Dra Vs Sin Dra

TITLE: DIFFERENCES IN LINEA ALBA STIFFNESS AND LINEA ALBA DISTORTION
BETWEEN WOMEN WITH AND WITHOUT DIASTASIS RECTI ABDOMINIS: THE

IMPACT OF MEASUREMENT SITE AND TASK.
First author: Nicole Beamish (PT, PhD)

Queen's University, Kingston ON, Canada
Second author: Natasha Green (PT,

MScPT)
University of Ottawa, Ottawa ON, Canada
Third author: Elyse Nieuwold (PT, MScPT)

University of Ottawa, Ottawa ON, Canada
Downloaded from www.jospt.org by Springfield College on 03/31/19. For personal use only.
Fourth author: Linda McLean (BScPT,

PhD) University of Ottawa, Ottawa ON,
Canada
Corresponding author: Linda McLean;

linda.mclean@uottawa.ca; School of
Rehabilitation Sciences, 200 Lees Ave,
E260C, Ottawa, ON, K1N 6N5
Statement of Institutional Review Approval: This study was approved by the University
J Orthop Sports Phys Ther
of Ottawa Health Sciences and Sciences Research Ethics Board (H05-16-11).
Statement of sources of grant support: Infrastructure support was provided by the Natural
Sciences and Engineering Council of Canada and operating funds were provided through
the University of Ottawa Research Development Fund.
Public trials registry: This study was not registered as a clinical trial.
1 ABSTRACT
2 STUDY DESIGN: cross-sectional, observational cohort
3 BACKGROUND: The biomechanical implications of diastasis recti abdominis (DRA) are
4 unknown.
5 OBJECTIVES: (1) To investigate the impact of DRA, measurement site and task on inter-rectus
6 disstance (IRD), linea alba (LA) stiffness and LA distortion measured at rest, and during head lift
7 and semi-curl-up tasks. (2) To describe the relationships among IRD, LA stiffness and LA
8 distortion.
9 METHODS: B-mode ultrasound imaging and shear-wave elastography were used on a sample
10 of 20 women. IRD, LA stiffness and LA distortion were measured at three locations while
11 women were at rest, and repeated head lift and semi-curl-up maneuvers. All outcomes were
12 compared between groups (DRA/no DRA), sites and tasks. Linear regression models were used
13 to evaluate the relationships among IRD, mean and peak LA stiffness and LA distortion.
14 RESULTS: Eleven women with and nine without DRA participated. Women with DRA
15 demonstrated lower peak and mean LA stiffness and higher LA distortion compared to women
16 without DRA. In women with DRA, IRD and LA distortion were not influenced by measurement
17 site; IRD decreased, LA distortion increased and LA stiffness did not change during the head lift
18 and semi-curl-up compared to rest. In women without DRA, the LA was least stiff closest to the
19 umbilicus; it increased in stiffness during the head lift and curl-up, and did not distort or change
20 in IRD.
21 CONCLUSIONS: DRA is associated with low LA stiffness and distortion during a semi-curl-up
22 task; the amount of distortion is a function of both the IRD and LA stiffness.
23 Key words: linea alba, shear-wave elastography, inter-rectus distance, ultrasound imaging
1
24 Word Count: 4047
25
26 INTRODUCTION
27 Diastasis recti abdominis (DRA) is a separation of the abdominal muscles in the midline
28 and is seen in 33%-74% of women in the postpartum period.2,5,24,31,37,38 While a clinical
29 diagnosis of DRA is made through palpation,32,39 inter-rectus distance (IRD) measured using B-
30 mode ultrasound (FIGURE 1) is more precise, and has demonstrated excellent
31 reliability13,16,18,28,39 and concurrent validity.27,39 IRD has thus been used to study the severity and
32 impact of DRA in women.1,5,10,12,17,23,29,33,35,39
33 While larger IRD has been associated with lower body image satisfaction17 and self-
reported abdominal pain,17,33 the evidence for an association between IRD and motor impairment
34
35 is less clear.10,17,23,29,39 Some authors have sought but found no evidence that IRD is associated
36 with low back pain or impariment29, while others have found impaired trunk flexion 9,23,37 and
37 rotation12,23 strength in women with DRA. In a recent cross-sectional study, we found that while
38 women with DRA demonstrated impaired trunk rotation strength and capacity to perform a sit-up
39 at one year post-partum, their isometric flexion force and trunk endurance were unaffected.12
40 The ability of the linea alba (LA) to transmit forces across the midline may have a greater
41 impact on function than the magnitude of the IRD.22 Lee & Hodges recently presented a new
42 ultrasound measure, the distortion index, as a means of evaluating the contribution of the LA to
43 load transfer. A LA that is intact and unstrained would presumably not distort during a curl-up
44 because it is under tension. If the LA is not intact, however, the distortion index would
45 theoretically be infinite as the fascia separates under tension. While the distortion index may
46 provide insight into the functional impacts of DRA, it has not been validated against LA
47 stiffness.
