Professional Documents
Culture Documents
BACHELOR OF
PHYSIOTHERAPY
BY,
NIDA GULMOHMED SHAIKH
(February 2013)
ACKNOWLEDGEMENT
Indeed I am very glad to present this dissertation as a part of my Bachelor
program. Also I wish to express my sincere gratitude to all those who really
helped me with it.
I am deeply grateful to the GOD ALMIGHTY and my parents for the inner
strength and guiding light which makes my day bright and my problem solvable.
Am indebted to my project guide Dr.Mamta Bolade (MPT) whose constant
interest in the project keeps me going. Had it not been for her advice and
counseling at every step of this project, this mission would have never taken
such form. During my entire course Bachelor program I was truly blessed by the
constant support of my principal and I am very grateful for this constant support
and shall always cherish his valuable suggestions. My gratitude extends to all
other staff members for their encouragement.
I am also grateful to my friends and my batch mates who were with me
throughout the entire project completion and their easy understanding ways
comforted me all the way.
[NIDA
GULMOHMED SHAIKH]
CERTIFICATE
The work has been verified by me from time to time and I am satisfied
regarding the authenticity of the dissertation and confirm to the standards of
Tilak Maharashtra University.
Dr.Mamta Bolade
(MPT in Neuro)
Guide
CERTIFICATE
This is to certify that Ms.Nida Gulmohmed Shaikh has prepared a project entitled
EFFECTIVENESS OF ABDOMINAL MUSCLE STRENGTHENING OF DIVERCATION
OF RECTII IN POST NATAL FEMALES under the supervision and guidance of Dr. Mamta
Bolade ( MPT in Neuro) in partial fulfillment and regulations for awarding her Bachelor of
Physiotherapy degree to my satisfaction.
University , Pune411037.
College Seal
Dr. Ujwal Yeole
(MPT.in Neuro)
(Principal)
CONTENTS
1.
INTRODUCTION
a) DEFINATION
b) INCIDENCE AND PREVELANCE
c) ANATOMY, BIOMECHANICS, PATHOPHYSIOLOGY
AND CLINICAL FEATURES
d) NEED OF STUDY
2.
3.
HYPOTHESIS
4.
REVIEW OF LITERATURE
5.
6.
7.
DISSCUSSION
8.
CONCLUSION
9.
REFERENCE
10.
ANNEXURE
a) MASTER CHART
b) ASSESMENT FORM
c) SCALE
exclusion
ABSTRACT
ABSTRACT
AIM : To find the effectiveness of abdominal muscles strengthening of divercation
of rectii in post natal females.
RESULTS : Individuals given exercises (group A) were seen with more abdominal
muscle strength as compared to those given only the abdominal corset (group B) .
INTRODUCTION
INTRODUCTION :-
DIVERCATION OF RECTII :-
CAUSES :The rectus abdominus is kept in line by your transverse abs and your oblique abs during
pregnancy your abdominal muscles are tend to separate due to the growth of your baby in
your uterus. This growth exerts pressure on the rectus abdominus muscles, causing them
to split. Women who experience rapid growth of their stomachs during pregnancy are
10
more likely to suffer from separated abdominal muscles. Women with particularly weak
abdominal muscles may also end up with a split between the left and right side of the
rectus abdominus.
Separated muscles are actually fairly common during pregnancy. About one third of all
pregnant women experience separated muscles at some point throughout their pregnancy.
Separation of the stomach muscles is more likely to occur during the second trimester of
pregnancy. However, separation also frequently occurs during labor.
SYMPTOMS :Separation of the abdominal muscles is typically painless but there are few symptoms that
will help you to identify the condition. A small amount of separation of midline one or
two fingers width is common after most pregnancies and is not a problem. But if the gap
at your midline is:
a. More than 2cm or 2 finger widths
b. Does not shrink as you deepen the work of your abdominals
c. You can see a small mound protruding at your midline
OCCURANCE :Diastasis rectii occurs in pregnancy as a result of hormonal effect on the connective tissue
and the biochemical changes of pregnancy. It causes no discomfort. It can occur above, below
or at the level of umbilicus but it is less common in women with good abdominal tone prior
to pregnancy.
Routine assessment for this condition is highly recommended and easily done in
conjunction with an abdominal strength testing.
