|Year : 2023 | Volume
| Issue : 1 | Page : 30-36
Low back pain and motor control dysfunction after pregnancy: The possible role of rectus diastasis
Reetta Tuominen1, Tiina Jahkola1, Jani Mikkonen2, Hannu Luomajoki3, Jari Arokoski4, Jaana Vironen5
1 Department of Plastic Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
2 Department of Surgery (Incl. Physiatry), Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
3 Institute of Physiotherapy, ZHAW School of Health Professions, Zurich University of Applied Sciences, Zurich, Switzerland
4 Department of Physical and Rehabilitation Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
5 Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
|Date of Submission||20-Dec-2022|
|Date of Decision||17-Feb-2023|
|Date of Acceptance||24-Feb-2023|
|Date of Web Publication||30-Mar-2023|
Department of Plastic Surgery, Helsinki University Hospital and University of Helsinki, PL 266, 00029 HUS
Source of Support: None, Conflict of Interest: None
Purpose: Pregnancy-related low back pain is a common condition. Persistent postpartum diastasis recti may cause back pain and motor control dysfunction. The role of diastasis in pregnancy-related back pain remains debatable. This study aimed to compare participants with increased symptoms after index pregnancy with those reporting no change in back pain or subjective movement control and to analyze inter-rectus distance. Materials and Methods: This case-control study included a cohort of women who delivered 1 year earlier. We recruited participants with increased symptoms (n = 14) after index pregnancy and controls (n = 41) and recorded their inter-rectus distance using ultrasound. A questionnaire was completed, and an ultrasound performed twice for each study group. Results: At the baseline, there was no significant difference in inter-rectus distance between cases and controls (mean 2.45 ± 1.01 cm and 2.09 ± 1.03 cm, respectively). A year after index pregnancy symptomatic cases had significantly wider inter-rectus distance than controls (mean 3.45 ± 0.90 cm and 2.40 ± 0.79 cm, respectively). Motor control dysfunction test results were not associated with core stability problems or back pain in this cohort. There was a difference in the sit-up test between cases and controls (mean 4.7 ± 4.2 and 8.2 ± 3.9, respectively). Conclusion: Women who reported increased back pain and core instability after index pregnancy had wider inter-rectus diameter than controls. In the case group with more symptoms after pregnancy, the classification of rectus diastasis (RD) changed from mild abdominal RD (2–3 cm) to moderate (>3–5 cm). RD may contribute to persistent pregnancy-related lumbopelvic pain.
Keywords: Health-related quality of life, motor control, pregnancy-related back pain, rectus diastasis
|How to cite this article:|
Tuominen R, Jahkola T, Mikkonen J, Luomajoki H, Arokoski J, Vironen J. Low back pain and motor control dysfunction after pregnancy: The possible role of rectus diastasis. Int J Abdom Wall Hernia Surg 2023;6:30-6
|How to cite this URL:|
Tuominen R, Jahkola T, Mikkonen J, Luomajoki H, Arokoski J, Vironen J. Low back pain and motor control dysfunction after pregnancy: The possible role of rectus diastasis. Int J Abdom Wall Hernia Surg [serial online] 2023 [cited 2023 Jun 4];6:30-6. Available from: http://www.herniasurgeryjournal.org/text.asp?2023/6/1/30/372941
| Introduction|| |
Pregnancy-related lumbopelvic pain (PLBP) is common during and after pregnancy.,, Pregnancy can also result in persistent thinning and widening of the linea alba leading to abnormal separation of the two rectus abdominis muscles. This is diagnosed as rectus diastasis (RD). As anterior abdominal wall biomechanically influences the movements and stability of the lumbopelvic spine, RD can contribute to back pain and motor control (MC) dysfunction.,, The connection of PLBL and RD is less studied even though the states have similarities. Pregnancy-related lumbopelvic pain is a wide concept and consists of PLBP, pregnancy-related pelvic girdle pain (PGP), and a combination of these two. Changes in muscle activity have been observed, as well as changes in motor coordination. Although PLBP and PGP are the most common complications of pregnancy, the underlying etiology remains unknown.
