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Rectus diastasis and back pain

The back pain is the most frequent and disabling disorder reported to me by patients during a visit for diastasis recti.

The 'normal' narrative of these patients (who, I remind you, for the most part are young, very sporty and absolutely 'healthy' before their pregnancies) is that, since after childbirth, they have started to suffer from back painwhich has worsened over time to the point of becoming, in some cases, excruciating (one patient told me that it can appear at any time of the day and that she often has to lie on the floor in the office and remain motionless for several minutes to make it pass); that they have already undergone orthopaedic and physiatric examinations, and that the response has always been the same: "no spine-related problems, should instead cure diastasis".

But why would an alteration in the muscle geometry and contraction vectors of the abdominal wall cause the back pain?

The 'pathophysiological pivot' of low back pain in diastasis of the rectus is the thoracolumbar band.

From a purely anatomical point of view, the description of the thoracolumbar fascia is rather complex, but we can summarise it as follows.

The thoracolumbar fascia covers the deepest muscles of the dorsal region of the trunk, attaching medially to the spinous apophyses of the vertebrae. In the lumbar region, which is the one we are interested in, the thoracolumbar fascia consists of three laminae: posterior, middle and anterior.

- The back sheet is rather thick and attaches to the spinous processes of the lumbar and sacral vertebrae and to the supraspinous ligament; from these insertions, it heads laterally to cover the erector muscles of the spine;

- The medium lamina inserts medially to the transverse processes of the lumbar vertebrae, the iliac crest and the inferior margin of the last rib;

- The anterior lamina  covers the anterior surface of the quadratus quadratus muscle of the loins, attaching medially to the transverse processes of the lumbar vertebrae.

The posterior and middle laminae fuse together at the lateral border of the erector spinae muscles; at the level of the lateral border of the quadratus lumborum muscle, the posterior lamina is joined to them, and from this fusion originates the posterior aponeurosis of the transverse muscle of the abdomen.

This cold anatomical description will be more 'digestible' if one views the thoracolumbar fasciaback pain, REPA, Cuccomarino in the illustration opposite, taken from the superb 'Anatomy of Gray'.

In practice, in the part immediately adjacent to the spine, the thoracolumbar fascia is divided into three leaflets, which enclose two important muscles (the loin squarepart of the posterior wall of the abdomen; and theerector spinae(which is actually made up of several groups of muscles but can be considered, for practical purposes, as a single functional unit, which is extremely important because its contraction modifies the lordosis and kyphosis curves of the spine). These three leaflets fuse laterally to form a fibrous, rigid structure on which the transverse and internal oblique muscles of the abdomen. This means that the contraction of the internal oblique and transverse muscles of the abdomen will exert tension on the thoracolumbar fascia.

One of the immediate consequences of rectus diastasis is that the lateral muscles of the abdominal wall (external and internal oblique and transverse) lose the ability to contract effectively. This inability is reflected in reduced pressure within the abdomen and reduced traction of the thoracolumbar fascia. This, with the passage of time, causes a shortening of the erector spinae muscle, and thus a increased pressure on intervertebral discscausing the appearance of back pain.

Thus, adequate maintenance of the muscle tone of the anterolateral wall of the abdomen counteracts the contraction of the erector spinae muscle, reducing the pressure on the intervertebral discs, the cause of chronic, intractable low back pain in patients with diastasis of the rectus. Intra-abdominal pressure also plays an important role in this. In patients with diastasis of the rectus, intra-abdominal pressure, due to inefficient contraction of the muscles of the anterolateral wall of the abdomen, is reduced. Reconstruction of the linea alba through the plication of the recti, which is the basis of any repair of the abdominal diastasisIt re-establishes the correct vectors necessary for an effective contraction of the abdominal wall muscles - thus an adequate tension of the thoracolumbar fascia and an equally adequate increase in intra-abdominal pressure.

This was recently demonstrated by an elegant study by Metin Temel of the University of Hatai in Turkey. In his work, Temel showed that plication of the recti is able to reduce in back pain, REPA, rectus diastasis, Cuccomarinosignificantly the angles of thoracic kyphosis and lumbar lordosis, and the lumbosacral angle, of patients with diastasis of the rectus associated with chronic low back pain. The reduction of these angles, demonstrated by radiographic methods, was associated in the postoperative period with a spectacular reduction in back pain in these patients. In the following table, taken from the aforementioned work by Temel, the VAS values referring to pre- and postoperative back pain are graphically represented: the clear reduction in pain after the rectus muscle plication operation is evident.

However, the 'simple' surgical reconstruction of the muscle vectors of the abdominal wall is not alone sufficient to guarantee neither the tension of the thoracolumbar fascia nor the increase in intra-abdominal pressure. Our intra-operative experience shows that, in the majority of patients, direct electrostimulation of the rectus muscles, which we use to 'mark' the perimeter of the diastasis,back pain, REPA, rectus diastasis, Cuccomarino very often does not evoke any muscle contraction, neither before nor after the plication: it is as if the muscles have forgotten how to contract. This also occurs if it is the lateral muscles of the abdomen that are being electrostimulated. It is as if the central nervous system no longer receives the so-called propioceptive signals from these muscles, and therefore cannot send the impulses necessary for their contraction.
If, therefore, our work were limited to surgery, the result would be unsatisfactory: abdominal swelling would not improve, intra-abdominal pressure would not increase, the load on the intervertebral discs would not be reduced, nor would all those changes in the relationships between the pelvic floor and abdominal muscles (which I will discuss in another article) that can act on urinary incontinence be realised.

For this reason, we have developed, first in Italy, a physiotherapy protocol both pre- and post-operative, which through a series of very special exercises of hypopressive gymnastics is able to 'reactivate' the propioceptive pathways between the abdominal muscles and the brain and thus restore the brain's 'command' over the abdominal muscles: and it is precisely physiotherapy, set in a context of corrected muscle vectors reconstructed by surgery, that accounts for the extraordinary results, also from an aesthetic point of view, of the REPAour minimally invasive surgical technique for repairing the diastasis of the rectus abdominis muscles.

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