Low tone of abdominal musculature is not the sole cause of Diastasis Recti in post
partum women. Most commonly it is the outcome of the overall lack of balance between all
muscles within abdomen as well as the diaphragm and the muscles of pelvic floor. Diastasis
rectii occur in pregnancy possibly as a result of hormonal effect on the connective tissue and
the biomechanical changes of pregnancy. It causes no discomfort, it can occur above, below
11
or at the level of the umbilicus but appears to be less common below the umbilicus. It appears
to be less common in women with good abdominal tone prior to pregnancy.
A small amount of separation of midlineone to two fingers widthis common
after most pregnancies, and is not a problem. A diastasis recti looks like a ridge, which runs
down the middle of the belly area. It stretches from the bottom of the breastbone to the belly
button, and increases with muscle straining. If the gap of more than 2cm or 2 finger width at
the midline indicate Diastasis rectii. The abdomen does not shrink as you deepen the work of
the abdominals. Small mound protruding at the midline is also seen.
INCIDENCE :This condition is not exclusive to childbearing women but is seen frequently in this
population.
Diastasis is commonly found in women ( i.e. 80 % )and occasionally in men ( i.e. 7 -10
%)
This condition is more pronounced in indian population due to multiple pregnancy.
The abdominals are composed of several muscles: the rectus abdominus, transverse
abdominus, and the external and internal obliques.
12
The abdominal muscles sit on the front and sides of the lower half of the torso, originating
along the rib cage and attaching along the pelvis.
Rectus abdominus When fully developed the rectus abdominus is the most prominent
abs muscle. It runs the length of your abs area, from your pubic bone to the lower chest.
Contraction of this muscle flexes your torso. If your torso is moving towards your hips
(crunches) you are focusing on the upper abs. if your hips are moving towards your torso i.e
reverse crunches, you will focus on the lower section of abs.
.External oblique
Your external oblique runs diagonally down from your lower eight ribs, attaching to the top
half of your hip and your rectus abdominis. The external obliques, along with the internal
obliques twist your body at the waist and straighten your body when its bend to the side.
Some exercises that work your obliques are: crossovers, bicycles and side bends. Some
examples: Baseball, tennis, golf and other racket sports.
13
Internal oblique
The internal obliques lie underneath the external obliques and run in a diagonally opposite
direction. The internal obliques work with the externals to rotate the trunk. Unlike the
external obliques, they are not visible when fully developed.
Transverse Abdominis
14
Of the four muscles of the abdominal muscle group, the transverse abdominis is the one that
does not cause trunk movement. It is the suck in your gut muscle that pulls the abs wall
inwards. It is located deep in your abdomen, underneath your obliques. It holds your organs
in place and forces, expiration when contracted. This muscle is often overlooked, which is a
mistake because training it properly can pull your stomach in, giving you a slimmer profile.
The mid-section muscles consist of the rectus abdominis and the internal and external
obliques.
15
The muscle is enclosed in a sheath formed by the aponeurosis (broad, flat and thin connective
tissues) of the other abdominal muscles.
The rectus abdominus flexes the spinal column bringing the rib cage and the towards each
other, and assists in sideward bending. It is also actively involved in stabilizing the trunk
when the head is raised in a supine position.
The external oblique muscles are the most outmost fibres of the trunk, and are located on
each side of the rectus abdominis.
The lower and middle attachments of the external obliques are to the anterior crest of the
pelvis and from the ribs to the crest of the pubis. The external oblique muscle actually
becomes the inguinal ligament. The fibres of this muscle run diagonally forming a V shape
similar to putting your hands into your coat pocket.
Beneath the external muscles running at approximately right angles to them are the internal
oblique muscles which form an inverted V shape.
The deepest layer of abdominal muscles the transversus abdominis is not involved in
movements of the trunk. Instead this respiratory muscle plays an important function in
forceful expiration of air from the lungs as well as compression of the internal organs.
The hip flexors bring the legs and trunk toward each other. Full sit ups involve the hip flexors
which may cause the lower back to arch and unwanted back pain particularly in individuals
with relative weak abdominals.
Traditional sit ups emphasize sitting up rather than merely pulling your sternum down to
meet your pelvis. The action of the psoas muscles which run from the lower back around to
the front of the thighs, is to pull the thighs closer to the torso. This action is the major
component in sitting up. Because of this sit ups primarily engage the psoas making them
inefficient at exercising your abs, because the psoas work best when the legs are close to
straight so for most of the sit ups (as they are when doing sit ups) the psoas are doing most of
the work and the abs are just stabilizing.