Our group conducted a large epidemiological study concerning the normative values of inter-rectus diameter (IRD) in nulliparous and parous Finnish population. A number of women reported increased back pain and/or decreased MC function in a repeated questionnaire conducted a year after index pregnancy. In the present study, we recruited individuals from this subgroup. We also recruited controls reporting no change in their bodily experience during follow-up. The aim of this study was to analyze IRD and core function in these groups. IRD was recorded 12 months after the index pregnancy with relaxed core muscles in supine position by using ultrasound (US).
| Patients and Methods|| |
Design and participants
A case–control study was conducted in Helsinki University Hospital during January 1, 2018, to March 31, 2021. The study was approved by the Regional Ethics Review Board in Helsinki HUS/3331/2017. The study is registered with clinicaltrials.gov/, Identifier NCT05485844.
Participants completed a questionnaire during early pregnancy and 1 year after index pregnancy. The first questionnaire was filled in and the baseline width of linea alba was measured by abdominal US in connection of the first early pregnancy screening during January 1, 2018, to March 8, 2019. The median US timing was at gestational week 13, and the median answering time to the first questionnaire was at gestational week 15. The second questionnaire was completed 12 months since the last delivery. Two screening questions were used to grade the participants [Table 1]. Exclusion criteria in both groups were pregnancy during the second questionnaire and body mass index over 28 kg/m2 [Figure 1].
|Table 1: Pregnancy-recovery screening questions (1 and 2) and the distribution of answers|
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Altogether 36 individuals scored at least five points reflecting to a substantial increase in RD-related symptoms after pregnancy out of which 14 participants were randomly recruited [Table 1]. Another 94 individuals scored the lowest possible two points. Of them, three controls per case were recruited, altogether 42 controls. With one dropout, the total number of controls was 41. All participants had at least 12 months from the last delivery.
Two specially trained physiotherapists conducted MC tests. The width of linea alba was measured with a high-end US. The physiotherapists were blinded with group allocation and the previous IRD measurement. Each participant received study information and completed a written consent.
An electronical questionnaire was sent to a given e-mail including RAND36 validated health-related quality of life (HRQoL) questionnaire and Oswestry 2.0 low back disability index., The questionnaire is described in detail in our previously published original article. Participants did not know their own exposure status or their IRD when answering the questionnaires.
Motor control tests
MC tests are described in detail by Luomajoki et al., Three tests were adopted from six test batteries assessing MC of lumbopelvic spine. Tests have shown to have acceptable interrater reliability. Acute and chronic low back pain and painlessness can be differentiated., Waiter’s bow is a flexion MC test of the lumbopelvic spine. Extension MC is assessed with a test called pelvic tilt. One leg stance test is a version of postural and balance evaluation. Further tests, active straight leg (ASLR), which screens lumbar spine stability and abdominal bracing ability were performed. In addition to established MC tests, a sit-up test was recorded with a simple version: with arms crossed in front of the chest, elbows touch the knees in upright position. Also, the fashion how the person laid down and stood up from the lying position was evaluated: did a person show substantial difficulties or was the performance efficient and functional. All tests were video recorded, and the performances were analyzed blindly by one independent clinical test specialist (J.M.).
All statistical analyses were made using NCSS 12 Statistical Software (2018). NCSS, LLC. Kaysville, Utah, USA. The alpha level for all statistical tests was set to 0.05. Equal-variance t test was used to compare numerical variables when distributions were approximately normal. Mann–Whitney’s U test was used when the variable distributions were non-normal. The Fisher exact test was used to assess MC dysfunction test differences between cases and controls.
| Results|| |
During early index, pregnancy IRD was measured in 933 women, of whom 397 answered the first questionnaire. A year after index pregnancy, 268 answered the second questionnaire. Cases were defined by pregnancy-recovery screening questions [Table 1]. According to screening questions, 17 individuals had considerably more MC dysfunction and 37 had more low back pain after index pregnancy than before. The baseline data of the 14 cases and 41 controls, who were recruited for the study, are presented in [Table 2]: BMI and age-matched between groups. Cases had had more pregnancies (mean 2.5 ± 0.7) compared with controls (2.0 ± 0.7, P = 0.003). The mean IRD at the baseline measurement was 2.45 ± 1.01 cm in the case group and 2.09 ± 1.03 cm in the control group with P = 0.72. At the second measurement, a year after index pregnancy IRD was 3.45 ± 0.90 cm in the case group and 2.40 ± 0.79 cm in the control group with P = 0.004. The range of IRD after index pregnancy in the case group was 1.3–4.3 cm [Table 2] and [Figure 2].
