EFFECTIVENESS OF ABDOMINAL MUSCLE STRENGTHENING OF DIVERCATION OF RECTII IN POST NATAL FEMALES

A project report submitted in partial fulfillment of the requirements for Bachelor of Physiotherapy of Tilak Maharashtra Vidhyapeeth, Pune.

BACHELOR OF PHYSIOTHERAPY

BY,

NIDA GULMOHMED SHAIKH

(February 2013)

TILAK MAHARASHTRA VIDHYAPEETH, PUNE.

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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]

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CERTIFICATE

`This is to certify that the dissertation entitled “ EFFECTIVENESS OF ABDOMINAL

MUSCLE STRENGTHENING OF DIVERCATION OF RECTII IN POST NATAL

FEMALES’’ has been successfully completed by Ms.Nida Gulmohmed Shaikh under my

supervision and guidance towards the partial fulfillment for the requirement for the Bachelor of

Physiotherapy degree to Tilak Maharashtra University.

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.

I have great pleasure in forwarding and recommending the work to Tilak Maharashtra

University.

Dr.Mamta Bolade

(MPT in Neuro)

Guide

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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.

I have a great pleasure in forwarding this work to Tilak Maharashtra

University , Pune—411037.

College Seal

Dr. Ujwal Yeole

(MPT.in Neuro)

(Principal)

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CONTENTS

1. INTRODUCTION

a) DEFINATION

b) INCIDENCE AND PREVELANCE

c) ANATOMY, BIOMECHANICS, PATHOPHYSIOLOGY AND CLINICAL FEATURES

d) NEED OF STUDY

2. AIMS AND OBJECTIVES

3. HYPOTHESIS

4. REVIEW OF LITERATURE

5. MATERIAL AND METHODOLOGY

a) POPULATION

b) SAMPLE SIZE

c) SAMPLING DESIGN

d) STUDY DESIGN

e) STUDY SETTING

f) SELECTION CRITERIA(inclusion and exclusion criteria)

g) MATERIAL USE

h) OUTCOME MEASURE

i) PROCEDURE

6. RESULT AND TABLES

7. DISSCUSSION

8. CONCLUSION

9. REFERENCE

10. ANNEXURE

a) MASTER CHART

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b) ASSESMENT FORM

c) SCALE

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ABSTRACT

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ABSTRACT

TITLE : Effect of abdominal muscles strengthening of divercation of rectii in post natal females.

AIM : To find the effectiveness of abdominal muscles strengthening of divercation of rectii in post natal females.

STUDY DESIGN : Experimental study.

SET UP : Saifee hospital, Charni Road.

Noor Hospital, Mohammed Ali Road

METHODOLOGY : 30 patients from age group of 28 – 38 years with diastasis rectii were selected for the study by scanning for inclusion & exclusion criteria using clinical attachments and by examining the patients. Once diagnosed for diastasis rectii, patients were divided into 2 groups , each consisting of 15 patients. Group A were given exercises. Group B were given abdominal corset. The MMT scale was used before and after the treatment to see the strength of abdominal muscles.

OUTCOME MEASURES : The MMT scale.

DATA ANALYSIS : Student –t test was used ,paired t-test.

RESULTS : Individuals given exercises (group A) were seen with more abdominal muscle strength as compared to those given only the abdominal corset (group B) .

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INTRODUCTION

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INTRODUCTION :-

DIVERCATION OF RECTII :-

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 begin to pull apart. The left and right sides of this muscles separate,

leaving a gap in between. Separated muscles do not tear or rupture so little pain is

involved at least initially. Instead the muscle thin out, creating a space in the abdomen.

This gap can get worse over time and may result in future health complications.

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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

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 ½ 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.

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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

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 midline—one to two fingers’ width—is 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.

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ANATOMY OF ABDOMINAL MUSCLES :-

The abdominals are composed of several muscles: the rectus abdominus, transverse

abdominus, and the external and internal obliques.

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 –

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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.

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.

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Transverse Abdominis –

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.

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PHYSIOLOGY OF ABDOMINAL MUSCLES :-

The mid-section muscles consist of the rectus abdominis and the internal and external

obliques.