16
Rectus abdominus :Flexes the spine (bringing the rib cage closer to the pelvis). This is seen in the abdominal
crunching movement. When the movement is reversed, the rectus abdominus acts to bring the
pelvis closer to the rib cage (e.g with a leg raising movement).
Transverse abdominus :Acts as a natural weight belt keeping your insides in. this muscle is essential for trunk
stability as well as keeping your waist tight.
Internal And External Obliques :Work to rotate the torso and stabilize the abdomen.
17
It is referred to as carrying of one or more offspring, known as a fetus or embryo, inside the
uterus of a female. In a pregnancy, there can be multiple gestations, as in the case of twins or
triplets. Obstetrics is the surgical field that studies and cares for the high risk pregnancy.
Childbirth :It usually occurs about 38 weeks after conception, i.e approximately 40 weeks from the last
normal menstrual period (LNMP) in humans. The world health organization defines normal
term for delivery as between 37weeks and 42weeks. The calculation of this date involves the
assumption of a regular 28 day period.
One scientific term for the state of pregnancy is gravid, and a pregnant female is sometimes
referred to as a gravida.
Similarly the term parity is used for the number of previous successful live births.
Medically a woman who has never been pregnant is referred to as a nulligravida, and a in
subsequent pregnancies as multigravida or multiparous. Hence during a second
pregnancy women would be described as gravida2,para1 and upon delivery as
gravida2,para2. An in progress pregnancy as well as abortions, miscarriages or stillbirths
count for parity values being less than the gravida number, whereas a multiple birth increase
the parity value. The medical term for a woman who is pregnant for the first time is a
primigravida.
The term embryo is used to describe the developing offspring during the first eight weeks
following conception, and theterm fetus is used from about two months of development until
birth.
In many societies medical or legal definitions, human pregnancy is some what arbitrarily
divided into three trimester periods, as a means to simplify reference to the different stages of
pre natal development. The first trimester carries a highest risk of miscarriages(natural
death of embryo or fetus)
18
During the second trimester, the development of the fetus can be more easily monitored and
diagnosed. The beginning of the third trimester often approximates the point of viability, or
the ability of the fetus to survive, with or without medical help, outside of the uterus.
Progression :-
Initiation:Pregnancy occurs as the result of the female gamete or oocyte being penetrated by the male
gamete spermatozoon in a process referred to in medicine as fertilization, or more
commonly known as conception. After the point of fertilization it is referred to as an egg.
The fusion or male and female gametes usually occurs through the act of sexual intercourse.
However the advent of artificial insemination and in vitro fertilization have also made
achieving pregnancy possible in cases where sexual intercourse does not result in fertilization
Perinatal period:-
Perinatal defines the period occurring around the time of birth, specifically from 22
completed weeks (154days) of gestation(the time when birth weight is normally 500gm) to
seven completed days after birth.
Legal regulations in different countries include gestation age beginning from 16-22
weeks(5months)before birth.
Postnatal period:-
Duration :19
The expected date of delivery (EDD) is 40 weeks counting from the last menstrual period and
birth usually occurs between 37 and 42 weeks, the actual pregnancy duration is typically
38weeks after conception. Though pregnancy begins at conception, it is more convenient to
date from the first day of a womans last menstrual period, or from the date of conception if
known. Starting from one of these dates the expected date of delivery can be calculated. 40
weeks is nine month and six days, which forms the basis of Naegeles rule of estimating date
of delivery.
Pregnancy is considered at term when gestation attains 37 complete weeks but is less than
42(between 259 and 294 days since LMP). Events before completion of 37 weeks(259 days )
are considered pre term, from week 42(294 days ) events are considered post term. When a
pregnancy exceeds 42 weeks the risk of complications for women and the fetus increases
significantly. As such, obstetricians usually prefer to induce labour, in an uncomplicated
pregnancy , at some stage between 41 and 42 weeks..
Fewer than 5% of births occur on the due date; 50% of births are within a week of the due
date and almost 90% within two weeks. It is much more useful, therefore to consider a range
of due dates, rather than one specific day with some online date calculators providing this
information.
Changes in the body during pregnancy are most obvious in the organs of the reproductive
system.
Uterus :Changes in the uterus are phenomenal. By the time the pregnancy has reached term, the
uterus will have increased five times its normal size:
In width from 4 to 24 cm
21
The capacity of the uterus must expand to normally accommodate a seven pound fetus
and the placenta, the umbilical cord, 500 ml to 1000 ml of amniotic fluid, and the fetal
membranes.