In RAND36 HRQoL survey, each item is scored on a 0–100 range so that the lowest and highest possible scores are 0 and 100, respectively. Scores represent the percentage of total possible score achieved. The screening question results were in line with HRQoL scores: the HRQoL scores of the cases decreased between data points, reflecting worse health, as expected based on screening [Figure 3]. After index pregnancy, the HRQoL domains (physical functioning, bodily pain, and general health) scored less than population norm in the case group. On the contrary, the scores of controls slightly increased between data points and were above the population norm at the time of the second questionnaire. The age-matched population mean values are from Finnish-validated version of the survey.
|Figure 3: Results in Health-Related Quality of Life questionnaire RAND36|
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In MC evaluation, the only statistically significant finding between cases and controls was in the observation of how a person is laying down: 11 out of 14 symptomatic cases had a functional performance and three had substantial difficulties while all controls laid down without deviation (P = 0.014) [Figure 4]. There was a statistical correlation with the sit-up test: in the case group, the mean count of sit-ups was 4.7 ± 4.2 and in the control group 8.2 ± 3.9, P = 0.01. As cases were defined with back pain or MC dysfunction, the MC tests were analyzed also in relation with self-reported MC dysfunction only. There were no differences between the study groups in three MC tests (Waiter’s bow, pelvic tilt, or one-leg stand).
|Figure 4: Core stability tests scaled with succession percentage in study groups|
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| Discussion|| |
Approximately, 50% of all pregnant women suffer from PGP and/or PLBP and 7% have symptoms after pregnancy., Strenuous work, previous low back pain, and previous PLBP are risk factors for PGP and/or PLBP. The causes leading to persistent low back pain are generally considered to be multidimensional: genetic, biopsychosocial, and lifestyle factors, as well as pain modulation characteristics and comorbidities. In our data, the prevalence of MC dysfunction was 6% (17/274) and back pain 13% (37/273), which is in line with previous data.
RD causes low back pain and MC dysfunction problems to some individuals. In a systematic review, Benjamin et al. concluded that there is weak evidence that RD may be associated with pelvic organ prolapse, and RD severity associated with impaired health-related quality of life, impaired abdominal muscle strength, and low back pain severity. In a recent guideline, core instability and weakened bodily perception are mentioned as probable effects of RD. Mostly, studies addressing the correlation of symptoms and RD are made with dichotomous grading, with low RD diagnostic cut-off value. Less is known of the effects of severe diastasis.
There are a few studies addressing the possible association of RD and PLBP/PGP. Gluppe et al. studied the relationship of IRD and symptoms with 36 individuals and matched controls with age and parity. Eight of 35 (23%) women were classified with mild, 13/35 (37%) with moderate, and 4/35 (11%) with severe RD. RD was defined in Candido et al. classification: mild (25–35 mm or visible protrusion with diastasis less than 25 mm), moderate (35–50 mm), and severe (>50 mm). Women with RD had no higher prevalence of pelvic floor dysfunction (PFD), low back and PGP than women without RD. In RD group, mean IRD was 43.5 mm and in the control group 23.3 mm. Subgroup analyses comparing women with severe (n = 4), and moderate RD with women without RD showed no difference in abdominal strength, report of PFD, LBP, PGP, and abdominal pain than women without RD. There were confounding factors in the study: in the case group, the postpartum timing was as low as 6 weeks, implicating that RD was not persistent type and the age variance was wide (18–70 years).
Parker et al. also found no association between RD and back pain but they concluded that persons with RD had a higher degree of abdominal or pelvic region pain and that more than 60% of those with RD had some type of pelvic pain. In this study, cases were individuals seeking medical care for lumbopelvic or pelvic area diagnoses. RD was diagnosed with low cut-off point of 2.2 cm. Dalal study concerning women with different lumbo-pelvic diagnoses reported that 25/30, that is, 83% of the women had RD defined with low cut-off value IRD more than 2 cm. The same study found a relationship between pelvic pain and dysfunction (PFDI) and RD. In this study, participants had delivered 3 months or more prior, implicating some of the abdominal walls were still in reverting state. Measurements were performed with finger width method.