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

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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.

BIOMECHANICS OF ABDOMINAL MUSCLES:-

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.

ANATOMY & PHYSIOLOGY OF PREGNANCY :- 17

Pregnancy (latin graviditas):-

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

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pre natal development. The first trimester carries a highest risk of miscarriages(natural

death of embryo or fetus)

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:-

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Duration :-

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 woman’s 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 Naegele’s 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.

PHYSIOLOGY OF PREGNANCY :- 20

a) CHANGES OF THE REPRODUCTIVE SYSTEM DURING

PREGNANCY :-

Approximate height of the fundus at various weeks of pregnancy.

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:

length from 6.5 to 32 cm.

In depth from 2.5 to 22 cm

In width from 4 to 24 cm

In weight from 50 to 1000 grams

In thickness of the walls from 1 to 0.5com

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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.

1. Growth of the uterus occurs at a steady, predictable pace.

2. Measurement of the fundal height during pregnancy is an important factor that is

noted and recorded.

3. Growth that occurs too fast or too slow could be an indication of problems.

4. The size of the uterus usually reaches its peak at the 38 week gestation. The uterus

may drop slightly as the fetal head settles into the pelvis, preparing for delivery. This

dropping is referred to as lightening. This is more noticeable in a primigravida than a

multigravida.

CHANGES OF THE SKIN DURING PREGNANCY :-

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.

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(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.

BIOMECHANICAL ALTERATION DURING

PREGNANCY :-

There is a realignment of the spinal curvatures during pregnancy to maintain

balance. It is due to the increase in size of the uterine and pressure on the

abdominal wall. The patient with head and shoulders thrust backward and

chest protruding outward to compensate. This gives the patient a “wadding”

gait.

There is a slight relaxation and increased mobility of the pelvic joints,

which allows stretching at the time of delivery of the infant.

Postural changes during pregnancy :-

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SYSTEMIC CHANGES DURING PREGNANCY :-

PREGNANCY WEIGHT GAIN :-

The total weight gain in pregnancy is about 10 to 15 kgs

a. Fetus – 3 to 4 kgs

b. Placenta – 1 ½ to 1 1 kgs

c. Amniotic fluid – ¾th 1 kg

d. Uterus and breast – 2 ½ to 3 kgs

e. Blood and other fluids – 1 ½ to 4 kgs

f. Muscles and fat – ½ to 3 kgs

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PELVIC VISCERA, FASCIAE AND LIGAMENTS :-

The uterus increases from a pre-pregnant size of 5 to 10 cm (2 by 4 inches) to 25 cm by 36

cm (10 by 14 inches). It increases five to six times in size. 3000 to 4000 times in capacity. 20

times in weight by the end of pregnancy. Each muscle cell in the uterus has increased

approximately 10 times its length prior to pregnancy. Once the uterus expands upward and

leaves the pelvis, it becomes an abdominal organ than a pelvic organ.

Ligaments connected to the pelvic organs are more fibro elastic than ligaments supporting

joint structures.

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 baby’s 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:-

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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

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.

Complications associated with separated muscles :-

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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

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.

(a) Head Lift Exercise 1 :-

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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.

NEED OF THE STUDY :-

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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.

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AIMS & OBJECTIVES

AIMS AND OBJECTIVES:-

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AIM:-

TO DETERMINE THE EFFECT OF ABDOMINAL MUSCLE STRENGTHENING IN

DIVERCATION OF RECTII IN POST NATAL FEMALES.

OBJECTIVE :-

TO DETERMINE THE EFFECT OF STRENGTHENING ABDOMINAL MUSCLES IN

DIASTASIS RECTII IN POST NATAL FEMALES IN THE AGE GROUP OF 28-38

YEARS.

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HYPOTHESIS

HYPOTHESIS :-

RESEARCH HYPOTHESIS :-

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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.

