Tara is a physiotherapist and a mother of one child who is 13 months old. She presented with concerns about persistent, intermittent, pain in her low thorax and upper lumbar regions, as well as the visual profile of her 13-month post-partum abdomen. She was looking for ‘core strengthening’ guidance and thought that this would eliminate her back pain and improve the appearance of her abdomen. Tara also had questions regarding the pros and cons of a surgical repair of her abdominal wall, believing that she had a midline ‘hernia’ of her linea alba (LA). She had an uncomplicated pregnancy except for a series of incidents between 21 and 23 weeks when she felt a ‘ripping sensation’ of the LA just above the umbilicus. She felt this ‘ripping’ when she rolled in bed, ‘moved the wrong way’ or lifted heavy objects. Her baby was delivered by Caesarean-Section after her induced labour failed to progress following three hours of pushing.
Tara reported persistent, intermittent pain in her low thorax and upper lumbar regions, which would radiate to include her mid-thorax with increasing activity. Specifically, she felt achiness, fatigue and tenderness to touch localized to the area of the T8, T9 and T10 spinous processes. The onset of these symptoms was insidious, beginning a few months after her delivery, and localized to the thoracolumbar region initially. The symptoms progressed and spread to include the mid-thorax as she increased rotation loads through her trunk with running and kayaking. She did not report any associated, or independent, neurological symptoms such as pins/needles or numbness during any movements or loading of her trunk or extremities. On the Patient Specific Functional Scale (Horn et al 2012, Stratford et al 1995), she reported difficulty with lifting (6/10), running (2/10) and paddling her kayak (1/10). For this scale, 0 equals unable to perform the stated activity and 10 equals able to perform at pre-injury levels. Essentially, she found any task that required loading, especially repetitive rotation of the trunk, aggravating. Her pain was not exacerbated by static loading tasks, such as sitting or prolonged standing.
When asked more about her experience and limitations with running, Tara said it was easier for her to rotate her thorax to the left when she ran and felt she had to ‘pull her left shoulder forward’ to rotate to the right. When asked about her breathing, she reported difficulty breathing during her first two post-partum weeks: ‘I was unable to take a normal deep breath in standing. My upper abdomen would draw in and lower abdomen would pop out’. This symptom settled quickly but returned when she resumed running; she felt her breathing was ‘uncoordinated’. She did not report any urinary leakage with running or any other tasks that increased her intra-abdominal pressure.
Tara’s general health was good with no medical precautionary conditions present. Historically, she reported an episode of unilateral low back and pelvic girdle pain ten years prior that resolved when she reduced her ‘volume’ of dancing. She had not had her spine or thorax imaged.
Tara’s Personal Profile (Social History)
Tara was currently working four days per week in a private orthopaedic physiotherapy practice. Outside of work and caring for her family, she cross-country skied and attended both yoga and Pilates classes. She had not been able to return to running or kayaking at her pre-pregnancy levels, two activities she missed.
Tara believed that she had an abdominal hernia due to tearing of her LA and that this was the result of the series of ‘ripping sensations’ she experienced in the second trimester of her pregnancy. In addition, she felt that her abdominal muscles were weak and that in compensation she was over-using her back muscles, but she did not feel she knew how to correct this imbalance. She believed that her over-used back muscles were contributing to the thoracolumbar ache and fatigue, as well as the local tenderness she experienced when the T8, T9 or T10 spinous processes were palpated. Tara also questioned whether it was possible to restore optimal strength of her abdominal wall without surgical repair of the hernia. She was coping well with both her work and home duties and did not appear overly vigilant to her pain or anxious/worried when telling her story. She was frustrated by her lack of ability to return to her pre-pregnancy levels of fitness and sport, which would seem a reasonable emotion given her circumstances.