The abdominal contents are displaced to the sides as the uterus grows in size which
allows for ample space for the uterus within the abdominal cavity.
Alterations in hormonal balance and mechanical stretching are responsible for several
changes in the integumentary system. The following changes occur during pregnancy:
(a) Linea Nigra :- This is a dark line that runs from the umbilicus to the symphysis pubis
and may extend as high as the sternum. It is a hormone- induced pigmentation. After
delivery, the line begins to fade, though it may not ever completely disappear.
(b) Mask of pregnancy (chloasma) :- This is the brownish hyper pigmentation of the
skin over the face and forehead. It gives a bronze look, especially in dark
complexioned women. It begins about the 16th week of pregnancy and gradually
increases, then it usually fades after delivery.
22
(c) Striae Gravidarum (stretch marks) :- This may be due to the action of the
adrenocorticosteroids. It reflects a separation within underlying connective tissue of
the skin. This occurs over areas of maximal stretch the abdomen, thighs and breasts.
It usually fades after delivery although they never completely disappear
(d) Sweat glands :- Activity of the sweat glands throughout the body usually increases
which causes the woman to perspire more profusely during pregnancy.
23
PREGNANCY WEIGHT GAIN :The total weight gain in pregnancy is about 10 to 15 kgs
a. Fetus 3 to 4 kgs
b. Placenta 1 to 1 1 kgs
c. Amniotic fluid th 1 kg
d. Uterus and breast 2 to 3 kgs
e. Blood and other fluids 1 to 4 kgs
f. Muscles and fat to 3 kgs
MUSKULOSKELETAL SYSTEM :Abdominal muscles are stretched to the point of their elastic limit by the end of pregnancy.
This greatly decreases the muscles ability to generate a strong contraction and thus decreases
their efficiency of contraction. The shift in the center of gravity also decreases the mechanical
advantage of the abdominal muscles.
Hormonal influence on the ligaments is profound, tensile strength. This change is primarily a
result of change in relaxin and progesterone levels. Joint hyper mobility occurs as a result of
ligaments laxity and ligaments injury, especially in the weight bearing joints of the back,
pelvis and lower extremities.
The pelvic floor muscles must withstand the weight of the uterus, the pelvic floor drops as
much as 2.5cm (1 inch). The pelvic floor may be stretched, torn or injured during the birth
process. Stretch and compression of the pudental nerve occurs as the babys head travels
through the birth canal. This compromise to the pudental nerve is most intense during
pushing. As a result the pelvic floor is vulnerable from both a muscular and neurologic
perspective during labor and vaginal delivery.
As the musculoskeletal changes occur during pregnancy, along with other muscles abdominal
muscles also become weak and at the same time size of the uterus increases 5-6 times
because of which linea alba splits and the is known as diastasis recti.
POSTURE AND BALANCE CHANGES:The center of gravity shifts upward and forward because of the enlargement of the uterus and
breasts. This requires postural compensations for balance and stability. The shoulder girdle
25
and upper back become rounded with scapular protraction and upper intremity internal
rotation because of breast enlargement and postpartum positioning for infant care. Tightness
of the pectorial stabilizers also contributes to this postural changes. Cervical spine and
forward head posture develops to compensate for the shoulder alignment.
Lumbar lordosis increases to compensate for the knees hyperextend probably because of
changes in the line of gravity. Weight shifts towards the heels to bring the center of gravity to
a more posterior position. Changes in posture do not usually correct spontaneously after
childbirth and the pregnant posture may be maintained as a learned posture.
During pregnancy a women develops postural changes that are necessary for her to maintain
balance in the upright posture.
As the abdominal muscles are stretched and tone is diminished, they lose their ability to
contribute effectively to the maintenance of neutral posture with the biomechanical changes it
was thought that lumbar lordosis increases.
As pregnancy continues, production of the hormone relaxin increases & reaches peak
between 38 to 48 weeks.
Relaxin creates joint laxity which is necessarily the enlarging uterus. Joint laxity is more
pronounced in multi-parous as compare to nulli-parous women.
In the lumbar spine joint laxity is most notable in the anterior and posterior longitudinal
ligaments. This weakens the ability of static supports in the lumbar spine to withstand the
shearing forces.
As a result there may be an increase in discogenic symptoms and on pain coming from, the
facet joints in the pelvis, it laxity is the most prominent in the symphysis pubis and the SI
joints.
