I Have a Diastasis Recti Abdominis and You’d Never Guess It

By Dalton Derthick

A Diastasis Recti Abdominis (DRA) is an increase in width of the Linea Alba or a splitting of the rectus abdominis. Basically, there’s a space down the middle of your stomach that is between your abs. Now, having some gap there is normal, it’s only considered pathological if you have more than 2 fingers width between your abdominals.

The majority of people who have a DRA are either women who have gone through pregnancy and those who are considered obese. This makes sense considering the widening of the abdomen would naturally stretch the abdominals as well. Now here’s the kicker, I’m neither obese nor a pregnant woman. In fact, I’m considered to be in “good physical shape” with a defined rectus abdominis and a workout regimen that consists of 5 days in the gym per week. There is some information stating that a family history of hernias could also be a link to acquiring a DRA so maybe it’s just in my genetics but I think it may be more than that.

That brings me to my next point, the Transverse Abdominis (TA). This is a muscle that lies deep to your rectus abdominis and your obliques. Think of this muscle as a corset that wraps around the area below your rib cage and above your pelvis. The job of this muscle is mainly of stabilization in preparation for movement. This muscle is very important to have properly firing to avoid back pain, Sacroiliac dysfunction, pelvic floor dysfunction and for me in particular, preventing a DRA. I first noticed the gap in my stomach when I was very young, probably around 12 or so, but didn’t know any better. Now that I am a second year PT student, I’m aware of the weakness and the lack of neuromuscular coordination in my TA and how important the function of this muscle is in stabilizing the core. So even though I may have defined abdominals, I actually have very weak core strength.

So, maybe you have a DRA? Here’s a quick tutorial on how to test yourself. First step, lie on your back with your knees bent (hooklying). Step 2, take a deep breath in and during your exhale lift your head to do a mini crunch. 3rd step, place the tips of 3 fingers in the middle of your stomach, start just above your belly button. While doing this, you want to feel if your abdominal muscles are “pushing your fingers out”. If they aren’t, and you feel a bit of a crevice or a hole that is wider than 2 fingers, then you more than likely have a DRA. Perform the above steps for the level of the belly button, 2 inches below the belly button, and 2 inches above the belly button. If you are having difficulty determining your gap with this test, you may try doing a leg lift and holding, almost like a V-up position. While in this position, see if you have a bump or bulge in the middle of your stomach. Having a DRA is not the end of the world! It can be resolved without surgery but you should see a PT to help you with an exercise plan.

Lastly, a message to the Physical Therapists of the world, it’s time to regularly start assessing for DRA’s in all patients that may come in with back pain or SI pain no matter the presentation of the patient because if I can have a DRA as a young active male, then I believe anyone can have one.

About the Author: Dalton is a second year DPT student at A.T. Still University in Mesa, Arizona. He enjoys watching and participating in sports as well as maintaining an active lifestyle. In his free time, you can find him on the golf course or at the local gym lifting weights.

Does Telerehabilitation Have a Place in the Management of Stress Urinary Incontinence? A Review

By Yewande Apatira

Health care is changing! The push for decreased healthcare costs with same or better outcomes has led to increased research and implementation of cost-efficient healthcare strategies. An example of a potentially cost-efficient strategy is telehealth. “Telehealth is the use of electronic communication to remotely provide health care information and services” (APTA). More specifically, telemedicine is the exchange of medical information, while telerehabilitation is the delivery of rehabilitation services. These services may include assessment, monitoring, prevention, intervention, supervision, education, consultation and counseling. Some benefits to telehealth are increased accessibility to healthcare for patients in rural areas, and time and cost efficiency. In order to practice telerehabilitation, national and state legislation, and insurance coverage terms need to be considered. For more information on telehealth, visit the American Physical Therapy Association website (www.apta.org/Telehealth/).

A study was conducted in Sweden from December 2009 to April 2013, to examine the short and long term outcomes of an internet-based treatment program for stress urinary incontinence (SUI) compared to a treatment program sent by post. The results of the study were published in two separate articles in 2013 and 2015.  The following is a review of both articles.

Method

Recruitment/Selection

Participants were recruited via advertisements published on medical-related websites and in daily newspapers. Interested women were required to answer a 17-item survey that included the Incontinence Severity Index and questions on type of urinary incontinence (UI) to determine eligibility. The questions were posted on an open access website dedicated to the study. Two hundred and fifty participants were found eligible and underwent baseline assessments. Data on medical history, socio-economic status, internet usage, motivation and symptoms of anxiety and depression were collected with a questionnaire. The eligible women also completed the standardized outcome measures for the study and 2-day bladder diaries. In addition, over-the-phone interviews were conducted by a urotherapist.