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REVIEW OF LITERATURE

Review of literature:-

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1) The Effects of an Exercise Program on Diastasis Recti Abdominis in Pregnant Women

Chiarello, Cynthia M.; Falzone, Laura A.; McCaslin, Kristin E.; Patel, Mita N.; Ulery, Kristen R.Journal of Women’s 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 Dysfunction-Are 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 lumbo‐pelvic 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,

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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.

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.

3) The Relationships Between Inter-recti Distance Measured by Ultrasound Imaging and Abdominal Muscle Function in Postpartum Women: A 6-month Follow-up Study

Lih-Jiun Liaw, Miao-Ju Hsu, Chien-Fen Liao, Mei-Fang Liu, Ar-Tyan Hsu

DOI: 10.2519/jospt.2011.3507

Abstract

This study was done to investigate the natural recovery of IRD and abdominal muscle strength and endurance in women between 7 weeks and 6 months postpartum, and to examine the relationship between IRD and abdominal muscle function.

40 postpartum (25-37 years of age) and 20 age-matched, nulliparous females participated. IRD was measured at 4 locations (upper and lower margin of the umbilical ring, and 2.5 cm above and below the umbilical ring) with a 7.5-MHz linear ultrasound transducer. Trunk flexion and rotation strength and endurance were measured with manual muscle testing and curl-ups. Evaluation was conducted at 4 to 8 weeks and 6 to 8 months after childbirth in postpartum women, and only once for the nulliparous female controls.

During follow-up, the IRD at 2.5 cm above the umbilical ring and at the upper margin of the umbilical ring decreased (P = .013 and P = .002, respectively). The strength and static endurance of the abdominal muscles improved over time (P<.05). A negative correlation between IRD and abdominal muscle function at 7 weeks and 6 months postpartum was found (r = 0.34 to 0.51; P<.05, except for trunk flexion strength at 6 months postpartum [P = .064]). In addition, IRD changes between 7 weeks and 6 months postpartum were correlated with improvement in trunk flexion strength (Spearman rho = 0.38, P = .040). At 6 months after childbirth, postpartum women had greater mean ? SD IRDs at all 4 locations (from cranial to caudal: 1.80 ± 0.72, 2.13 ± 0.65, 1.81 ± 0.62, and 1.16 ± 0.58 cm) than those of nulliparous females (0.85 ± 0.26, 0.99 ± 0.31, 0.65 ± 0.23, and 0.43 ± 0.17 cm) (all P<.001). All

36

abdominal strength and endurance measurements were less than those of nulliparous females (all P<.001).

The IRD and abdominal muscle function of postpartum women improved but had not returned to normal values at 6 months after childbirth. Future research is essential to explore 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

4) Incidence of diastasis recti abdominis during the childbearing year.

by J S Boissonnault, M J Blaschak Physical Therapy (1988) Volume: 68, Issue: 7, Pages: 1082-1086

Abstract

This study was conducted to determine :-

1) the incidence of diastasis recti abdominis among women during the childbearing year

2) the location of the condition along the linea alba.

Clinicians have long noted its presence, prenatally and postnatally, but the magnitude of the problem is currently unknown. A cross-sectional design was used to test 71 primiparous women placed in one of five groups, based on placement within the childbearing year. A commonly accepted test for diastasis recti abdominis was performed. Palpation for diastasis recti abdominis at the linea alba was performed 4.5 cm above, 4.5 cm below, and at the umbilicus. Diastases were observed at all three places, but most often at the umbilicus. A significant relationship (p less than .05) was found between a woman's placement in her childbearing year and the presence or absence of the condition. Diastasis recti abdominis was observed initially in the women in the second trimester group. Its incidence peaked in the third trimester group; remained high in the women in the immediate postpartum group; and declined, but did not disappear, in the later postpartum group. These findings demonstrate the importance of testing for diastasis recti abdominis above, below, and at the umbilicus throughout and after the childbearing year

5) Physical therapy treatment for diastasis rectii (case report)

by Michelle E Collie, Bette Ann Harris

Medicine › Miscellaneous Papers

37

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.

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

MATERIAL AND METHOD

39

METHOD OF COLLECTION:-

1) STUDY DESIGN AND SETTING :-

a) STUDY DESIGN

Randomised controlled trial.