Three tasks, based on Tara’s goals, were chosen for evaluation. These tasks also relate to the known function of the abdominal wall:
- Standing posture (position from which lifting and running begins)
- Supine lying curl-up task (requires co-ordinated activation of all abdominal muscles)
- Seated trunk rotation with and without resistance (essential for running and kayaking)
Flexion, extension and sideflexion of the trunk were not tested since these cardinal plane motions, in isolation, do not specifically relate to the aggravating component (trunk rotation) of her meaningful tasks (running and paddling). In addition, no specific neurodynamic tests were included in this examination since there was no indication from her story that this system was contributing to her complaints or her functional limitations.
Standing Posture – Relevant Positional Findings of the Trunk
Tara was not experiencing any pain or discomfort in her thorax or upper lumbar spine at the time of this examination. In standing, her pelvis was rotated to the right in the transverse plane. Her lower thorax was rotated to the left and her middle thorax was rotated to the right. Segmental thoracic ring shifts (Lee L-J 2003a) were noted in both regions of the thorax. Specifically, the 8th thoracic ring was shifted to the right and the 9th to the left. The 4th thoracic ring was shifted to the left and the 3rd to the right.
Tara had five segments within her trunk that were not optimally aligned in standing: the 3rd, 4th, 8th and 9th thoracic rings, as well as the pelvis. To determine the clinical relevance of these asymmetries, a series of regional and segmental asymmetry corrections were made. When her pelvis was manually corrected (to derotate the right transverse plane rotation and center her pelvis over her feet), the alignment of both her lower and middle thorax was worse. Overall, her standing posture was worse and she felt more twisted with this correction. This suggested that treating her pelvic alignment directly would not improve the overall posture of her trunk in standing. In addition, her ability to paddle her kayak and run would not improve if her thorax was more ‘twisted’.
When the 8th thoracic ring was manually corrected (derotate/correct the segmental thoracic rotation/shift to align the adjacent rings), the position of the 9th thoracic ring improved spontaneously, as did the alignment of her pelvis. This suggested that treatment directed towards correcting the alignment of her 8th thoracic ring would improve both the 9th thoracic ring and the pelvic posture in standing. However, this correction did not change the position of the 3rd or 4th thoracic rings. Correcting the 4th thoracic ring improved the 3rd, but not the 8th or 9th rings.
Tara’s standing posture improved the most when both the 4th and 8th thoracic rings were manually corrected simultaneously. None of these manual corrections provoked any symptoms in her thorax or upper lumbar spine. Conversely, Tara noticed the automatic correction in the alignment of her pelvis when her 4th and 8th thoracic rings were simultaneously aligned. She felt ‘less twisted’ and actually had not realized that she was twisted until the two thoracic ring corrections (4th and 8th) were released.
Correcting the alignment of two of her thoracic rings made Tara aware of the relationship between her thorax and pelvis in standing. Her existing body schema was twisted (Berlucchi 2010) but she was unaware of this until the twist was reversed and she ‘attended’ to the response of her body as the correction was released. This is often a ‘Wow’ moment for patients when they realize where they are ‘living in their bodies’ (i.e. acquire a new body schema). Focused attention and awareness are two key conditions necessary for change; these are neuroplastic principles increasingly recognized as critical for musculoskeletal rehabilitation (Boudreau et al 2010, Snodgrass et al 2014, van Vliet et al 2006).
When standing, the profile of Tara’s relaxed abdomen was protuberant and when asked to ‘connect to her core’ excessive activation of the EO abdominals occurred. While this strategy drew her abdomen inward, it did not eliminate the protrusion completely (Figure 2a,b). Her abdomen continued to appear, and feel, highly pressurised.
When the 4th and 8th thoracic rings were manually corrected immediately prior to Tara’s ‘connect’ cue, she noticed a decrease in the pressure sensation of her lower abdomen and when attention was directed to the profile of her abdomen she was pleasantly surprised at the change.
Supine Curl-up Task
The supine curl-up task was chosen to evaluate Tara’s abdominal wall and LA, since this task should involve co-activation of all muscles of the abdominal wall (Andersson et al 1997). With no cue, or instruction, Tara’s automatic strategy for the supine curl-up task produced more bulging of her abdomen and asymmetric narrowing of the infrasternal angle (right side greater than left) (Figure 3a,b).
