A Review of Diastasis Rectus Abdominis:  A Clinical Guide For Those Who Are Split Down The Middle

Among the new things that I’d like to roll out this year are book reviews.  For those of you who haven’t met me in person, I love history.  I also love my profession and the craft of manual therapy.  So, when those two passions collide, I end up purchasing classic books pertaining to manual therapy to have in my personal library.  So, I was going to start writing some reviews of those older texts to remind people not to be a chronological snob.  Because so much of what we practice in this art form of manual therapy comes from clinicians long before us.

Having said those things, you can imagine my delight after interviewing some well-known manual therapists around the world who were already authors.  After my interview with Diane Lee, I thought a great way to kick off this new series of book reviews would be to read and write about her newest book (see title above).  What follows is my attempt at keeping things relatively simple with the 5 W’s we learned about in elementary school (I always remembered the “and sometimes How” at the end of the 5 W’s). 

So here you go, I hope you find this review useful!

Who – Diane Lee is the author of this text.  You may remember her from my conversation with her last year.  You can listen to that here.  I’ve continued my laziness in writing a bio for others and have borrowed (…ahem…) Diane’s bio from her website www.learnwithdianelee.com:

Diane graduated with distinction from the University of British Columbia with a Bachelor degree in the Science of Rehabilitation in 1976. She has been a member of the Canadian Physiotherapy Association since 1976 and a fellow of the Canadian Academy of Manipulative Therapy since 1981 (FCAMT). She completed  certification in Intramuscular Stimulation (IMS) in 2001, Yoga teacher training in 2012, pelvic floor certification in 2013 and was recognized by the Canadian Physiotherapy Association as a clinical specialist in Woman’s Health in 2016.

She was an instructor and a chief examiner for the Orthopaedic Division of CPA’s fellowship examinations (CAMT) for over 20 years and has extensive experience in curriculum development both for the CAMT program and her own series of courses.

She is well published (books, chapters and journal articles) and the innovator of two pelvic support belts for which she holds the patent; The Com-Pressor and the Baby Belly Pelvic Support (www.babybellypelvicsupport.com).

Diane owns, directs and is a practicing physiotherapist at Diane Lee & Associates http://www.dianelee.ca. She has continued to maintain an on-going clinical practice for over 40 years and while she follows the research evidence closely, she draws from this deep clinical experience for her teaching and lecturing in the clinic, in Canada and internationally.

Diane has had the honour of collaborating with local, national and worldwide authorities to further her own education and integrates this knowledge into courses/models she teaches.  Her combined clinical and education experience culminated in the co-development of The Integrated Systems Model for Disability & Pain (ISM), (Lee Diane & Lee Linda-Joy 2007 – 2013) the model she continues to teach and now solely evolve under the abbreviated title – the Integrated Systems Model – alongside her senior assistants from Diane Lee & Associates.

Learning how and when to use various assessment and treatment approaches is a key component of the Integrated Systems Model. The ISM Series course welcomes contributions from leaders such as Dr. Hollis Herman, Mark Finch and Dr. Gail Wetzler.  Collectively, we come to learn with each other and from each other, that’s what good teachers do.

WhatDiastasis Rectus Abdominis:  A Clinical Guide For Those Who Are Split Down The Middle is a text that is written for the clinician… hence the “clinical guide” in its name. 

From the get-go, Diane makes a considerable effort to explain to the reader the reason why a clinical guide for this condition is so necessary.  A nice revelation to myself was to hear how prevalent DRA is, but also the (not so) far reaching effects a lack of integrity in the abdominal wall can have.  Symptoms and dysfunctions such as lower back pain, pelvic girdle pain, pelvic organ prolapse, urinary incontinence, etc. 

One very nice feature for this book is the use of QR codes that are placed throughout each chapter.  These link to online videos that show live patients for assessment and treatment demonstrations.  Another benefit of these linked videos are the images of real-time ultrasound that Diane has performed on her patients to further give credence to the concepts that she presents in this clinical guide.

The book itself is structured into six different chapters. 

Chapter 1:  Pregnancy and the Abdominal Wall – chapter one focuses on discussing some statistics and reasoning why a clinical guide for this condition is necessary.  The reader (myself) quickly understands the paucity of guidance that we clinicians have to treat, manage, or direct care for conditions that compromise the abdominal wall (LBP, PGP, POP, UI, DRA).  Appropriate research is in full stock in this chapter and cited often in each paragraph.  Readers will have just as much time on their hands chasing down this literature as it takes to finish this entire book!

Chapter 2:  Anatomy of the Abdominal Wall – this is one of my favorite chapters in the book (I know, there aren’t that many chapters) because of all the anatomy pictures and explanations.  Each layer of the abdominal wall is described and detailed with phenomenal pictures of fresh cadavers, coronal sections of (not so fresh) cadavers, and pictures from Guimberteau and Armstrong’s Architecture of Human Living Fascia.  The most important part of this chapter though is how Diane ties in all their inter-related function.  Finally, to really help show how nice the “Take Home Message” pieces are during these initial chapters, I’ll quote the last one here:  “Anatomically, the individual abdominal muscles are part of an integrated myofascial system that runs from the 5th thoracic ring to the pelvis connecting the left and right sides through a highly organized fibrillar network known as the linea alba.  This integrated myofascial system is continuous with the muscles of the shoulder girdle, mid-thorax and neck superiorly, and the lower thorax, lumbar spine and pelvis posteriorly and anteriorly.  The aponeurosis of the deepest abdominal, TrA, is continuous with the diaphragm above and the pelvic floor below.”