If you are suffering from separated muscles during pregnancy or in the postpartum period,
it is important to take steps to encourage your muscles to reattach on their own and they may
26
actually continue to separate after you have given birth. If left untreated, separated muscles
can cause health complications, including:
(1) Chronic lower back pain (due to the fact that the abdominal muscles help to
support your back and spinal column)
(2) Altered posture due to weak abdominal muscles (which is in turn weakens
your back muscles, leading to back pain).
TREATMENT FOR DIVERCATION OF RECTII :There are some easy ways to help treat separated muscles after you have given birth.
Abdominal exercises, bracing the abdomen by using abdominal corset, and Incase of tearing
surgery is recommended.
STRENGTENING OF ABDOMINAL MUSCLES :Simple abdominal exercises can help to bring the left and right sides of your rectus
abdominus back together. These abdominal exercises are designed to help target weak
muscles and will not cause extra stress to your stomach or back.
Work to perform three sets of ten repetitions each.
Before you begin any type of exercise, though be sure to consult with your health care
provider. These stomach exercises are suitable if you have undergone a cesarian section as
long as your stitches have been removed and your scars have healed.
27
Lie on your back with your knees bent and feet flat on the floor. Work to bring
your navel as close as possible to your spine, so it looks as if your stomach is
caving in. Hold this for a minute or two, while continuing to relax and breathe.
(b) Head Lift Exercise 2 :Lie on your back with your knees bent and feet flat on the floor. Place both of your
hands on your abdomen, fingers pointing towards your pelvis. Exhale and lift your
head off of the floor, while pressing down with your fingers.
(c) Head Lift With Pelvic Tilt :Lie on your back with knees bent and feet flat on the floor. Press your buttocks
down or contract gluteus ,this causes posterior tilting of pelvis. Then exhale & lift
your head & maintain the pelvic tilt.
(d) Leg Sliding :Lie on your back with your knees bent and feet flat on the floor. Exhale and extend
one leg out in front of you. Wait for your abdomen to contract and then inhale and
place your leg back on the floor. Alternate legs.
(e) Head Lift With Towel :Wrap a long towel around your stomach with the ends in front of your abdomen.
Do a crunch. As u raise your shoulders and head off of the ground, pull the ends of
the towel towards one another.
Diastasis rectii may produce musculo-skeletal complaints such as low back pain as a
result of a decreased ability of the abdominal muscle to control the pelvis and lumbar spine.
Functional limitation can also occur such as inability to perform independent supine to sitting
transitions. Severe cases of Diastasis rectii may progress to herniation of the abdominal
viscera.
Abdominal exercise is very important not because they help in shaping abs but
because they help in strengthening your spine in order to reduce the backaches. They are also
meant for promoting good posture.
As this condition is very common in post natal women there is a need to correct the
condition in females among the age group of 28 to 38 years.
29
30
OBJECTIVE :-
31
HYPOTHESIS
There is a significant effect of abdominal muscle strengthening exercises against the control
group in divercation of rectii in the age group of 28 to 38 years old postnatal females.
NULL HYPOTHESIS :There is no significant effect of abdominal muscle strengthening exercises against the control
group in divercation of rectii in the age group of 28 to 38 years old postnatal females.
33
REVIEW OF LITERATURE
Pregnant Women
34
Chiarello, Cynthia M.; Falzone, Laura A.; McCaslin, Kristin E.; Patel, Mita N.; Ulery, Kristen
R.
Journal of Womens Health Physical Therapy. 29(1):11-16, Spring 2005.
Abstract:
The purpose of this project was to determine the effect of an abdominal strengthening
exercise program on the presence and size of DRA in pregnant women.
Subjects were comprised of 8 pregnant women participating in an abdominal exercise
program and 10 non-exercising pregnant women. Diastis recti abdominis was measured using
a digital caliper at 3 marked sites along the midline of each subject's abdomen: 4.5 cm above
the umbilicus, at the umbilicus, and 4.5 cm below the umbilicus. Two measurements were
taken at each site, and the average was used for statistical analyses. Descriptive statistics were
generated, and independent t-tests were performed on each subject characteristic. An analysis
of covariance was computed with the number of previous pregnancies as the covariate to
control for the difference between the subject groups.