2) SOURCE OF DATA:

a) METHODOLOGY :-

i) POPULATION

Females between 28 - 38 years of age.

ii) SELECTION CRITERIA :-

a) INCLUSION CRITERIA:

Age : 28-38 years.

Sex : females

Post delivery : within 1 week

Type of Delivery : normal

History of : splitting of abdominal muscles

b) EXCLUSION CRITERIA:

Cessarian delivery

Trauma at abdomen

Any abdominal surgery

Un co-operative patients.

Subject who is not able to understand the procedure

3) SAMPLING METHOD AND SAMPLE SIZE :-

40

a) SAMPLING METHOD

Simple random sampling method.

b) SAMPLE SIZE.

30 subjects

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 :-

(a) Head Lift Exercise 1

(b) Head Lift Exercise 2

(c) Head Lift With Pelvic Tilt

(d) Leg Sliding

(e) Head Lift With Towel

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.

a) DURATION OF STUDY :-

41

Duration – 1 week.

b) MATERIALS USED :-

1. MMT scale.

2. Abdominal corset

5) OUTCOME MEASURES AND STATISTICAL ANALYSIS :-

1) OUTCOME MEASURES :-

MMT scale for abdominals

2) STATISTICAL ANALYSIS :-

Student T- test

CONSENT FORM

Investigator: Ms NIDA .G. SHAIKH

Purpose of research

I. have been informed that this study is carried to know the effect of abdominal muscle strengthening exercises.

42

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 researcher’s instruction as has been told to me.

Risk and comfort

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 won’t 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.

43

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 compensation will be provided. I understand that my agreement to participation in this study and I am not waiver any kind of my legal right, I explained to. . the purpose of the best of my ability.

Investigator: Ms. Nida .G. Shaikh

Investigator signature: 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

44

Phone no: Mobile:

Inclusion criteria:

Is the subject between 28-38 yrs of age? (Y/N)

Is the subject female ? (Y/N)

Does the subject has a history of split of abdominal muscles? (Y/N)

Is the subject undergone normal delivery ? (Y/N)

Exclusion criteria:

Does the subject have any other condition such as (Y/N)

infective condition of abdomen like tumor,etc.. ?

Is the subject undergone cessarian delivery ? (Y/N)

Does the subject has any trauma at abdomen ? (Y/N)

Has the subject undergone any abdominal surgery? (Y/N)

Is the subject un co-operative ? (Y/N)

Is the subject not able to understand the procedure ? (Y/N)

Chart for experimental group

45

APPENDIX IV

46

Outcom Pre training score Post training scoreMMT Scale

Chart for control group

Outcome measure

Pre training score Post training score

MMT scale

Signature of the subject.

Signature of the witness.

Signature of the investigator.

Date

Two Finger Test :-

Hook lying position•

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•

If separation exists, fingers will sink into the gap•

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

•Instruct client to performed a self-diastasis test

MMT Scale :-

ABDOMINALS MMT (MANUAL MUSCLE TESTING)

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.

APPENDIX V

Abdominal Strengthening Exercises:- 47

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

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 15-

20mins two session/day

48

RESULT AND TABLE

RESULT AND TABLES:-

GROUP A

49

TABLE 1

Treatment N Mean St Dev SE Mean

PRE- Treatment 15 1.000 0.000 0.000

POST- Treatment 15 2.200 0.775 0.200

Difference 15 -1.200 0.775 0.200

95% CI for mean difference: (-1.629, -0.771)

T-Test of mean difference = 0 (vs not = 0): T-Value = -6.00 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

50

TABLE 2

Treatment N Mean St Dev SE Mean

PRE- Treatment 15 1.000 0.000 0.000

POST- Treatment 15 1.667 0.488 0.126

Difference 15 -0.667 0.488 0.126

95% CI for mean difference : (-0.937, -0.396)

T-Test of mean difference = 0 (vs not = 0) : T-Value = -5.29 P-Value = 0.000

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.