Participants were randomized into two treatment groups, 124 into the internet-based arm of the study (mean age, 47.9 years), and 126 into the postal treatment arm (mean age, 49.8 years). There was no masking of the participants, healthcare providers or researchers involved in the study. The duration of intervention for both groups was three months, and the programs were comprised of information on SUI and pelvic floor muscle training (PFMT). Adherence to training- frequency and duration of PFMT- was tracked in both groups. The internet-based group was provided login information through which they could access training information. Their program was divided into eight levels, and though they could self-progress their PFMT, only two levels could be accessed at a time. Furthermore, participants in this group completed weekly evaluations and training diaries that were submitted to urotherapists. They could also contact the urotherapists for information via encrypted e-mail.

Treatment Programs

The participants in the postal group were provided with all exercises at the start of the study with instructions to self-progress the exercises. They did not receive support from the urotherapists, and were only required to submit their training reports at the first follow-up (after four months). Their information was sent via postal means, and they had no face-to-face contact with the researchers or email support.

The treatment program included:

• Illustrations
• Maximal contractions for strength: 8s x 8-10 reps x 3 times daily
• Submaximal contractions for endurance: 15 to 90s x 1 rep x 3 times daily
• Quick contractions: 3s x 8-10 reps x 2-3 times daily
• The “Knack”: pelvic floor contraction prior to and during exertion
• Cognitive behavioral technique (CBT) assignments (if applicable): lifestyle change, identification and change in behaviors of avoidance and redundant security measures
• Weekly training report
• Email support by urotherapist

*The postal group received all but the last three parts of the treatment program.

Outcome Measures

The primary outcome measures were the Incontinence Questionnaire Short Form (ICIQ-UI SF) and ICIQ-LUTSQoL. Frequency, amount of leakage and impact on quality of life were measured using the ICIQ-UI SF, and symptom specific quality of life (QoL) was measured using the ICIQ-LUTSQoL. Higher scores on these measures indicate increased severity and impact on QoL respectively. Secondary outcome measures included the patient global impression of improvement (PGI-I), health related Qol (EuroQoL), incontinence episode frequency (IEF) calculated from the 2-day bladder diaries, usage of urinary aids, and satisfaction with the treatment program. Data on primary and secondary outcomes were collected at baseline, four months, one and two years.

Results

The groups were homogeneous at baseline for demographics and primary outcome measures.

4-month follow–up

At four-months follow-up, 107 and 113 participants in the internet-based and postal treatment groups respectively completed the follow-up.

Primary Outcomes: Both groups demonstrated statistically significant improvement in all primary outcomes, with no significant differences between groups. However, when considering only the severity of leakage measured by the ICIQ-UI SF, participants with severe leakage at baseline in the internet-based group had significant improvement compared to those in the postal group.

Secondary outcomes: More subjects in the Internet group reported leakage after treatment as “much better” or “very much better” when compared to those in the postal group. This was statistically significant. The number of UI episodes per week (IEF) was significantly decreased within both groups, with significant differences between groups, favoring the Internet group. Usage of incontinence aids was also significantly different between groups, the Internet group reported use of less aids post-intervention.

One and two–year follow–ups

At one-year follow-up, 88 women in the Internet group and 81 in the postal groups completed the assessments. Of the 167 participants remaining after one year, 9.6% had sought other treatments for SUI, but were still included in the analyses. After two years, 75 and 80 participants were left in the Internet and postal groups respectively. Approximately 12.3% had sought other treatments.

Primary Outcomes:  There were significant within group improvements compared to baseline but no significant between group differences, after one and two years.

Secondary Outcomes: Reported improvement in leakage was not statistically different between groups at one-year follow-up. However, the internet group had a significant improvement in leakage compared to the postal group at the two-year follow-up. Health related QoL did not improve significantly in either group after one year, but there was a significant improvement after two years in the internet group. There were no between group differences in health related QoL at one- and two-year follow-ups.The proportion of participants using incontinence aids at one- and two-year follow-up decreased significantly within groups. More participants in the internet group after one year and two years reported satisfaction with treatment results, but there were no between group differences. The authors reported that separate analyses excluding those who underwent surgery during follow-up period yielded similar results.

The results of the study are interesting and support the use of telehealth and even postal treatment programs in the management of SUI for short and long term positive outcomes. However, there were several limitations to the study. First, the authors compared two remote strategies. Further research would be needed to compare internet-based care to face-to-face, and a postal treatment program to face-to-face care. In addition, participants who dropped out of the study had more severe UI and were younger. Women included in this study also had to have access to the internet. Therefore, research to identify characteristics of patients who will benefit from this form of management would be beneficial. With the changing climate of healthcare, strategies that can potentially decrease costs and still provide significant positive outcomes in the short and long terms will be of great value.