90% of non-exercising pregnant women exhibited DRA while only 12.5% of exercising
women had the condition. The mean DRA located 4.5 cm above the umbilicus was 9.6 mm
(+/- 6.6) for the exercise group and 38.9 mm (+/- 17.8) for the non-exercise group. The mean
DRA located at the umbilicus was 11.4 mm (+/- 3.82) for the exercise group and 59.5 mm
(+/- 23.6) for the non-exercise group. The mean DRA located 4.5 cm below the umbilicus
was 8.2 mm (+/- 7.4) for the exercise group and 60.4 (+/- 29.0) for the non-exercise group.
Thus occurrence and size of DRA is much greater in non-exercising pregnant women
than in exercising pregnant women.
2) Diastasis Rectus Abdominis and Lumbo-Pelvic Pain and DysfunctionAre They Related?
Parker, Meredy A. PT, DPT1; Millar, Lynn A. PT, PhD, FACSM2; Dugan, Sheila A. MD3
Abstract
The purpose of this study was to examine the clinical assumption that the presence of
diastasis recti abdominis (DRA) causes lumbopelvic pain (LPP) or dysfunction.
Subjects (n=39; PG) included women seeking medical care for lumbar or pelvic area
diagnoses (>18 years old) who had delivered at least one child. A control group (n=53; CON)
of women were included, as well as a third group (n=8; LAP) with a history of a laparoscopy.
Subjects completed the Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire,
and the Modified Oswestry Low Back Pain Disability Questionnaire, as well as 2 Visual
Analog Scales (VAS) for pain. A dial caliper was used to measure the distance between the
rectus bellies. Differences between groups were analyzed using ANOVAs.
35
The incidence for the DRA was 74.4% for the PG, 50.9% in the CON, and 100% in the
LAP groups. There was a significant difference between groups for all pain and dysfunction
scales. There was also a significant difference between those with and without DRA for the
VAS scores for abdominal and pelvic area pain. Otherwise, there was not a significant
difference between those with and without DRA for any other LPP or function scales.
Thus Women with a DRA tend to have a higher degree of abdominal or pelvic region
pain.
the need for intervention and, if needed, the effectiveness of specific intervention to reduce
the size of IRD in postpartum women.
J Orthop Sports Phys Ther 2011;41(6):435-443, Epub 2 February 2011.
doi:10.2519/jospt.2011.3507
Abstract
The purpose of this case report is to illustrate the use of specific abdominal exercises for the
management of unresolved diastasis recti in a woman 6 years postpartum.
37
This case describes a 34-year-old woman referred for physical therapy with a
diagnosis of diastasis recti and report of increasing abdominal pain and swelling over the last
4 years . She was 6 years postpartum and 5 years posthysterectomy. A diastasis recti of 4
fingerbreadths was noted during physical therapy examination as well as impairments of
decreased abdominal muscle performance and motor control. Limited physical function was
reported with the patient unable to perform activities other than light household duties and
had reportedly adopted a sedentary lifestyle.
An abdominal muscle pelvic CT scan confirmed the clinical findings of diastasis of
the rectus muscle with images obtained in spinal flex- ion. Physical therapy treatment
consisted of a 3- month program that emphasized specific exercises for transversus abdominis
strength. Treatment was initially carried out 3 times a week and was decreased to once every
other week by the time of discharge. A daily home exercise program was included as a
component of the physical therapy program and it was recom- mended to be continued
indefinitely and at the time of discharge.
Following the 3- month physical therapy program, the pain complaints resolved
completely and the previous level of function was restored.
38
MATERIAL METHODOLOGY
2) SOURCE OF DATA:
a) METHODOLOGY :i) POPULATION
Females between 28 - 38 years of age.
ii) SELECTION CRITERIA :a) INCLUSION CRITERIA:
Sex: females
b) EXCLUSION CRITERIA:
Cessarian delivery
Trauma at abdomen
Un co-operative patients.
4) PROCEDURE :30 subjects females satisfying the inclusion criteria will be selected, written
consent will be taken from the selected subjects and randomly assigned as follows.
Experimental Group - 15 subjects
Control Group - 15 subjects
Separation of rectus abdominis is assessed in both experimental and control group
using finger test & MMT for rectus abdominis.
Experimental group will receive abdominal strengthening exercises for a period
of 1 week. Exercises are performed for 15 20 mins for two sessions per day. The duration
of the exercises can be gradually increased to 30 mins.
TREATMENT :-
The control group will be using only abdominal corset for 1week.
After a week post treatment evaluation is done in both groups using MMT scale
and the scores will be recorded.
MMT scale.
2.