When she held the curl-up position, the left and right recti could be easily separated along the entire length of the LA (Figure 4) by hand. The inter-recti distance (IRD) was two finger widths (during the curl-up) and of particular note was the lack of tension in the LA. This task did not provoke any symptoms in her thorax or upper lumbar spine.
Ultrasound imaging (UI) provided more information on Tara’s abdominal wall function:
- UI of the lateral abdominal wall during a supine curl-up using an automatic strategy: Tara had difficulty co-activating the right TrA and IO compared to the left.
- UI of the LA during a supine curl-up using an automatic strategy: just above the umbilicus the IRD was 2.55cm at rest and narrowed to 1.99cm during the curl-up. The LA appeared distorted or slack, a finding consistent with the previously noted lack of palpable tension.
- UI of the lateral abdominal wall during a supine curl-up using a ‘connect to core cue’ strategy: Tara was able to produce an isolated contraction of both the left and right TrA when she used imagery and cues to activate her pelvic floor (Sapsford et al 2001); however, she was not able to sustain activation of the right TrA and perform a curl-up task unless she manually corrected the 8th thoracic ring (Lee L-J 2007) (also noted to be shifted to the right in supine lying).
- UI of the LA during a supine curl-up while correcting the alignment of the 8th thoracic ring in addition to using a ‘connect to core cue’ strategy: just above the umbilicus the IRD widened to 2.85cm and the distortion of the LA decreased (Figure 5). Both of these imaging findings suggested that tension of the LA increased with this combined strategy, and this was confirmed with manual palpation.
Seated Trunk Rotation With and Without Resistance
Increased effort was required for Tara to rotate her thorax to the right and when the 8th thoracic ring shift (to the right) was manually corrected, her range of right rotation increased and her effort to perform this task decreased (Lee L-J 2003a, 2012). No symptoms other than ‘resistance’ and ‘effort’ were reported during the seated trunk rotation task. A similar finding was noted with respect to the 4th thoracic ring that was shifted to the left and restricting left thoracic rotation. Left rotation of the trunk/thorax improved with manual correction of the 4th thoracic ring (range of motion improved and the effort to perform the task was reduced). A simultaneous correction of both the 4th and 8th thoracic rings did not further improve either right or left thoracic rotation; a single ring correction was enough for each direction.
When a resisted left rotation load was applied to the trunk through her bilaterally elevated arms, marked loss of low thorax control was evident (Figure 6a). In spite of the loss of regional alignment and control, no pain was provoked with this single (non-repetitive) loading task. When instructed (cued) to pre-activate TrA prior to loading, Tara’s trunk control improved when resistance was applied to right trunk rotation but not to left rotation. Previous evaluation via UI revealed that the 8th thoracic ring required correction before activation of the the right TrA was sustained. When the alignment of the 8th thoracic ring was corrected and its position controlled during the application of the left rotation load, Tara’s low thorax/upper lumbar control, as well as her ‘experience of core rotation strength’ significantly improved (Figure 6b). The ‘gestalt’ of Tara’s experience in her body was related to function and performance, as opposed to the provocation/alleviation of pain during this assessment.
Further testing was done to determine why the 8th thoracic ring was translated to the right/rotated to the left in standing, sitting and lying and failed to transfer loads effectively during resisted left trunk rotation. Findings from these tests resulted in the following observations/deductions:
- The joints of the 4th and 8th thoracic rings demonstrated normal mobility and passive integrity and testing did not provoke pain (Lee D 2003). This is consistent with the finding that both the 4th and 8th thoracic ring shifts were manually correctable.
- Increased resting tone was noted in the right EO, specifically in the part of this muscle that attaches to the anterior aspect of the right 8th rib (Figure 3). The attachment of the right EO to the 8th rib was tender on local palpation. The increased EO tone, and the resultant vector of force it produced on the right 8th rib, was palpable when manually correcting the alignment of the 8th thoracic ring; however, the local tenderness/discomfort was not reproduced with this manual correction, only with direct palpation. The 9th thoracic ring shift to the left corrected when the 8th ring was aligned, suggesting that its position was compensatory.
