resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
An MD Who Understands the Opioid Epidemic
Doctors of chiropractic have an important role to play in ending the opioid epidemic and dealing with chronic pain by conservative means (see our top story in this issue) – but who's to blame for opioid dependence and abuse in the first place?
A Long-Overdue Win for Oregon Medicaid Patients - and the Implications for Other States
Beginning July 1, 2016, Oregon Medicaid patients with spinal pain (cervical, thoracic, lumbar, pelvic) who are determined to be low risk based on a biopsychosocial assessment tool (STarT Back – Keele University) can receive four chiropractic visits per episode.
Increasing the Value of Spine Care: CMS Approves New Low Back Pain Registry
The Centers for Medicare and Medicaid Services has approved the Spine IQ Low Back Pain Registry as a qualified clinical data registry for the Physician Quality Reporting System (PQRS) in 2016.
Acupuncture Muscle Trigger Point and Oriental Medicine Sports Therapy
It is difficult to ascertain the internal condition of professional basketball player Lebron James during game one of the 2014 NBA finals, in which he developed debilitating muscle cramps that led to his premature removal from the game.
Beating the Odds: Interview With Para-Powerlifter Adeline Dumapong-Ancheta
Since October 2015, the FICS Foundation, the charitable organization affiliated with the International Federation of Sports Chiropractic (FICS), has been supporting disabled athletes internationally.
Acupuncture's Impact on the World
For several years, I have been hearing about the town of Rothenburg, Germany. It seemed just a dot on a map until I arrived. It is the home of the TCM Kongress which began in 1968. It has been held annually for 47 years and it has only missed one year.
Insuring Quality Control in Herb Importation: An Interview with Wilson Lau
Wilson Lau is the vice president of Nuherbs, a Chinese herb importation company based in San Leandro, California. Before joining Nuherbs, he trained as a lawyer specializing in FDA law.
Sit or Stand? Analyzing a Mixed Message
I'm more than a bit confused. At my age, that seems to be a rather common occurrence. However, today more than ever, I'm getting a mixed message.
Introducing the Acupuncture Today Digital Edition
In response to the changing habits of our readers, Acupuncture Today will introduce a digital edition of the publication (in addition to our print edition) beginning with the August 2016 issue.
Treating Hip & Groin Pain With Abdominal Release of Upper Lumbar Nerve Impingements
Have you encountered patients with groin and hip pain you can't seem to solve? You know it's not a worn-out hip; you suspect the pain is somehow connected to the spine. But somehow, you just can't help them break through.
What's New in Phytonutrition: Mangifera Indica, "The King of Fruits"
One hundred percent pure Indian green mango fruit (mangifera indica), harvested at a special degree of ripeness for efficacy and taste, can now be concentrated as a phytonutrient nutraceutical powder.
An Emerging Partnership Model
Maryland University of Integrative Health (MUIH) has educated integrative health and wellness practitioners for the last 40 years, originally as an acupuncture clinic and school. The institution's transformative, relationship-centered programs integrate traditional wisdom with contemporary science
How to Stay Sane During the Elections: Understanding Through the Lens of Chinese Medicine
In Chinese Medicine philosophy, everything consists of Yin and Yang. The law of polar opposites – one cannot exist without its opposite.
Three Tips to Help You Analyze the Acupuncture Case Studies of the NCCAOM Exam
Confirm the answer quickly by the elimination method. Case study:
After two treatments for back pain, a patient presents for a third
session complaining of rapid breathing and wheezing that is made worse
during cold weather.
Multivitamin Supplement May Reduce Breast Cancer Recurrence
There is a great deal of controversy regarding the value of multiple vitamin supplements in cancer prevention.
Kansas Achieves Licensing Law
Kansas Governor Sam Brownback signed House Bill 2615 into law on Friday, May 13, 2016. HB2615 includes provisions for the licensure of acupuncturists in the state of Kansas.
Adventures with the San Jiao
Those of us who have been in practice for several decades relish the way meridians and points reveal new diagnostic clues and new insights. I love to encourage my students to see this as an adventure that goes way beyond the textbooks.
The Pertinent Negative
We all have to perform evaluations on patients. Most of us don't like doing it – exams take time, and worse it takes even more time after the evaluation to put together a narrative summary of the findings. Sometimes, this process becomes downright tedious.
AOM Hospital-Based Practice: A Future Reality?
The natural evolution of health care on the planet is integrative health. We may have some challenges ahead, but based on my research, all indicators are pointing in a positive direction. There seems to be an evolving consciousness among our patient population that is "getting it."