2
48 With recent advances in ultrasound imaging, tissue stiffness can be measured in vivo
49 using shear-wave elastography14,21,25,26 (FIGURE 2b). This approach has good to excellent
50 accuracy20,41 and good reliability when measuring muscle shear modulus at rest,21 under
51 strain14,20,26 and during isometric contraction.3,4,14 Shear-wave elastography may help us to
52 understand the biomechanical implications of DRA as well as the distortion index proposed by
53 Lee&Hodges.22
54 The anatomy of the LA is heterogeneous along its length,11 and there is a lack of
55 consistency around measurement sites and tasks used to evaluate DRA.39 Indeed, IRD has been
56 found to have lower reliability16,19 and validity27 at sites below the umbilicus than above it.
57 Further, a range of tasks has been used when measuring IRD.39 Understanding how measurement
58 site or task difficulty influence measures relevant to DRA is important if we are to understand
59 the functional implications of these outcomes.
60 The aims of this study were therefore to: 1) examine the impact of measurement site and
61 task on morphological and biomechanical features of the LA in women with and without DRA;
62 2) investigate the two-and three-way linear relationships among IRD, LA stiffness and LA
63 distortion , and 3) determine whether linear relationships between IRD, LA stiffness and LA
64 distortion are different between women with and without DRA.

65 METHODS
66 The study was found to comply with the standards for the ethical conduct of research by
67 the University of Ottawa Health Sciences and Sciences Research Ethics Board (H05-16-11), and
68 all volunteers provided written informed consent before participating.
69 The sample size was determined a priori based on values reported by Lee & Hodges,22
70 where, at α=0.05 and at 80% power, seven participants would be adequate to detect signifcant
3
71 differences in IRD between measurement sites (𝑚𝑒𝑎𝑛 𝑑𝑖𝑓𝑓𝑒𝑟𝑒𝑛𝑐𝑒 (𝑥̅𝑑𝑖𝑓𝑓 ) = 1.29, sd = 0.77),
72 eight would be adequate to see differences in IRD between rest and the semi-curl-up task (𝑥̅𝑑𝑖𝑓𝑓
73 =1.19mm, sd= 077), and three would be adequate to detect differences in the distortion index
74 between women with and without DRA at the level of the umbilicus (𝑥̅𝑑𝑖𝑓𝑓 = 0.069, sd=0.013).
75 Based on the reported correlation between IRD and the distortion index22, a sample of 19 was
76 estimated to be adequate to detect a moderate negative correlation (r=-0.60).
77 Participants
78 Women were recruited via flyers placed at local recreational facilities and businesses in
79 the Ottawa-Gatineau region. Women were eligible to participate if they were nulliparous or had
80 delivered their most recent baby, vaginally, at least one year previously. Women were ineligible
81 if they reported being pregnant, having a history of abdominal, gynecological or urological
82 surgery, having a condition that could affect muscle contractility or lumbopelvic function, having
83 any respiratory dysfunction, or having a history of any pathology (e.g., fracture, surgery,
84 neoplasm) that could interfere with their capacity to perform the study tasks.
85 Evaluator qualifications and training
86 All imaging was performed by a physiotherapist with post-graduate training and over 400
87 hours of experience in B-Mode imaging of the muscles of the abdominal wall (NB). The
88 physiotherapist received 5 hours of training on shear-wave elastography at the LA by the senior
89 author (LM), and practiced image acquisition for >20 hours prior to data collection. The senior
90 author consulted during imaging when questions/difficulties arose.
91 Procedure
92 Women had their height, weight, waist and hip circumference measured using standard
93 procedures. They provided information on the number of pregnancies carried to term, the ages of
4
94 any children, and their habitual weekly amount of physical activity using a custom questionnaire.