- No apparent atrophy, or inhibition, of the deep segmental muscles pertaining to the 8th thoracic ring was palpable (i.e. multifidus/rotatores or intercostals).
Treatment – First Session
The EO vector (i.e. tension) that was preventing the 8th thoracic ring from moving optimally during right rotation of the thorax was released (reassessed by palpation) using a positional release technique (Lee D, Lee L-J 2011b). Subsequently, the 8th thoracic ring was no longer held in left rotation/right translation (repeated standing posture assessment) and the amplitude of her active right thoracic rotation increased. Tara noticed an immediate decrease in the effort required to rotate her thorax to the right (repeated seated trunk rotation without resistance). The resting tone of the part of the EO attaching to the right 8th rib was significantly reduced on palpation. When a left rotation load was applied to the trunk through her bilaterally elevated arms, she was still unable to control her lower thorax suggesting that her motor control strategy was still not optimal for regional control of the low thorax.
Tara was then taught a home exercise to maintain the reduced tone and optimal length specifically in this part of the EO. This required manual correction and stabilization of the right 8th rib (part of the 8th thoracic ring) as she then rotated her pelvis (and legs) to the left in supine lying. This exercise is a modified ‘Wipers Pose’ in yoga. At the initiation of the task, inhalation is used to facilitate posterior rotation of the right 8th rib, and thus right rotation of the entire ring (Figure 1b), as the legs and pelvis are taken to the left. Prior to bringing the pelvis back to neutral, exhalation is used to facilitate greater activation of the right TrA (Hodges & Gandevia 2000).
UI is a powerful biofeedback tool (Tsao & Hodges 2007) and was used to teach Tara more about the dys-synergies in her abdominal wall and to understand (left brain) and internalise (right brain) better ways to recruit and use these muscles for her trunk control during rotation loading (running and kayaking). Time was spent empowering her with the education and sensorial experiences she needed to continue to build a different ‘brain map’ for using her abdomen (Tsao et al 2010). We talked about how this was not about ‘exercise’ and ‘strength’, but rather about motor control and muscle patterning. Better strategies needed to be ‘re-built’ first and then she could progress to strengthening exercises. I introduced her to the science of neuroplasticity and directed her to articles and related books on the topic for her own personal and professional learning (Boudreau et al 2010, Doidge 2007, Siegel 2010, Snodgrass et al 2014, Tsao et al 2010). She was encouraged to release her right EO and engage her right TrA frequently over the next seven to ten days, and then to integrate a pre-contraction of the deep abdominals (both TrAs) with the rest of her core muscles whenever she lifted/loaded her trunk. In addition, she was taught to correct the alignment of the 8th thoracic ring in sitting and encouraged to practice maintaining this correction (initially manually and then with imagery) as she rotated her thorax to the right. Once the 8th thoracic ring mobility and control was restored in this task, I felt she would be able to increase her loads and move towards integrating this new strategy into her running and kayaking.
This session was booked as a consultation only since Tara lived a considerable distance from my clinic and was initially interested in just one session for an opinion on appropriate exercises for her ‘core’ and advice on surgery. Consequently, we did not have a follow-up session for one month.
Tara noticed progressive improvement in her functional abilities and significant reduction in both her low thorax and upper lumbar pain with repetitive loading tasks since learning to ‘re-organize the use’ of her abdominal wall and regain control of her 8th thoracic ring. She reported the local tenderness at the spinous processes of T8-T10 persisted, however the intensity and frequency of the ‘achiness and fatigue’ was less and more activity (e.g. longer running time) was required to provoke the symptoms. She was not kayaking yet. She was pleasantly surprised at the change in her abdominal profile (Figure 7a,b).