Abdominal corset
CONSENT FORM
have been informed that this study is carried to know the effect of
Procedure
I understand that my Pain will be assessed by Ms.Nida .G . Shaikh with MMT
scale. And I have to undergo 7days of treatment (experimental group) /
abdominal corset (control group). I am aware that I have to follow the
researchers instruction as has been told to me.
Risk and comfort
42
I understand that there is no potential risk associated with this study and this
study will not produce any harm to me by participating. I understand that there
wont be any discomfort throughout the study. I am aware that Ms. Nida .G.
Shaikh will help me for better understanding of the procedure.
Benefits
I understand that this study helps to know the efficiency of abdominal muscle
strengthening exercises in divercation of rectii.
Alternatives
I understand the procedure being studied is the standard way than compared to
other studies which can be conducted by using other tools.
Confidentiality
All the data recorded will be kept in strictest confidence. Apart from the
researcher no one will ever access to the data without your permission. If the
data is used for publication in the medical literature or for the teaching purpose,
no names will be used
Photograph consent
Ms. Nida .G. Shaikh has explained to me that photographs are required in order
to illustrate various aspects of the study for the thesis and other articles, and at
presentations or conferences. These images may also be converted to electronic
formats for use in multimedia presentations and documents accessible to others
by computers for promoting this research. By giving my consent I authorise Ms.
Nida .G. Shaikh to use any of the photographs taken of me in printed format, in
slides for presentation, and in electronic format.
Request for more information
I understand that I may ask any questions of the study at any time, Ms. Nida .G.
Shaikh is available to answer my questions, and copy of this consent form will be
given to me for my careful reading.
Refusal or withdrawal of participation.
I understand that my participation is voluntary and may refuse to withdraw
consent and discontinue participation at any time. I also understand that she may
not include my participation in the study at any time after she has explained the
reason for doing so.
Injury statement
I understand that in the unlikely event of the injury resulting directly/indirectly from
my participation in this study, medical treatment will be available but no further
43
date:
I confirm that Ms. Nida .G. Shaikh has explained me the purpose of research
study, the procedure and the possible risk and benefits that I may experience, I
have read and I have understood this consent to participate as a subject in this
research project.
Candidates signature:
date:
Witness signature:
date:
APPENDIX III
PROFORMA
Name
Group
Age
serial no:
Sex
date of assessment:
Address
Phone no:
Mobile:
Inclusion criteria:
(Y/N)
(Y/N)
44
(Y/N)
Exclusion criteria:
(Y/N)
(Y/N)
(Y/N)
(Y/N)
(Y/N)
(Y/N)
Outcom
MMT
Scale
Date
APPENDIX IV
Slowly actively raise the head and shoulders off the floor, reaching her hands
towards the knees, until the spine of the scapulae leaves the floor
Place fingers of one hand horizontally across the midline of the abdomen at the
umbilicus
The number of fingers that can be placed between the rectus muscle bellies
measures diastasis
Less than 2 fingers or 2 cms is normal; more than 2 fingers or 2 cms is abnormal
MMT Scale :-
1) Head Lift Exercise 1 :Hold for 30 seconds then relax - repeat 10 times for 15-20mins
two session/day
2) Head Lift Exercise 2 :Hold for 30 seconds then relax - repeat 10 times for 15-20mins
two session/day
3) Head Lift With Pelvic Tilt :Hold for 30 seconds then relax - repeat 10 times for 15-20mins
two session/day
47
4) Leg Sliding :Hold for 30 seconds then relax - repeat 10 times for 15-20mins
two session/day
5) Head Lift With Towel :Hold for 30 seconds then relax - repeat 10 times for 1520mins two session/day
48
Treatment
Mean
St Dev
SE Mean
PRETreatment
15
1.000
0.000
0.000
POSTTreatment
15
2.200
0.775
0.200
Difference
15
-1.200
0.775
0.200
49
P-Value
= 0.000
The treatment given showed improvement from the pre-treatment mean 1.000
and post-treatment mean 2.200 with T- Value= -6.00 and P-Value=0.000 and the
above graph also represent the increase in range post-treatment.
GROUP B
TABLE 2
Treatment
Mean
St Dev
SE Mean
PRETreatment
15
1.000
0.000
0.000
POSTTreatment
15
1.667
0.488
0.126
Difference
15
-0.667
0.488
0.126
50
P-Value =
The treatment given showed improvement from the pre-treatment mean 1.000
and post-treatment mean 1.667 with T- Value=-5.29 and P-Value=0.000 and the
above graph also represent the increase in range post-treatment.