95 Women were then positioned in supine on a plinth with their head resting on a thin pillow. A
96 Supersonic™ Aixplorer ® UltrafastTM ultrasound system (SuperSonic Imagine, Aix-en-
97 Provence, France) interfaced with a 10-MHz linear transducer (Model SL15-4) was used.
98 Imaging was done at three locations over the midline anterior abdominal wall: the superior
99 border of the umbilicus, then 3cm and 5cm above this site,16,19 where measurement of IRD is
100 reliable15,16,19,28 and valid27 (IRD measurements are less reliable16,19 and valid27 below the
101 umbilicus). Three B-mode videos were captured concurrently with shear-wave elastography
102 images at each location during each task (rest, head lift, semi-curl-up). There were two cases
103 where the investigator was unable to visualize the entire width of the LA. In one case a
104 curvilinear probe with a stand off pad was used, and in the other, panoramic imaging was used.18
105 All images were captured at end-exhalation, with breathing paused until after the images were
106 captured. When performing the head lift, women kept their arms at their sides, paused their
107 breathing at end-exhalation, gently lifted only their head off the pillow without altering their
108 neck or spine posture, and held this position. When performing the semi-curl-up, women kept
109 their arms at their sides, paused their breathing at end-exhalation, and lifted their head and
110 shoulders until the inferior angles but not the spines of their scapulae remained in contact with
111 the plinth. Positioning was verified and corrected by the physical therapist, and trials were
112 repeated as necessary. During each task, the ultrasound video was captured until the desired
113 position was achieved and held, while clear B-mode images and full shear-wave elastography
114 colourmaps were obtained. The ultrasound probe was removed completely and was replaced
115 after >60 seconds of rest was provided between trials and tasks.
116 Data Processing
5
117 The on-board software available on the Supersonic® AixplorerTM ultrasound system was
118 used for image processing. For each outcome, measurements were made for each of the three
119 trials at each measurement site during each task. IRD was defined by the length of a straight line
120 starting from the medial border of the hyperechoic fascia surrounding the hypoechoic rectus
121 abdominis muscle on one side and ending at the medial border of the hyperechoic fascia on the
122 opposite side12,13,16-19 (FIGURE 1). Participants were classified as having DRA based on Hills et
123 al.12 if IRD>2.2 cm at 3cm above the umbilicus AND mean IRD >2.2 across the three
124 measurement sites.
125 The distortion index was calculated as described by Lee & Hodges;22 the area enclosed
126 by the traced path of the LA (FIGURE 2c) and the IRD was divided by the IRD. Where the LA
127 distorted anteriorly, the anterior boundary of the fascia was traced, whereas where the LA
128 distorted posteriorly (e.g. FIGURE 2c), the posterior boundary was traced. Tissue stiffness was
129 calculated within a region, drawn freehand, bounded by the superficial and deep borders of the
130 LA (FIGURE 2d). The software automatically computed mean and peak stiffness, in kilopascals
131 (kPa), within this bounded area, and both values were retained for analysis.
132 Image analysis was performed by two MSc physiotherapy students (EN, NG) who
133 received hands-on training by the study senior investigator (LM, ⁓10 hours) and by the study
134 physiotherapist (NB, ⁓10 hours). The students practiced the image analysis independently (10
135 hours each) while analyzing images unrelated to this study. They then compared their results and
136 discussed discrepancies prior to beginning image analysis for the current study. The two raters
137 independently analyzed images to generate IRD, distortion index and mean and peak LA
138 stiffness from each video clip while blinded to participant demographic data, clinical
139 examination findings, and each other’s results.
6
140 Shrout and Fleiss36 Model 3 Intraclass Correlation Coefficients (ICCs) were used to
141 evaluate within- and between-rater reliability of all ultrasound outcomes. The within-rater
142 reliability was adequate for IRD (ICC=0.965-0.983) and for mean (ICC=0.868-0.913) and peak
143 (ICC = 0.721-0.901) LA stiffness recorded across the three tasks, while it was lower for the
144 distortion index, ranging from ICC=0.433 to ICC=0.869. The between-rater reliability was
145 adequate for IRD (ICC 0.944-0.955) and for mean (ICC=0.981-0.994) and peak (ICC= 0.979-
146 0.996) LA stiffness, but was more moderate for the distortion index (ICC = 0.746 to 0.766). In
147 three cases (mean LA stiffness at rest, distortion index on head lift and on semi-curl-up), the
148 within-rater ICCs were significantly (t-test at α=0.05) higher for Rater 2 than for Rater 1,
149 therefore the values obtained by Rater 2 were retained for analysis.