Chronic Pain: Become Part of the Solution
I have lectured to more than 7,000 chiropractic physicians over the past five years regarding the chronic pain and opioid epidemic in this country.
Tai Chi Documentary Premier
First Run Features recently announced the world theatrical premiere of Barry Strugatz's documentary The Professor: Tai Chi's Journey West, which premiered last month at the Laemmle Music Hall in Los Angeles.
What You Say Isn't Always What Patients Hear
A few years ago, my aunt Edna (name changed for the purpose of this story) suffered a stroke. After a short hospital stay, she was transferred to a nursing home for rehabilitation. When she arrived at the nursing home, Edna requested a private room.
August, 2011, Vol. 11, Issue 08
A Common Problem for New Moms and Professional Athletes
By Elaine Stillerman, LMT
The softening, stretching, and weakening of the linea alba of the rectus abdominis and the subsequent lateral widening of the rectus muscles are generally, but not exclusively, considered to be caused by pregnancy.This is the case for nearly 90 percent of the maternal population. As the baby grows, the uterus displaces from a pelvic organ to an abdominal organ resulting in stretched and weakened abdominal muscles. For some pregnant women, the rectus abdominis can stretch longitudinally as much as 115 percent.
The pressure against the connective tissue that connects the two sides of the rectus – the linea alba - by the growing uterus as well as the hormonal influences of relaxin, create a separation of the rectus abdominis along the linea alba called the diastasis recti. "Diastasis" is a Latin word that means separation.
This diastasis does not necessarily heal on its own during postpartum recovery. As a matter of fact, in many instances women have a diastasis for the rest of their lives if they don't do appropriate corrective exercises that will repair the separation (or have them surgically repaired which was the technique used to fix severe separations). The sequelae of a diastasis might be chronic backaches and lumbar instability, and in severe cases, ventral or umbilical hernias for anyone, female or male, with this abdominal weakness.
As the baby grows, the maternal rib cage expands as much as 2-3" anterior and lateral. The rectus, which inserts into the 5-7th ribs, also stretches laterally. The same condition occurs at the pubic symphysis, the origin of the rectus. However, the maladaptive posture of pregnancy – anterior pelvic tilt, exacerbated lordotic curve, protracted neck, hyperextended knees, etc. – and the musculoskeletal discomforts that arise from this posture can be minimized with shorter abdominal muscles and a stronger, more intact abdominal core.
A large diastasis during pregnancy can prolong labor. Since core strength is lax, the uterus bulges forward even more, creating a more pronounced lordotic curve and anterior pelvic placement. This is why a second time mother looks bigger earlier in her pregnancy. The fetal head doesn't align within the pelvis as well as it would if the core were strong and intact, and it is more difficult to engage weak abdominal muscles while pushing, so labor often takes longer.
Not Just A Problem For Moms
But you don't have to be pregnant or a mother to have a diastasis. World class athletes and weekend warriors who do the wrong types of abdominal exercises (i.e. crunches or cross over twists) often develop this separation over time. Even Joseph Pilates, the developer of the popular eponymous exercise system, had a diastasis which got bigger as he got older. While many of his exercises target the core abdominal muscles, many of these exercises can contribute to a diastasis.
Carrying excess abdominal fat also puts pressure against the linea alba and can cause a diastasis for men and women. And people with chronic backaches or back issues fail to recognize that back instability often is caused by weak abdominal muscles and a diastasis recti.
Testing for the presence of a diastasis on your clients or on yourself is easy. You are looking for two conditions: the number of fingers that fit inside the separation and the condition of the connective tissue. The connective tissue will be superficial, moderate or deep. The deeper the connective tissue is, the closer it is to the visceral organs and the longer it will take to close the diastasis.
Have your client lie down on their back and with their knees bent. Place your fingertips in the umbilicus and have your client lift their head (not the shoulders) a few times as you press slightly deeper. Feel for the edges of the rectus muscles coming up. The number of fingers that fit in the space between the edges tells you how wide the separation is. A half a finger width indicates no diastasis. A finger or greater indicates there is one.
Now feel how deep your fingers go. If you feel a pulse, the connective tissue is deep and weak. Test three inches above and below the umbilicus, along the linea alba. When you test yourself, assume the same back-lying position and place your fingers pointing down toward your feet. Test at all three areas.
