelvic floor muscles are considered a trunk stabilizer and work synergistically with the abdominal muscles; thus my rationale for including the pelvic floor with TA activation. Research also suggests that pregnancy contributes to pelvic floor weakness and complications associated with this such as incontinence and pelvic pain, even years following pregnancy. The pelvic floor acts as the base of the core, the TA acts as the sides, and the diaphragm as the lid. Thus she was instructed in diaphragmatic breathing as well. This allows for re-education of the core muscles working together as a functional unit29,35.
She met Goal #3 this date by demonstrating correct body mechanics with transitional activities. Performed repeatedly throughout the day, transitional activities can contribute to back pain when performed incorrecty. Gaining this neuromuscular reeducation of the core muscles during transitional activities can prove difficult for some patients. She was able to learn this quickly and effectively adding it to her daily routine, helping to decrease back pain.
Visit Two:
Pt had to cancel her next appointment because of lack of childcare. She returned to the clinic two weeks later, after performing HEP as instructed. DRA measurements had reduced this date as compared to initial evaluation (Table 4). She noted reduction in overall pain to 1/10. Focus for treatment this date was to continue to progress home exercise program. (Appendix 4)
TABLE 4
Location Measurement
4.5 cm above the umbilicus 3.0 cm
Umbilicus 2.0 cm
4.5 cm below the umbilicus 0.5 cm
REFLECTION
According to research, DRA reduction is not typical in 2 weeks15. This may have been observed for several reasons. She was very compliant with her HEP and utilized the biomechanics handout for lifting and ADL’s. She had also been using the MuTu® video for 6 weeks prior to beginning therapy and possibly just beginning to show signs of DRA reduction. Making a few postural corrections with initiation of PT at this time may have been the key to such a rapid decrease in these measures15.
An additional 6 exercises were added to her home exercise program and she was instructed to alternate between the two programs. This allows for some variety and decreased chance of burn out. The HEP this date continued to emphasize neutral pelvis, diaphragmatic breathing, and pelvic floor contractions; however increased the difficulty level of the balance and core activation using the stability ball.
Visit Three:
The patient returned to the clinic 2 weeks later with no noted pain in the back and minimal observation of bulge in the abdomen. Her diastasis had significantly reduced (Table 5). Pt stated that she was pleased with the results thus far and was ready to progress to independent management. Education on lifting was reviewed this date and pt was observed performing lifting of 30# from floor to waist as well as carrying 30#. Progression of home program is recorded in Appendix 5.
TABLE 5
Location Measurement
4.5 cm above the umbilicus 1.5 cm
Umbilicus 1.0 cm
4.5 cm below the umbilicus 0.5 cm
REFLECTION
A 30# box was used to simulate lifting and carrying her growing children. Generally, children are more difficult to handle than a box as they are cumbersome and moving. Simulation with a box is not ideal; however practical in the clinic. She was able to demonstrate this activity accurately and without pain thus achieving this goal.
At this point, she had achieved all of her goals, was not having any pain, and was ready to return to working out and running. I would have liked to follow up with her in a month to ensure that back pain did not return with resuming exercise activities and re-measure DRA; however she requested discharge this date as she was pleased with her results thus far and had difficulty coming in for appointments because of child care.
Outcomes
The patient was seen a total of 4 sessions over a six week period of time. She reported compliance with home programs and these progressions. The Oswestry decreased from a 4 to a 0 and she had no reports of pain. She had not yet returned to working out with Body Pump® or Combat® because she wanted to wait until discharge from physical therapy in order to resume these activities. She had begun running again, however only short distances on the treadmill, in order to progress back into marathon running. She was able to demonstrate proper lifting and carrying techniques for her children without noted increased pain. She did demonstrate clinical significant closure of the diastasis rectus abdmoinis to less than 2 cm at each site5 and proper recruitment and activation of the core muscles during daily activities.
REFLECTION
She did have difficulties attending weekly appointments because of 2 small children at home. Working with moms can sometimes prove difficult in this regard, because small children are either in the clinic, or make it difficult for the mother to attend as scheduled. This patient was very complaint and performed her HEP as instructed and thus was able to progress HEP bi-weekly. Had she been issued PSFS at initial evaluation, it likely would have shown more of a marked improvement than the Modified Oswestry.
Discussion
This case demonstrates significant closure of DRA in 34 year old female 2 years post partum utilizing DRA curl up, transitional movement biomechanics and stability ball activities with emphasis on TA, pelvic floor and diaphragmatic breathing. There is currently no established protocol for treatment of DRA, and many therapists use a multi-treatment approach18. This patient demonstrated a significant reduction in the DRA and was able to abolish her back pain, returning to high level work outs and marathons as well as caring for her children at home.
REFLECTION
As a practicing women’s health physical therapist, the considerations I used to guide my evaluation and treatment were based on the patient’s values and goals, known research at the time, and clinical experience. She reported very low pain levels; however it was unresolving. In my experience many women feel as though pain is a “normal” part of pregnancy and are not concerned with it until it does not resolve following the delivery of child. This pain was altering her life and preventing her from doing the exercise activities and caring for her children as she was able to do previously.
This patient was highly motivated and had already been researching and seeking out treatment for her pain and bulge. It is likely that the MuTu® DVD program allowed her to begin reeducation of the musculature; however because of her scar tissue and anterior pelvic tilt posture, was unable to achieve the results she was looking for. Also, this is a 12 week program and she was only 6 weeks into it. Research shows that it take 6 weeks to see signs of reduction, so it is likely that she was just beginning this process upon arrival to physical therapy and making minor adjustments to posture and tissue restrictions allowed progression to occur quickly. She did demonstrate good body awareness, better than many of the patients I have seen. She was able to recognize and maintain corrections to posture with minimal cuing. Had she not been as body aware and motivated, more details as I discussed in the objective data may have needed to be recorded. She may have had trigger points and soft tissue restrictions and could have needed to be addressed in order to allow for more neutral pelvic tilt. If she had not been as body aware and motivated, I may have needed to see her more often in the clinic in order to ensure lack of compensations and progress her accordingly. Had she been referred to PT during second pregnancy, when pain began, DRA could have been addressed at this time and monitored. It is unlikely that DRA would have reduced during the pregnancy; however can be maintained and then reduction following delivery. This could have gotten her back into running and working out much sooner. Education is needed to the public as well as OB-GYN doctors that DRA is treatable conservatively allowing reduction of back pain, urinary dysfunction, cosmetic deformities, and improving an individual’s quality of life.
References
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