150
151 Data Analysis
152 Statistical analyses were performed using IBM SPSS Statistics Version 24 (IBM
153 Corporation, Armonk, NY); α=0.05 was used for all hypothesis testing. Data were tested for
154 normality using the Shapiro-Wilk test.
155 The impact of DRA status, measurement site (at, 3cm and 5 cm above the superior border
156 of the umbilicus) and task (rest, head lift, semi-curl up) was tested separately for each primary
157 outcome (IRD, mean and peak LA stiffness, distortion index), using repeated-measures analyses
158 of variance models which included all two- and three-way interactions. Bonferroni corrections
159 were used where indicated.
160 Linear regression analyses were used to determine the relationships among IRD at rest,
161 IRD during head lift and IRD during semi-curl-up, and between mean and peak LA stiffness to
162 evaluate potential redundancies and collinearity in subsequent models. Based on the results,
7
163 univariate regressions between IRD and LA stiffness and between IRD and LA distortion were
164 computed using only IRD at rest. In each model, the outcome was the mean value across the
165 three trials recorded at each of the three measurement sites, the strength of the relationship was
166 evaluated using the correlation coefficient (R), model significance (p), model variance (R2),
167 normality of the residuals and the relationship between residuals and fitted values. Each model
168 was computed for the whole dataset, then with the sample separated by cohorts (with/without
169 DRA). A multivariate regression analysis was then used to evaluate the combined effect of IRD
170 and peak LA stiffness on the distortion index recorded during the semi-curl up.
171 Secondary analyses using covariate (ANCOVA) models investigated the effect of
172 demographic factors including parity (yes, no), age, waist-hip ratio, and physical activity level on
173 the primary outcomes.
174 RESULTS
175 Sample characteristics
176 Twenty women participated; demographic data are reported in TABLE 1.
177
178 The impact of DRA status, measurement site and task
179 All primary outcomes were normally distributed and are summarized in TABLE 2. There
180 were significant interaction effects among DRA status, measurement site and task (FIGURE 3).
181 For IRD, there was no significant 3-way interaction, but there was a DRA status by site
182 interaction (F=4.31, p=0.014) and a DRA status by task interaction. While women with DRA
183 had larger IRDs than those without DRA, and they demonstrated no effect of measurement site
184 on their IRD, they demonstrated a reduction in their IRD on the semi-curl-up compared to rest
8
185 whereas the women without DRA did not. The women without DRA had larger IRDs at the
186 superior border of the umbilicus than at 3cm above the umbilicus.
187 For the distortion index, there was a 3-way interaction between DRA status, site and task.
188 Using pairwise comparisons, fixing task, there was no DRA status by site interaction (F=1.48,
189 p=0.229). Fixing DRA status, there was a site by task interaction (F=3.27, p=0.038). Fixing site,
190 there was a significant DRA status by task interaction (F=4.28, p=0.014). At all sites, women
191 with DRA had more LA distortion than women without DRA, and the women with DRA
192 demonstrated more distortion on the semi-curl-up than at rest (FIGURE 3b) while the women
193 without DRA demonstrated no difference in distortion among tasks.
194 The results were similar between mean and peak LA stiffness. There was no 3-way
195 interaction, and there was no 2-way interaction between DRA status and measurement site
196 (F=1.25, p=0.288; F=0.93, p=0.395), but there were interactions between DRA status and task
197 (F=44.05, p<0.001; F=26.35, p<0.001) and between site and task (F=3.49, p=0.008; F=3.03,
198 p=0.017). The women without DRA experienced the greatest stiffness in their LA during the
199 semi-curl-up and the lowest stiffness in their LA at rest, while the women with DRA did not
200 experience any increase in mean or peak stiffness in their LA during the head lift or the semi-
201 curl-up compared to rest (FIGURE 3c and d; FIGURE 4). Among women in both groups, during
202 the semi-curl-up, the mean and peak LA stiffness was lower at the superior border of the
203 umbilicus that it was as the other sites.