In some parts of the United States, patients seeking physical therapy management for UI have to travel long distances to see a physical therapist. With telehealth they may only need to travel once or even not at all for an assessment and to continue via the internet. In other clinics there are long waitlists for women’s and pelvic health specialists. In these situations, telehealth may decrease the burden on patients and on therapists. Patients in rural areas would be able to access care from expert women’s health and pelvic health therapists. With further research and changes in current legislation and insurance reimbursement, telerehabilitation could have a place in the management of stress urinary incontinence.

References

• Sjostrom M, Umefjord G, Stenlund H, Carlbring P, Andersson G, Samuelsson E. Internet-based treatment of stress urinary incontinence: a randomised controlled study with focus on pelvic floor muscle training. BJU Int. 2013;112(3):362-372.

• Sjostrom M, Umefjord G, Stenlund H, Carlbring P, Andersson G, Samuelsson E. Internet-based treatment of stress urinary incontinence: 1- and 2-year results of a randomized controlled trial with a focus on pelvic floor muscle training. BJU Int. 2015;116(6):955-964.

 

Insight into Interstitial Cystitis

By Hannah Guilbeau

One evening I was sitting on the couch with my granny and a commercial for some brand of tampons came on the television. I heard granny giggle and became curious about what joke I was missing. The gist of her explanation was that you just didn’t talk about “that stuff” much less advertise it when she was younger. Although progress has been made with feminine issues in general, we still have a long way to go with the discussion of pelvic floor dysfunction. It is so important for women to know they are not alone (although it is not normal and they can get help) and even young women can suffer from these issues.

Thinking back on that moment with granny, I began to see how I had personally seen a woman struggle (silently for a while) with PFD at a young age and feel as if she was never going to get better. Interstitial Cystitis (IC) is a disease I have become very familiar with because my best friend has recently been diagnosed. Seeing her struggle with this was not easy and  I wanted to help so I began researching this disease. I asked her about what questions she had and I believe that most women with IC have these same questions. So although these are not extensive answers or questions, I think they will offer some insight to patients, family, and friends.

1. What causes Interstitial Cystitis?

IC is also known as bladder pain syndrome. The cause of IC is unknown but it has been reported to behave like an autoimmune disease with remissions and flares. It is not an infection but is commonly mistaken as a urinary tract infection especially in younger females since they are usually not aware chronic bladder issues could affect them at their age. IC onset is most common in women 30-40. In IC the bladders protective layer that shields it from the irritation of acidic urine is damaged. Also, there is a change in the nerves that carry signals from the bladder and a signal of the bladder being full can now become a painful feeling. It is important to know that IC is often progressive especially when proper treatment is not achieved.

2. Is there a cure for IC?

Unfortunately, there is not a cure but with proper treatment it is possible to become pain and symptom-free. Physical therapists can provide interventions such as patient education, manual techniques, strengthening and stretching. With IC urinary frequency is a major issue and starting these patients on a bladder training program is key. Also, these patients tend to have a high tone pelvic floor that can be helped with manual therapy of the external pelvis (getting their pelvis in proper alignment), relieving trigger points (levator ani, obturator internus, and piriformis muscles) and biofeedback/electrical stimulation. Diet is a way patients can gain control over this disease. Once they know what foods to avoid, it makes a huge difference in bladder symptoms. There is an app called ICN food list that tells you what foods are bladder friendly, what foods you could try and what foods to avoid. This app is very helpful for those new to the bladder friendly diet.

3. Will IC affect my fertility or getting pregnant?

Many women with IC have pain during intercourse and it leads them to think they may have problems getting pregnant. IC does not affect fertility. However, sex can be very painful for these patients if they are not getting proper treatment but with the interventions listed above remission is possible. Whitmore states some self-care strategies include, “emptying the bladder before and after sex, avoiding prolonged intercourse, minimizing pressure on the urethra, and taking an analgesic or antispasmotics before engaging in sexual activity.” Physical therapists play a huge role in decreasing their pain but these patients can also benefit from a referral to a sex therapist.

Lastly, the book titled The Better Bladder Book by Wendy Cohan, RN is a great resource to learn more about IC. Wendy was diagnosed with IC and struggled with the frustration of knowing there was no official cure. However, she did not give up hope on finding a way to decrease her symptoms and pain. This book presents the holistic treatment plan that allowed her to recover from this disease.

 

References:

The Better Bladder Book: A Holistic Approach to Healing Interstitial Cystitis & Chronic Pelvic Pain by Wendy Cohan, RN

“Complementary and Alternative Therapies as Treatment Approaches for Interstitial Cystitis” Author : Kristene E. Whitemore, MD

 

Author: Hannah Guilbeau is a 3^rd year physical therapy student at LSUHSC Shreveport in Louisiana. She is the Assistant Director of Administration in the SoWH Student Special Interest Group. She is looking forward to attending the Pelvic Physical Therapy Level 1 course this fall.