Fraser et al. studied the role of weakened anterior abdominal musculature on degenerative spondylolisthesis. RD was measured with muscle contraction that is likely to underestimate the real IRD., Nevertheless, there was an association with RD and degenerative back problem. Hills et al. studied 18 individuals with IRD over 2.2 cm and 22 controls and concluded IRD more than 2.2 cm in primiparous women at 1-year postpartum to be associated with lower trunk rotation strength and lower scores in the sit-up test.
In the present study, there was a statistical correlation between the increased symptoms and the level of IRD, although in the case group, the postpartum median IRD 3.26 ± 0.90 cm was not classified as severe but moderate RD. The mean parity status was two or more in both study groups. In literature, the number of pregnancies seems not to be a risk factor for PLBP.
According to one hypothesis, impaired MC and a lack of awareness of maladaptive movement patterns perpetuate LBP. In previous studies, patients with chronic LBP have significantly more positive tests in MCs tests than pain-free controls., In the present study, we examined if these tests would recognize symptomatic individuals. The chosen tests did not correlate with subjective experience of pain or discomfort in the back or with the ability to perform the same activity than before pregnancy from behalf of physical recovery.
The most important function of the rectus abdominis is the flexion of the trunk by sit-up kind of movement. In the present study, symptomatic cases carried out significantly less sit-ups per 30 s than controls. Some other studies have shown similar results.
There is some evidence that operative treatment of symptomatic RD reduces back pain and core instability.,, To standardize the evidence, an unequivocal classification system of RD is needed. There are few classifications system of RD: Beer, Ranney, Endohernia Society, and Nahas classifications.,,, Ranney classes for IRD severity (W1 < 3 cm, W2 = 3–≤5 cm, and W3 > 5 cm) are used also in Endohernia Society Classification system, where also other features in the abdominal wall are notified such as concomitant hernias as well as parameters of previous pregnancies, skin quality, and pain.
Abdominal RD is a widely discussed topic, especially in relation to operative treatment strategies.,,, Recently also guidelines to treatment indications have been published., EHS guideline concludes that the overall evidence is weak and does not strongly recommend any specific treatment algorithm for diastasis repair. The Swedish national recommendation discusses severe, over 5 cm inter-rectus distance as a width indication for operation. IRD up to 3 cm is common in parous population but severe diastasis is rare. In our previous study, only 1.6% of those having children had IRD wider than 5 cm. Mild and moderate diastasis alone does not seem to predispose to diastasis-related difficulties., One possible explanation is that RD predisposes to problems only when it is severe. A study of the effects of severe diastasis would require extremely large cohorts.
PLBP/PGP seems to have an overlap with RD. More studies are needed to address the possible connection of these phenomena.
Limitations of the study: Small sample size causes limitation, although this was compensated with multiple controls per case. The sit-up test has not yet been validated in this population. Based on this study, no conclusions can be made of the effects of severe diastasis.
| Conclusion|| |
The changes of the IRD may be one of contributing biophysical factors of musculoskeletal dysfunction leading to low back pain in some postpartum females.
The authors thank Timo Pessi, statistics; Timo Janhonen, physiotherapist; and Olivia Tast physiotherapist.
R.T., J.V., T.J., T.S., H.L., and J.A. were involved in study design. R.T., J.M., and J.V. were involved in data analysis, and R.T. and J.V. were involved in interpretation of the results. All writers contributed to the writing of the final report. J.V. was the principal investigator. All authors read and approved submission.
All procedures related to this study were in compliance with current Finnish law. This study was conducted in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. It was approved by the Institutional Multidisciplinary Ethical Review Board in Helsinki University Hospital (HUS/3331/2017) and in Helsinki University Hospital Research Council (HUS/26/2018). The agreement of participants was received according to the Ethical Board Permit.
Human and animal rights
This article does not contain any studies with human participants or animals performed by the authors.
Data and material availability
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Informed consent was obtained from all individual participants included in the study.
Financial support and sponsorship
Conflicts of interest
All authors declare that they have no conflicts of interest in this study.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]