204 Relationships amongst IRD, LA distortion and LA stiffness
205 A strong, positive, linear relationship was found between IRD measured during both the
206 head lift (r=0.971, R2=94.3%, slope=0.878cm/cm, intercept=0.170cm, p<0.001), and the semi-
207 curl-up (r=0.944; R2=89.1%, slope=0.745cm/cm, intercept = 0.421cm 4, p<0.001; FIGURE 5a)
9
208 compared to at rest. Positive, linear relationships were also found between mean and peak LA
209 stiffness (FIGURE 5b). At rest and during the head lift, the linear regression models were
210 significant (R2=62.3%; p<0.001, R2=71.2%, p<0.001 respectively), with slopes of 1.65kPa/kPa
211 at rest and 1.69kPa/kPa during the head lift. The model was strongest during the semi-curl-up
212 (R2=79.3%, p<0.001) with a slope of 1.51kPa/kPa. Measurement site did not significantly affect
213 the linear regressions between peak and mean LA stiffness.
214 At rest, there was a moderate negative univariate association between IRD and mean LA
215 stiffness while the univariate relationship between IRD and peak LA stiffness was not significant
216 (TABLE 3). During the semi-curl-up, the univariate relationships between IRD and both mean
217 and peak LA stiffness produced a good fit with the data.
218 Larger IRDs were associated with more LA distortion (TABLE 3) in the women with
219 DRA (FIGURE 5c); the linear regression models were substantively similar regardless of
220 whether the women were at rest, or were performing a head lift or a semi-curl-up.
221 When the univariate relationships between IRD and LA stiffness and distortion were
222 investigated separately by cohort (TABLE 3), the regressions remained significant, with similar
223 model parameters (R, R2, slope) for the women with DRA as was seen when all data were
224 combined. In contrast, the regressions were not significant for the women without DRA.
225 The univariate relationships between LA distortion and mean and peak LA stiffness were
226 moderate when recorded at rest; higher distortion indices were associated with lower stiffness
227 (TABLE 3). These relationships were stronger for the head lift and semi-curl-up, and were
228 relatively unaffected by DRA status (FIGURE 5d).
229 Because of the collinearity between mean and peak LA stiffness, for the multivariate
230 model, we chose to include only peak LA stiffness during the semi-curl up, as it produced the
10
231 strongest correlation with the mean stiffness, and the widest range of values. Using distortion
232 index during the semi-curl-up as the dependent variable and IRD recorded at rest and peak LA
233 stiffness recorded during the semi-curl-up as independent variables, the regression was
234 significant (F2,17=43.66, p<0.001). There was no two-way interaction between IRD and LA
235 stiffness. The model fit the data well, resulting in an adjusted R2 value of 81.79% and with both
236 IRD (F1,17=37.13, p<0.001) and LA stiffness (F1,17=5.17, p=0.036) contributing significantly to
237 the model fit:
238 𝐷𝑖𝑠𝑡𝑜𝑟𝑡𝑖𝑜𝑛 = −0.043 + 0.3261 ∗ 𝐼𝑅𝐷 − 0.00279 ∗ 𝑠𝑡𝑖𝑓𝑓𝑛𝑒𝑠𝑠
239 This model fit the data slightly better than the univariate regressions presented in TABLE 3.
240 Including cohort in the model resulted in no significant interaction effects between cohort and
241 either independent variable, and, while there was a marginal cohort main effect ((F1,16 = 4.10,
242 p=0.06), including cohort in the model did not produce a regression that fit the data (adjusted R2
243 = 84.59%) substantively better than the multivariate regression computed without cohort.
244 The effect of participant demographic characteristics on IRD, LA distortion and LA stiffness
245 There were no significant two-way interactions between task, age, parity, waist-hip ratio,
246 or self-reported habitual amounts of physical activity for any of the study outcomes. Older
247 women presented with larger IRDs (p<0.001) and less LA distortion (p=0.008) than younger
248 women. Parity was associated with lower mean (p=0.015) and peak (p=0.017) LA stiffness, but
249 because of the small sample, and the substantive collinearity (r>0.70, p<0.01) between age,
250 parity and DRA in our sample, we did not include these demographic factors in the linear
251 regression analyses.
252
253 DISCUSSION
11
254 The main findings of this study were that women with DRA demonstrated lower LA
255 stiffness and more LA distortion across all tasks and measurement sites compared to women
256 without DRA. Among women without DRA, the head lift and semi-curl up resulted in
257 progressively higher stiffness in the LA, regardless of measurement site, and the LA did not
258 distort. In contrast, among women with DRA the LA distorted along its length, and did not
259 become stiffer during the head lift or semi-curl-up. These results suggest that there are both
260 morphological and mechanical alterations in the LA among women with DRA.
