(Rectus divarication) Dr. Ali Abd El Monsif Thabet Diastasis recti (Rectus divarication) Dr. Ali Abd El Monsif Thabet

ANATOMY A-The fascial layers which are divided into: 1- Superficial layer, referred to as the fatty layer, is a single layer with varying amounts of fat. 2-Deep fascial layer, known as the membranous layer, is more membranous and contains elastic fibers.

1- External oblique muscle 2- Internal oblique muscle B- Anterolateral muscle group of the abdomen consist of four pairs of muscles which include (Fig. 1). 1- External oblique muscle 2- Internal oblique muscle 3- Transversus abdominis 4- -Rectus abdominis

C- The aponeuroses which are defined as flat sheets of densely collagen fibers usually consisting of several layers with few elastic fibers. D- The linea alba which is the result of the fusion of the right and left aponeuroses of the three pairs of the anterolateral abdominal muscles in the midline from sternum to the pubis.

Rectus sheath The rectus abdominis is entirely enclosed in a sheath formed by the aponeuroses of the muscles of the lateral walls of the abdomen.

Functions of the abdominal muscles 1- Protect the abdominal viscera and keep them in their positions 2- Maintain a good erect posture 3- Stabilize pelvis during straight leg raising 4- Help in respiration and defecation 5- Concern with forward flexion of the trunk 6- Help expulsion of the fetus during second stage of labour. 7- Improving the function of the pelvic floor muscles

Definition It is the separation of the rectus abdominis muscle which involve widening of the linea alba with gap greater than the normal distance between the rectus bellies (2 Cm or 2 fingers above umbilicus) palpated above, below or at the level of the umbilicus (Fig. 2).

Degrees 1- Complete separation 2- Incomplete / Complete separation There are three degrees of the rectus separation:- 1- Complete separation 2- Incomplete / Complete separation 3- Incomplete separation

Predisposing factors 1-Child bearing especially when there was succession of pregnancies 2- Corset for nonpregnant as well as pregnant is primary factor in development of diastasis 3-Hernias, the simplest form of a ventral or epigasteric hernia is the region of the linea alba and represents diastasis recti.

Predisposing factors 4- Conditions that results in a persistent excessive increase in intra-abdominal pressure favors the development of a diastasis such as lifting or carrying heavy objects or chronic cough. 5- Sudden strain or fall may also be the starting point of a diastasis 6- Decrease in the tone of the tissues of the abdominal wall as a result of general weakness may also predispose to diastasis development

Incidence Diastasis recti are not a condition limited to pregnant or postpartum women, it also can be seen in obese males, in patients with chronic lung disease, and in children (whose linea alba is wider than the adult)

Incidence Second trimester Childbearing period at full term 66% Immediate post-partum 50% Multiple gestation ↓Incidence in women with Good abdominal tone prior to pregnancy Above umbilicus 37% - At umbilicus 52%- Below umbilicus 11%

Implications Cosmetically Abnormal posture Functionally The implications of diastasis recti fall into two categories, one relates to cosmoses of the abdomen and the other to abdominal weakness and its effect on function, posture and low back pain. Cosmetically Functionally Abnormal posture

Assessment Rectus diastasis test This test can be done by the mother herself or by the therapist

Patient position: crock lying position Therapist position: stride standing position at the level of the waist line with the four fingers are fitted vertically across the linea alba between xiphoid process and umbilicus (about 4.5 Cm above the umbilicus). Procedure: the mother is asked to raise her head and shoulders off from the plinth until the spines of the scapulae left the plinth with arms extending towards the knees while the therapist measures for diastasis by turning here fingers horizontally across the linea alba between xiphoid process and umbilicus to determine how many fingers fit into the space between the borders of the two rectal bellies (Fig.5).

The palpation should assess the following 1- Width and length of any recti separation 2- Region of the greatest diastasis 3- Bulge of the abdomen on recti contraction 4- The women's ability to activate abdominal musculature 5- The endurance capacity of the abdominal musculature.

Treatment A- During pregnancy and labour Specially designed cotton corset (maternity belt) at 26 weeks (Fig.6) .

B-During postnatal period Rectus diastasis performed three days after delivery as muscles are too slack for a reliable result. If cesarean section performed wait proximally six weeks. If there is diastasis recti the following exercises are performed.

1- Corrective exercises for diastasis recti (Tupler technique) (Fig.7).

External support It can be used in association with Tupler technique in early postpartum period to approximate the recti muscles of the abdomen (Fig.8).

3- Isometric abdominal exercises 2- Correction exercise technique combined with posterior pelvic tilt 3- Isometric abdominal exercises

4- Electrotherapy a- Faradic current Frequency 50-70Hz, pulse duration 0.5-1 ms, maximum tolerated intensity, 3 sessions/week, each 30 min, for 24 sessions. b- High voltage pulsed current Frequency 100Hz, 3 sessions/week, each 30 min, for 24 sessions.

d- Different grades of antero-posterior flexion of the trunk When the diastasis is reduced with the above correction exercise technique progression is determined by the level of abdominal strength through graduated active abdominal exercises as follow:- a- Lateral trunk flexion b- Pelvic rotation c- Trunk rotation d- Different grades of antero-posterior flexion of the trunk

Surgical management It is often done in connection with a hernia repair or adominoplasty. Adominoplasty is used to correct deformations of the abdomen and involves removal distended and pendulous skin and fat, if diastasis present, it is repaired by suturing the rectus bellies together, then wearing an abdominal support for one moth after surgery and abdominal exercises initiated at the end of the fist month after surgery.

Advices 1- Avoid certain exercises such as straight leg raising, double leg lowering, sitting straight up from lying position. 2- Avoid constipation to avoid bearing. 3- Avoid using abdominal support unless in between corrective exercises when the diastasis more than 2Cm. 4- Avoid carrying heavy objects. 5- Applied post natal exercises till two months after delivery. 6- Avoid succession pregnancy (at least 3 years distance).

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