Diastasis Rectus Abdominis is a separation of the rectus abdominis (6 pack) muscle. There is a piece of connective tissue at the midline of the abdominal wall called the linea alba. When the rectus abdominis move apart, it can cause the linea alba to become overstretched (like a stretched out piece of saran wrap). The resulting lack of support at the front of the abdominal wall compromises the function of the entire inner core unit and can lead to unwanted changes in appearance.
The inner core unit is comprised of four main muscle groups that work synergistically: the transversus abdominis, the diaphragm, the multifidus, and the pelvic floor. These muscles turn on in advance of movement to provide a stable and controlled platform for movement. Correct core training involves engaging these muscles in the right sequence, to the right degree, and in anticipation of movement.
The pelvic girdle consists of 3 joints – the left sacro-iliac joint, the right sacro-iliac joint and the pubic symphysis. Imbalances or asymmetry of the bony pelvis (usually due to imbalanced muscular forces or tensions) can lead to pain at one, two or all three joints. Generally speaking, this is called pelvic girdle pain. There are various types of pelvic girdle pain (PGP) and it’s important to understand what is contributing to PGP so that treatment is effective.
Changes to the abdominal canister, increases in maternal weight, shifts in the centre of gravity, increased volume of blood – these are just a few factors that can cause muscular aches and pains during pregnancy as the body tries to find a new way of orientating against gravity. Upper or lower back pain, sciatica, restless legs, varicose veins, increased pelvic pressure, vulvar varicocities, pain in the tailbone, groin, hip or pubic pain, changes to walking pattern, general feeling of muscle fatigue – can all occur during pregnancy. It is important to get these things checked out so they do not become the ingrained pattern during the busy years of motherhood.
Wrist pain, upper or lower back pain, postural changes, muscle tension or weakness, persisting pelvic girdle pain are some of the common orthopaedic complaints in the months following childbirth.
The pelvic girdle, pelvic floor, uterine muscle, and inner core are all intimately involved during childbirth. The pelvis is baby’s first cradle and it’s orientation during pregnancy and childbirth can impact labour and delivery. The job of the pelvic floor is gently yield and open during labour. Therefore a flexible and compliant pelvic floor, along with a strong one, is ideal. Because many pelvic health conditions result from pregnancy and childbirth, prevention of dysfunction is a huge goal of pelvic floor physiotherapy prenatally. The goal is to decrease excessive strain and manage pressures on the pelvic floor during labour and delivery. Minimizing perineal tears and preventing pelvic floor avulsions is also a major focus of prenatal physiotherapy.
Return to a pain free life is possible! To heal from pain, physiotherapy treatment focuses on the pelvic tissues and more importantly, on the central nervous system since it is ultimately responsible for modulating the pain experience. Persistent pain in the pelvic region is pain that has been present for over 3 months. Official diagnoses or terms include:
- dyspareunia (painful intercourse)
- vulvodynia (generalized pain in the vulvar region)
- vestibulodynia (specific pain in the vestibule region of the vulva – also known as vulvar vestibulitis)
- clitroidynia (pain in the clitoral region)
- primary or secondary vaginismus (involuntary spasm of pelvic floor muscles with penetration attempts)
- coccydynia (pain in coccyx or tailbone)
- endometriosis (pain caused by endometrial tissue outside of the uterus)
- painful bladder syndrome (hypersensitivity and inflammation of the lining of the bladder wall – also known as interstitial cystitis)
- levator ani syndrome or proctalgia fugax (tension or spasm in a major group of muscles that make up the pelvic floor)
- pudendal neuralgia or pudendal nerve entrapment (irritation or compression of a major nerve supplying the pelvic floor muscles)
- persistent genital arousal disorder (unwanted and painful arousal of the genitals triggered by sexual or non sexual stimuli)
- other types of pain due to hormonal changes, menopause, abdominal or pelvic surgery, internal scar tissue, gut or bladder dysfunction, pelvic girdle pain, hip labral tears, myofascial or connective tissue dysfunction, trauma, or hypertonicity of pelvic floor muscles
Regardless of the location or nature of the pain, a bio-psycho-social approach is necessary for the effective treatment and ultimate elimination of pain. We focus on the whole person, not just the part.
Abdominal or pelvic surgery may be necessary or elective. It includes surgery to address incontinence, pelvic organ prolapse, or removal of cysts, fibroids, other growths, or adhesions. It may be an endometrial ablation or to surgery repair a diastasis recti. Interestingly, hysterectomy is one of the top 5 performed surgeries in Ontario (C-sections being number 1). When it comes to irreversible procedures, the risks, benefits, alternatives, success and failure rates, and general outcomes of surgery must be carefully evaluated before making the decision. Make sure you are well informed.
Pelvic floor physiotherapy treatment prior to surgery may help to delay or prevent surgery all together. Just as in any other situation (such as an ACL repair or knee replacement) going into pelvic surgery with as robust of a system as possible will lead to better post-surgical outcomes. Pre-operative physiotherapy is therefore recommended to maximize the state of the pelvic region prior to surgery. Post-operative physio is equally important for regaining optimal function and hopefully to prevent the need for future surgeries.
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Please check out the general learning page for articles, downloads, and links on various conditions, and links to various topics. Feel free to share them with your patients. If you are interested more in- depth research, you can download and read the journal articles below.