… just fascinating to see how everything is connected…

Chapter 3:  Function of the Abdominal Wall – as much as I enjoyed the previous chapter, this one was equally vital.  For myself (and I assume most readers), gaining a better understanding of the function of the entire abdominal wall and how it works together.  Those clinicians who have a good appreciation of soft tissue mobilization, opening statements include how vital “mobility is… both within and between the various layers of [tissue]”.  Not to be content with just detailing function of the abdominal wall, descriptions (with appropriate research cited) of how function is affected by pain/trauma are included to present to the reader how much our bodies (as an entire system) are altered.  Whether that is something subtle that requires more skill to discern or up front and in-your-face obvious that any joe schmo would notice.

Chapter 4:  Assessment of the Abdominal Wall – the initial sections of this chapter are dedicated to describing what the Integrated Systems Model (ISM) is and how it relates to the particular topic of DRA.  While there are numerous different aspects to consider for how (and why) a patient presents the way that they do at any given time, I nice graphic is shown that illustrates the clinical reasoning within the ISM.  That is the “Clinical Puzzle” image that has the patient in the center with the words “Story, Emotion, Meaning, Goals, Virtual Body” surrounding them; then, four key elements within the human body that can promote or limit mechanical function are listed “Myofascial, Articular, Neural, Visceral”. 

Following this introduction, nice outlines are presented for when the abdominal wall should be assessed, and how it would be done within the ISM.  The reader is quite easily educated how to observe various dysfunctions in the patient’s posture that tie in easily with previous chapters.  Functional tasks such as active straight leg raise or an abdominal curl-up task are shown to be effective tools for assessing the abdominal wall, especially when combined with a real-time ultrasound unit.  In fact, this chapter could serve as a crash-course in someways to learn how to image the abdominal wall using such a modality! 

By the end of this chapter, the reader should have a much more clear view of the conditions presented and how best to assess them through observation, palpation, and performance of functional tasks.

Chapter 5:  Abdominal Wall Case Reports – while there is huge importance within any medical profession to ensure practice is utilizing evidence-based data, case reports may often be looked down upon because they are “low on the ladder” of evidence.  However, case reports can often allow readers a peak into the thought processes of master clinicians (or at least it is hoped so!).  Having a chapter like this in a clinical guide is invaluable because the reader will really see how Diane assesses patients of differing presentations with all of the concepts previously mentioned in this text.  To me, that helps solidify that these ideas are indeed something worth learning more about.  Cases range from post-partum DRA that is more cosmetic for the patient instead of limiting function, to an “average” patient with loss of function due to symptoms, to a remarkable patient that eventually had to undergo surgical intervention to correct the DRA and restore function.  For that reason, it is nice to learn from these case reports because the reader is now armed with a patient’s story and course of care that led them to benefit from surgery (something that should not be taken lightly, for sure).  The case reports are rounded out by presenting other cases related to men and children with a DRA.   

Chapter 6:  Treatment of the Abdominal Wall – the final chapter of this guide is dedicated to completing the introduction of the Integrated Systems Model to the reader by describing how a patient would be managed with these particular impairments.  While a patient would certainly benefit from the guidance of a skilled physical therapist during there rehabilitation process, there are numerous self-treatments presented to speak directly to the patient themselves (as well as for the reader’s own self-maintenance routine).  While treatments presented are never intended to be fully comprehensive, they give the reader a fantastic jumping off point to facilitate the patient’s recovery of function.  Progressions from the most remedial activity/task to the much more challenging are presented to demonstrate how patients can best be taken through a program (I recommend trying out the different treatments presented, if for nothing else than to see how we could all benefit from some work on ourselves too!). 

When – Clinicians that are interested in this particular field of physical therapy should read this book right away.  And don’t let the title limit that audience.  Diane does a wonderful job throughout the entire text explaining how abdominal wall dysfunction impacts wide ranging problems throughout this region of the human body.  The most localized issues can commonly  be:  lower back pain, pelvic girdle pain, urinary incontinence, pelvic organ prolapse, and obviously diastasis rectus abdominis.

Where – For those of you who are interested in picking up this gem of a clinical guide, you need look no further than the following website – Diastasis Rectus Abdominis:  A Clinical Guide For Those Who Are Split Down The Middle

Why – The easiest answer to this would be any clinician that is practicing in the pelvic health arena.  Readers of this book are likely to come away with a much greater understanding of concepts they may not be familiar with, to optimize outcomes for their patients.  It would also be a nice resource to use when speaking with physicians or surgeons regarding a very logical treatment approach to your shared patients.  Of note, it is also very interesting to learn how a colleague of Diane’s who is a plastic surgeon has pioneered a different approach to surgical correction of DRA that has provided a superior outcome in terms of symptoms and function for patients requiring surgical intervention.  For that reason, if the reader works with surgeons that perform these procedures, this text would be a nice resource to share in hopes of improving patient outcomes.

How – The concepts presented in this clinical guide are not overly complex, but are presented in a very logical and evidence-based manner.  So, in order to best integrate this into your practice, consistent practice of the concepts mentioned will afford the reader improved results with patients.  If possible, a real-time ultrasound unit would do wonders to expedite the training of your hands and clinical reasoning for the patient presenting in front of you (as evidenced by all the imaging in this guide demonstrating everything that is presented).  As this piece of equipment is usually a luxury for most us, not having this should not be a deterrent for the hard work of training your hands or clinical decision making. 

 

 

Cheers,

 

Matt

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