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The pelvic floor, the victim

Last December I spent a few days in Mallorca visiting my friend Marcel Caufriezinventor of hypopressive gymnastics and the "Caufriez methodwhich play such a big part in the treatment of our diastasis patients. My wish was to learn from him all I could about the pelvic floor. Surgeons (I have no shame in saying this, and I challenge anyone to contradict me...) generally of pelvic floor know little about it, they are barely aware of its existence. Personally, I have only begun to be intrigued by this very complex anatomical structure (forgotten the day after taking my Anatomy exam all those years ago) since I embarked on my navigation in the wide sea of diastasis recti.

pelvic floor, Caufriez

There are several things one realises by spending some time with Marcel: the first is that he, without a doubt, is a genius. The second is that the things he says, like all genius things, are simple: you just have to think about them. What is really difficult is to acquire the ability to change perspective: things seem to have certain characteristics if we look at them from a certain point of view: but what if that changes? Everything can change.

How often do women, after a pregnancy, feel blamed for certain symptoms that are not at all uncommon and seriously interfere with their quality of life, such as theurinary incontinence, at pelvic floor?

But the pelvic floor is the victim, not the perpetrator. This distinction becomes important at the time of treatment: if what has just been said is true, treating only the pelvic floor will we obtain satisfactory results? Obviously not: the 'perpetrator' must be identified.

Today we know that the classical anatomical view of the abdominal wall, back muscles, the pelvic floor - the one taught in Anatomy courses in universities, for example - is insufficient. For example: if it is true (as it is) that the vast majority of the pelvic floor is formed by tendinous structures, then how much sense do rehabilitation manoeuvres such as the Kegel exerciseswhich, being muscle contraction exercises, are only directed at a small part of the structure? Yet Kegel exercises are still today, in many centres, one of the cornerstones of rehabilitation of the pelvic floor.

In fact, today we know that we no longer have to talk about the abdominal wall, pelvic floor, back muscles, but of core abdominal.

We can imagine the abdominal core as a single, large muscle-tendon structure whose main purpose is to control the intra-abdominal pressure. The lion's share is played by the muscles of the abdominal wall, whose actions induce direct reactions of the other parts: for example, if the abdominal wall contracts, the pelvic floor contracts; if the abdominal wall relaxes, the pelvic floor relaxes. And the abdominal muscular component is precisely the one that pregnancy damages, in a very high percentage of cases (Literature reports 33%, but it is probably more, many more).

linea alba, pelvic floor

Actually, to simplify, I made a mistake: pregnancy does not damage (except indirectly) the abdominal muscles, it damages the dawn line. Look at the beautiful picture opposite: the linea alba is that turquoise ribbon stretched between the sternum and the pubis. If we take away everything that is normally in between (muscles, serosae, viscera, vessels, etc.) we can see how it and the spinal column are addressed; and in fact we can think of the linea alba (and the rectus muscles that attach to it) as a kind of 'anterior spine'which is necessarily flexible and deformable to allow normal body movements, but which essentially counterbalances the action of the spinal column realthus giving the body the necessary scaffolding to maintain a correct posture.

Think: the 'antagonist' function of the spinal column real performed by the structures of the anterior midline of the abdomen is so important that in some animal species - the sharksin particular - these structures are cartilaginous, part of the skeleton. I speak of the coracal, or coracoal, a cartilaginous structure that in sharks extends from the skull to the pelvic region, consisting of two plates connected by a series of ligaments. The coracal, like the vertebral cartilages (in sharks, the skeleton is composed solely of cartilage) acts as a fulcrum for muscular movements. Isn't that extraordinary?

We do not have ventral cartilages - we could not have them, we would not be able to move in our environment - we have the dawn line which very often, as a result of pregnancy (or obesity, or ageing, or many other causes that I have already written about elsewhere) becomes thin and wide. This causes a abdominal core failure (whose mechanisms I have already explained in this article) with a severe alteration of pressure inside the abdomen. The functional results, with very complex mechanisms, are abdominal bloating, urinary incontinence, gastroesophageal reflux, constipation, slowed transit, lumbago and all the other functional symptoms associated with diastasis of the rectus.

What to take home from all this good talk? To solve many of the many functional problems that appear, along with diastasis, after pregnancy, health professionals must learn to see things in their entirety, changing the perspective from which they observe patients. No need for the puborectal muscle specialists or robotic surgery of the rectus abdominis muscles: you need someone who can see how the function of the components of the abdominal core is integrated, and how the part played by the 'abdominal band' (as Caufriez calls it, meaning the muscles of the anterolateral wall of the abdomen and all the fascio-tendinous structures connected to them) is the most important in maintaining this function, as our functional results after rectus diastasis repair surgery.

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