Treatment
Mean
St Dev
SE Mean
PostTreatment
15
2.200
0.775
0.200
15
1.667
0.488
0.126
15
0.533
0.990
0.256
Group A
(experimental
group)
PostTreatment
Group B
(control
group)
Difference
51
DISCUSSION
52
DISCUSSION:During pregnancy many women experience a separation of their stomach muscles. Known as
diastasis rectii, this condition occurs when the main abdominal muscles called the rectus
abdominus begins to pull apart. The left and right sides of this muscles separate, leaving a
gap in between.
As the musculoskeletal changes occur during pregnancy, along with other muscles abdominal
muscles also become weak and at the same time size of the uterus increases 5-6 times
because of which linea alba splits and this is known as diastasis recti.
In the study of Divercation of rectii in postnatal care 30 subjects were selected according
to inclusive and exclusive criteria which include Multigravid women among the age group of
28 to 38 years within first week after delivery.
The females were assessed for Divercation of rectii by placing the Patient is in hook lying
position. The Divercation is measured by the number of fingers that can be placed between
53
the rectus muscle belly. Any separation larger than 2 cm or two finger widths is considered
significant. Since a Divercation of rectii can occur above, below or at the level of the
umbilicus, test for it at all three areas.
After checking the presence of divercation, MMT(manual muscle testing) of Rectus
Abdominis muscle was checked. Almost, all the subjects demonstrate grade 1 MMT.
And finally the strengthening of Rectus Abdominis was given for a week and the results
noted. Before treatment the mean MMT was 1 and after treatment the mean MMT recorded
was 2 or 3.
Hence, the study is highly significant. This means that strengthening of Rectus abdominis is
effective in divercation of rectii.
Our observation indicates strengthening of rectus abdominus more in group A as compared to
group B.
Group A has a pre test mean value 1.000 to post test mean value 2.200 with T value -6.00 and
P value 0.000.while in group B pre test mean value 1.000 to post test mean value was 1.667
with T value -5.29 ands P value 0.000
The report supported the hypothesis that there is a significant effect of abdominal muscle
strengthening exercises (Group A) in divercation of rectii in the age group of 28 to 38 years
old postnatal females.
54
CONCLUSION
55
CONCLUSION:From the above study performed and data collected it is concluded that
strengthening of abdominal muscle is effective in divercation of rectii in postnatal
females.
56
57
The study was short term study result did not show much significant changes
between the two groups of patients, each group being treated with different
techniques.
Sample size was very small, so further study using a large sample size could be
better to compare the effectiveness of treatment.
58
59
REFRENCES
LIST OF REFERENCES :-
25. Martin EG, Lovett RW. A method of testing muscular strength in infantile
Paralysis. JAMA. pp. 15123. 1915 Oct 30.
ANNEXURE
62
___________
Date
ASSESSMENT FORM
64
Accidental65
INCLUSIVE CRITERIA :
1. AGE: 28-38
2. POST DELIVERY: WITH IN 1 WEEK
3. HOUSE WIVES.
4. MULTIGRAVID.
66
SCALE
67
GRADE 1:- Place the hand below L5 spine and ask to press the hand that is there is a
flicker of contraction.
GRADE 2:- Hook the finger and tell her to see the toes ie. head and cervical spine are off the
bed.
GRADE 3:- Hook the finger and try to sit ie. Scapula off the bed & patient is able to sit.
GRADE 4:- Hands across the chest and the patient is able to sit.
GRADE 5:- Both the hands clasped behind the head and the patient is able to sit.
68
MASTER CHART
69
GROUP A
MASTER CHART
SR.NO AGE GENDER
GROUP A
(EXPERIMENTAL
GROUP)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
29
28
32
30
28
35
29
33
30
29
29
36
29
30
34
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
70
PRE-
POST-
TREATMENT
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
TREATMENT
2
3
1
2
3
2
3
1
2
3
1
3
3
2
2
GROUP B
MASTER CHART
SR.NO
GROUP B
(CONTROL
GROUP)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
AGE
GENDER
PRE-
POST-
28
31
28
28
30
29
30
28
36
30
37
34
29
28
30
F
F
F
F
F
F
F
F
F
F
F
F
F
F
F
TREATMENT
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
TREATMENT
1
2
2
2
1
2
2
2
2
2
2
2
1
1
1
71