Physical examination of her standing posture revealed better thoracopelvic alignment; her pelvis was in neutral alignment, as were her 8th and 9th thoracic rings. Since minimal attention had been directed to her 3rd and 4th thoracic rings there was still some upper thorax asymmetry, however they were not interfering with her lifting or running ability.
Supine Curl-up Task
Clinically, both at rest and during her automatic supine curl-up task the infrasternal angle was more symmetric (Figure 8a,b), suggesting that the resting tone of the left and right EO and IO was more balanced.
Without ‘thinking of’ pre-contracting the TrAs, doming of the abdomen was still present and the LA still felt somewhat lax (Figure 9a) (i.e. was easily distorted with finger pressure). Pre-contracting the TrAs significantly increased the palpable tension in the LA and this was improved further by stabilising the 8th thoracic ring (Figure 9b), suggesting further control was still required during this task.
No manual interventions for release of the EO were given during this treatment session. We focused on more movement training and control of the 8th thoracic ring for achieving her goal of being able to run and kayak with ease and without exacerbation of back pain. Both tasks require controlled thoracopelvic rotation, while running also requires alternate flexion and extension of the hips.
Many postures/poses in yoga are useful for rehabilitation of fundamental and functional movements. Parivrtta anjaneyasana, the Sanskrit name for lunge with twist (Figure 10a,b,c), is a useful pose, or task, for runners. To perform this pose well, thoraco-lumbo-pelvic mobility and control (both segmental and regional) is needed, as well as lower extremity mobility and control that far exceeds that required for running. Tara was taught how to do this exercise or pose with optimal alignment, biomechanics and control from the 4th thoracic ring to her foot, with an emphasis on her 8th thoracic ring alignment, mobility and control when rotating to the right and the 4th thoracic ring when rotating to the left. To do this well, she needed cues/images to relax/release the right EO, correct/align/control the 8th thoracic ring, activate the right (and left) TrA, rotate her thoracic rings congruently to the right, flex the right hip and knee and extend the left while maintaining optimal foot control and contact with the floor – no small task! Multiple myofascial slings (Vleeming et al 1995), chains or trains (Meyers 2001) require collaboration to do this well, and with repetition (massed practice) and focused attention (awareness) a better strategy for thoraco-lumbar-pelvic rotation mobility and control can be trained.
Considerable time was spent in this second session ensuring Tara understood the movement practice and she continued to work on the release, alignment and control of her thoracic rings in relationship to her pelvis and hips independently. She was satisfied that she would be able to progress her training on her own and she was advised to return for follow-up advice as necessary.
Seven Months Later
I contacted Tara to ask how she was doing. Here is her emailed reply:
I am feeling really good about it all 🙂 I am able to participate in all desired sports/activities, though not yet to the same intensity as pre-pregnancy, but I am still steadily improving. [She also stated she was completely free from all pain in the thoracolumbar and mid-thoracic regions.]
Having said that I have been meaning to email you and ask your clinical opinion on what you would consider a realistic expectation of what my stomach can endure with respect to another pregnancy.
We are considering trying for baby #2 very soon and my only concern is how my stomach will tolerate the pregnancy. I know there are numerous variables and no concrete answers, but in your experience have you seen women with a situation similar to mine come out of a second or third pregnancy with minimal progression of their diastasis or should I be mentally prepared for things to likely be worse?
No matter what the answer, it isn’t going to sway my decision to have a second baby :), but I would like to be realistic about what I am getting myself into!
There is no literature or research to provide Tara with an evidence-informed answer. No studies have yet determined what causes the LA to widen excessively in some women during pregnancy. For Tara, according to Beer et al (2009) her IRD just above the umbilicus (her widest point) was only slightly wider (2.55 cm) than what is considered to be ‘normal’ (2.2cm) (at rest). In my opinion, her minor DRA was likely caused by the dys-synergy of abdominal recruitment pre-existing her first pregnancy and hopefully now that her abdominal musculature was more balanced and her 8th thoracic ring control was improving, her abdomen would tolerate the required expansion necessary for her second pregnancy without any long-term damage.