The effect of visceral manipulation on Diastasis Recti Abdominis

Participants

• Number: 3
• Description: 3 women of 33, 37 and 39 years of age, all with 2 past pregnancies and all with various intermittent problems including low back pain, abdominal pain and vulvar burning and itching. All problems that would prevent them from living normally by interfering with their socialization, care of children and housekeeping.
  At the moment of the visit, the pain intensity was equal to 2, 4 and 0 for the 3 patients, although they had previously experienced worse pain intensity, rated at 4, 8 and 5, all measured with Numeric Pain Rating Scale (NPRS). One patient reported bladder disorders (sense of incomplete emptying, nocturia and dysuria), while 2 reported bowel movement disorders (straggling to evacuate once every 4-5 days, possibly with the help of a laxative).

All patients reported having had complicated deliveries (eg, C-section for breech delivery with a significant scar, postpartum bleeding for 7 weeks, labor longer than 40 hours) and assuming various anti inflammatory drugs, steroidal and not, orally and locally.
The examinations showed a reduced lumbar range of motion (ROM), while also highlighting a muscle laxity and weakness at the pelvic and intravaginal levels, as well as several mesenteric and intestinal restrictions (an inguinal hernia in the third patient) and several postural alterations both at the lumbar and sacroiliac levels and at the systemic level (head, thorax and extremities).

During the examination all patients were positive for diastasis recti abdominis with a distance greater than 2 finger-width at least in 1 of the 3 measurement sites (ie, 3 fingers above the umbilicus, umbilicus level, and 3 fingers below). In detail:

• • 1st patient: 1,5 fingers above the umbilicus, 3 fingers at the umbilicus level and 2,5 fingers below the umbilicus
  • 2nd patient: 2 fingers above the umbilicus, 3 fingers at the umbilicus level and 1 finger below the umbilicus
  • 3rd patient: 3,5 fingers above the umbilicus, 4,5 at the umbilicus level and 2 fingers below the umbilicus. Therefore, it was decided to perform a visceral manipulation.

Interventions and evaluations

• Evaluation of the diastasis recti abdominis at the initial assessment and after each visit
• At least 4 sessions of primary visceral manipulation
  • 1st patient: 7 visits in 18 weeks
  • 2nd patient: 12 visits in 36 weeks
  • 3rd patient: 6 visits in 24 months
• Visceral manipulation: treatment of the mesenteric root (upper leaf, lower leaf, and both simultaneously), intestinal loops, mesentery and intestinal motility, as taught by the Barral Institute
• From the 4th and 5th visit other kinds of therapy have been added, like exercises to improve ROM, to promote diaphragmatic breathing, to strengthen the pelvic muscles, or articular techniques
• Visceral manipulation performed by two physical therapist with broad knowledge and experience and specialized in pelvic conditions

Results

The patients were discharged after 7, 12 and 6 visits respectively.

The 1st patient’s pain completely resolved and her ROM improved, with consequent complete resumption of daily activities. In addition, her diastasis recti abdominis did practically disappear (only 1 finger at the level of the umbilicus).

The 2nd patient resolved her pain problems (only some vaginal swelling persisted and some dysmenorrhea during ovulation), thus becoming able to resume socializing and moving without problems. Also, the bladder issues improved (only a subtle sense of incomplete emptying persisted), while the bowel movement disorders remained, although from once every 4-5 days she would now evacuate every day. She also saw the diastasis recti abdominis almost disappear (only 1.5 fingers at the umbilicus level). However, the pain and instability values of the pelvic floor measured by NIH-CPSI and Pelvic Floor Disability Index (PFDI-20) respectively were not lower at the time of discharge compared to the first visit.

The 3rd patient had no more pain and was therefore able to resume child care and housekeeping at her best. She reported less difficulties in the intestinal evacuation and her diastasis recti abdominis was significantly reduced (1 finger above the umbilicus, 1.5 fingers at the umbilicus level and 0.5 fingers below the umbilicus).

Discussion

Visceral manipulation has been shown to be able to promote the closing of diastasis recti abdominis and the improvement of its consequential pain, while improving physical function and quality of life.
These positive effects may depend on the capacity of visceral manipulation to act on the quality of the myofascial tissue, improving its depleted state, resulting from the endurance of forces greater than those physiologically manageable during pregnancy.

In the 3rd patient the closure of the diastasis might have been due to the presence of an inguinal hernia.
A limit of the study is having evaluated the diastasis subjectively instead of through ultrasounds, which would be more accurate and, amongst other things, could be carried out in real-time to monitor the actual progress of the diastasis.
Moreover, the implementation of other kinds of therapy after the 4th visit prevents us from crediting the results exclusively to visceral manipulation.