A brief review of abdominal muscle anatomy is important to understand how the action of one muscle affects the others. We have three layers of abdominal muscles: the outermost rectus abdominis, the deeper internal and external obliques, and the deepest abdominal muscle, the transverse abdominis (TVA). The rectus abdominis originates at the crest of the pubis and symphysis pubis and inserts into the costal cartilage of 5th -7th ribs and the side of the xiphoid process. It has two halves that are usually inch apart and are connected by the fibrous linea alba. Relaxing, forward pressure, and the growing uterus cause the linea alba to relax (allowing the muscles to move aside for fetal growth), stretch sideways, and become thinner. This is the diastasis.
The action of the rectus abdominis is trunk flexion, but when standing, it supports the visceral organs, holds the rib cage and pubis together and gives anterior support to the lumbar spine. Along with the gluteus maximus and hamstrings, it prevents an anterior pelvic tilt. Since this muscle is so compromised during pregnancy, it is easy to see how weakness in this muscle affects the entire core support and initiates the maladaptive posture associated with pregnancy.
The obliques are the middle layers of the abdominal core. The anterior division of the external obliques originates on the anterior surfaces of the 5th-8th ribs and inserts at the linea alba (as a broad abdominal aponeurosis). The lateral division of the external obliques originates at the lateral anterior surfaces of ribs 9-12 and inserts into the iliac crest along the outer lip. This group, along with the internal obliques, aids in trunk flexion and, when working unilaterally, rotates the trunk and flexes the trunk laterally. Since they attach to the rectus via the linea alba, it is easy to see how a rotational force pulls on the linea alba and stretches it even more. That is why cross-over abdominals do more harm than good.
The internal obliques cross in the opposite direction. The anterior division of the internal obliques originates in the inguinal ligament and medial lip of the pelvic crest and runs up and inserts at the crest of the pubis and linea alba (by the aponeurosis). The lateral division originates at the middle 1/3 of the iliac crest and inserts at the inferior borders of ribs 10-12.
The deepest abdominal muscle, the transverse abdominis, wraps around the abdomen and back like a belt or a girdle. It originates at the lateral 1/3 of the inguinal ligament, anterior 3/4 of the internal edge of the iliac crest, lumbodorsal fascia and the inner edges of the lower six ribs. It inserts into the – wait for it! – linea alba aponeurosis which passes behind the rectus abdominis. It functions to increase intra-abdominal pressure, assists in forced expiration, defecation, and during labor, stabilizes the lumbar spine and stabilizes the linea alba.
Based upon this anatomy, it makes perfect sense – and anatomical logic – that exercises that recruit the TVA are the ones that will make the diastasis smaller. This is even more apparent when you consider that the largest measurement of the diastasis usually is at the umbilicus and the muscle that works the rectus from the middle is the TVA.
The exercises that specifically target the TVA and shrink the diastasis are based upon a system of exercises called the Tupler Technique. The Tupler Technique is a four-step research-based program that includes: 1) specific exercises that isolate and work the TVA; 2) wearing and holding a splint. This splint does much more than the over-the-counter drug store splints or girdles. This specifically designed splint compresses the abdomen and approximates the rectus abdominis, making the exercises more efficient and repositioning the muscle to its correct position; 3) using the TVA with all activities; and, 4) using proper body mechanics when getting up and down from a back-lying position (no jack-knifes allowed).
The position you start in is very important, since the TVA is affected by gravity. The optimum way to begin these core strengthening exercises is in a seated or standing position. The head lifts of the Tupler Technique are only performed once the diastasis starts to heal. Belly breathing puts the TVA in the correct starting and ending position. If you imagine a horizontal elevator, the first floor is a neutral abdomen, the fifth floor is bringing the TVA all the way to the spine, and the sixth floor is an isometric contraction 'out the back'.
It is impossible to engage the TVA to fifth floor and hold it there if you are on your back and your shoulders come off the floor. That is why crunches and sit-ups don't work; they actually cause the abdomen to protrude and make the diastasis larger, the antithesis of what they are supposed to do.
When doing the head lifts of the Tupler Technique, the head comes up with the chin tucked in, as in a nod. And all cross-over exercises and sports (tennis, golf, etc) should be avoided when a diastasis is present because as we saw with the obliques, these forceful movements pull on the linea alba and further sheer it laterally.
The TVA is the missing link in core integrity – whether your client is pregnant, has a mommy pouch, is recovering from abdominal surgery, has a large belly or suffers from back pain and instability. Doing the Tupler Technique, regardless of how long the diastasis is there, will repair the diastasis and create a strong, integrated core.
Click here for previous articles by Elaine Stillerman, LMT.
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