GROUP A AND GROUP B POST –TREATMENT:-

51

TABLE 3

Treatment N Mean St Dev SE Mean

Post- Treatment

Group A

(experimental group)

15 2.200 0.775 0.200

Post- Treatment Group B

(control group)

15 1.667 0.488 0.126

Difference 15 0.533 0.990 0.256

95% CI for mean difference: (-0.015, 1.082)

T-Test of mean difference = 0 (vs not = 0): T-Value = 2.09 P-Value = 0.000

The Group A (experimental group) and Group B (control group) showed improvement from the post-

treatment mean 2.200 and 1.667 with T- Value= 2.09 and P-Value=0.000 and the above graph also

represent the increase in range post-treatment of Group A then Group B.

52

DISCUSSION

53

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

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

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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.

55

CONCLUSION

56

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.

57

SUGGESTIONS AND LIMITATIONS

58

SUGGESTIONS AND LIMITATIONS:-

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.

59

REFRENCES

60

LIST OF REFERENCES :-

1. Coulter ID. Chiropractic: a philosophy for alternative health care. Oxford: Butterworth-Heinemann; 1999.

2. Strang V. Essential principles of chiropractic. Davenport, IA: Palmer College of Chiropractic; 1984.

3. Green BN, Gin RH. George Goodheart, Jr., D.C., and a history of applied kinesiology. J Manipulative Physiol Ther. 1997;20:331–337. [PubMed]

4. Walther DS. Applied Kinesiology, Synopsis. 2. Pueblo, CO: Systems DC; 2000.

5. Walther DS. Applied Kinesiology, Chapter 6. In: Coughlin P, editor. Principles and Practice of Manual Therapeutics: Medical Guides to Complementary & Alternative Medicine. Philadelphia: Churchill-Livingstone: Elsevier Science; 2002.

6. Goodheart GJ. Applied Kinesiology Research Manuals. Detroit, MI: Privately published yearly; 1964.

7. Frost R. Applied Kinesiology: A training manual and reference book of basic principals and practices. Berkeley, CA: North Atlantic Books, Berkeley; 2002.

8. Leaf D. Applied Kinesiology Flowchart Manual, III. Plymouth, MA: Privately published; 1995.

9. Maffetone P. Complementary Sports Medicine: Balancing traditional and nontraditional treatments. Champaign, IL: Human Kinetics; 1999.

10. Christensen MG, Delle Morgan DR. National Board of Chiropractic Examiners. Greeley, CO; 1993. Job analysis of chiropractic: a project report, survey analysis, and summary of the practice of chiropractic within the United States; p. 78.

11. Christensen MG, Delle Morgan DR. National Board of Chiropractic Examiners. Vol. 92. Greeley, CO; 1994. Job analysis of chiropractic in Australia and New Zealand: a project report, survey analysis, and summary of the practice of chiropractic within Australia and New Zealand; p. 152.

12. American Chiropractic Association Database http://www.amerchiro.org/techniques Accessed February 15, 2007.

13. LeBoeuf C. A Survey of Registered Chiropractors Practicing in South Australia in 1986. J Aust Chiro Assoc. 1988. pp. 105–10.

61

14. Touch for Health Database http://www.touch4health.com/books.htm Accessed February 15, 2007 See also: A moment of silence for Dr. John Thie, Dynamic Chiropractic 2005;23(19).http://www.chiroweb.com/archives/23/19/11.html.

15. Swinkels RA, Bouter LM, Oostendorp RA, Swinkels-Meewisse IJ, Dijkstra PU, de Vet HC. Construct validity of instruments measuring impairments in body structures and function in rheumatic disorders: which constructs are selected for validation? A systematic review. Clin Exp Rheumatol. 2006;24:93–102. [PubMed]

16. Kaminski M, Boal R, Gillette RG, Peterson DH, Vilinave TJ. A model for the evaluation of chiropractic methods. J Manipulative Physiol Ther. 1987;10:61–4. [PubMed]

17. Fletcher RH, Fletcher SW, Wagner EH. Clinical epidemiology: the essentials. 3. Philadelphia, PA: Williams & Wilkins; 1988.

18. Janda V. PhD thesis. Charles University, Prague; 1964. Movement patterns in the pelvic and hip region with special reference to pathogenesis of vertebrogenic disturbances.

19. Bohannon RW. Manual muscle testing: does it meet the standards of an adequate screening test?Clin Rehabil. 2005;19:662–7. doi: 10.1191/0269215505cr873oa. [PubMed] [Cross Ref]

20. Karin Harms-Ringdahl. Muscle Strength. Edinburgh: Churchill Livingstone; 1993.

21. Kendall FP, McCreary EK, Provance PG. Muscles: Testing and Function. Baltimore, MD: Williams & Wilkins; 1993.

22. Daniels L, Worthingham K. Muscle Testing – Techniques of Manual Examination. 7. Philadelphia, PA: W.B. Saunders Co; 2002.

23. Walther DS. Applied Kinesiology, Synopsis. 2. Pueblo, CO: Systems DC; 2000.

24. Barbano RL. Handbook of Manual Muscle Testing Neurology. 2000. p. 1211.25. Martin EG, Lovett RW. A method of testing muscular strength in infantile

Paralysis. JAMA. pp. 1512–3. 1915 Oct 30.

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ANNEXURE

63

INFORMED CONSENT DOCUMENT

I __________________________________________________ hereby give

my consent to include me as the subject in the clinical study. I have been

informed to my satisfaction by the attending physiotherapist, the purpose

of this clinical study. I am aware that I may choose to stop being a part of

this study at any time without having to give the reason for doing so.

____________________________

Signature of attending Physiotherapist

___________

Date

__________________

Signature of Patient

___________

Date

64

ASSESSMENT FORM

65

NAME:-

AGE:-

ADDRESS:-

TEL NO.:-

OCCUPATION:-

DATE OF PRESENT DELIVERY:-

CHIEF COMPLAIN:-

PAST SURGICAL HISTORY:-

HISTORY OF PRESENT PREGNANCY:-

Planned- Accidental-

OBSTETRIC HISTORY:- NO.OF DELIVERY________

ON OBSERVATION:-

1. POSTURE AND ATTITUDE:- 2. SWELLING:-

ON EXAMINATION:-

1. MMT (MANUAL MUSCLE TESTING) :-

66

UPPER ABDOMEN - GRADE_______

LOWER ABDOMEN- GRADE_______

2.TEST FOR DIASTASIS RECTII:

PRESENT_____ ABSENT_______

INCLUSIVE CRITERIA :

1. AGE: 28-38

2. POST DELIVERY: WITH IN 1 WEEK

3. HOUSE WIVES.

4. MULTIGRAVID.

EXCLUSIVE CRITERIA:-

1. ANY ABDOMINAL SURGERY:

2. CESSARIAN DELIVERY:-

3. TRAUMA AT ABDOMEN:-

67

SCALE

68

ABDOMINAL MMT (MANUAL MUSCLE TESTING)

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.

69

MASTER CHART

70

GROUP A

MASTER CHART

SR.NO AGE GENDER PRE-

TREATMENT

POST-

TREATMENT

GROUP A 1. 29 F 1 2

(EXPERIMENTAL 2. 28 F 1 3

GROUP) 3. 32 F 1 1

4. 30 F 1 2

5. 28 F 1 3

6. 35 F 1 2

7. 29 F 1 3

8. 33 F 1 1

9. 30 F 1 2

10. 29 F 1 3

11. 29 F 1 1

12. 36 F 1 3

13. 29 F 1 3

14. 30 F 1 2

15. 34 F 1 2

71

GROUP B

MASTER CHART

SR.NO AGE GENDER PRE-

TREATMENT

POST-

TREATMENT

GROUP B 1. 28 F 1 1

(CONTROL 2. 31 F 1 2

GROUP) 3. 28 F 1 2

4. 28 F 1 2

5. 30 F 1 1

6. 29 F 1 2

7. 30 F 1 2

8. 28 F 1 2

9. 36 F 1 2

10. 30 F 1 2

11. 37 F 1 2

12. 34 F 1 2

13. 29 F 1 1

14. 28 F 1 1

15. 30 F 1 1

72

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