261 Inter-rectus distance
262 Although small differences were found when IRD was measured in women with DRA
263 when they performed the different tasks, the regression analyses suggest that IRD need not be
264 measured at multiple sites nor during a head lift or a semi-curl-up. The between-rater ICCs for
265 IRD at rest and during the semi-curl-up were consistent with published data16. The change in
266 IRD seen during the head lift and semi-curl-up was consistent with recent reports by Mota and
267 colleages30,34 and with Lee & Hodges22 who reported that the LA narrowed during a curl-up task
268 when no instruction was given about how to perform the task. The underlying cause of this
269 narrowing is unknown but may be an artifact of the measurement procedure (the muscle bellies
270 of the rectus abdominis may approximate due to increased bulk when contracting).
271 LA stiffness
272 While shear-wave elastography has been used for musculoskeletal applications,7,8 25 to
273 our knowledge, this is the first application of shear-wave elastography to study DRA. Measures
274 of LA stiffness appear to be sensitive to tissue anisotropy11, task, and DRA status. As such,
275 measurement site and task were more relevant to LA stiffness than to IRD; stiffness was
276 consistently highest during the semi-curl-up task and was consistently lowest at the superior
12
277 border of the umbilicus. LA stiffness appears to have excellent reliability both between and
278 within raters.
279 In the women with DRA, larger IRDs were associated with lower LA stiffness,
280 presumably because larger IRDs reflect greater tissue strain.39 The univariate linear regression
281 models between IRD and LA stiffness accounted for less than half of the variance in the data,
282 and were only significant among women with DRA. These findings support the hypothesis put
283 forward by Lee & Hodges;22 that the mechanical impact of DRA may be as or more relevant to
284 function than the IRD, and may explain why authors have failed to consistently detect
285 impairments associated with DRA.17,29 As illustrated in FIGURE 4, our results support the use of
286 shear-wave elastography to investigate LA biomechanical function, and the relationships

287 between LA stiffness and lumbopelvic function and the impact of rehabilitation interventions.
288 LA distortion
289 LA distortion at rest may not have adequate reliability for the evaluation of DRA, but
290 may be more reliable during the semi-curl-up. Our findings also suggest that the semi-curl-up,
291 but not the head lift, as is typically used for assessment of the IRD39 provides adequate challenge
292 to see LA distortion. In the women without DRA, there was little distortion of the LA, likely
293 because the intact LA is taut due to the tensile forces generated by the muscles of the lateral
294 abdominal wall. In some women with DRA, the LA was distorted even at rest (FIGURE 4e), and
295 this distortion increased during the head lift and semi-curl-up (FIGURE 4g), possibly reflecting a
296 substantive rupture of the LA (e.g. in FIGURE 4e there appears to be a complete rupture of the
297 attachment of the LA on the left side). Reducing LA distortion during functional tasks may
298 indeed be an objective for rehabilitation.
299 Relationships among IRD, LA stiffness and LA distortion
13
300 Both LA stiffness and LA distortion behaved as expected; when IRD was large, LA
301 stiffness was lower and LA distortion was higher- and the univariate relationships were strongest
302 during the semi-curl-up. The relationships between IRD and LA distortion were stronger than
303 those between IRD and stiffness. While the linear relationships between IRD and LA stiffness
304 were significant, other factors besides the IRD, such as damage to other aspects of the abdominal
305 musculature and sheaths, may influence the capacity of the LA to generate tensile force and may
306 account for some of the unexplained variance in the model. This is an area for future
307 investigation.
308 The range of IRDs (0.79 to 4.96cm) in this study was larger than that reported in Lee &
309 Hodges22 and may explain the stronger regression found here. More LA distortion was seen in
310 women with DRA, particularly among those who generated less LA stiffness during the semi-
311 curl-up. Understanding this multivariate relationship may be useful when evaluating the
312 functional impacts of DRA as well as changes in the biomechanical function of the LA induced
313 through rehabilitaiton interventions. In particular, a wide IRD may not be functionally
314 problematic if the LA still stiffens when a task demands load transfer across the midline. Some
315 women with DRA in our sample, particluarly those with 2.2cm<IRD <3cm, generated high
316 stiffness in their LA during the semi-curl-up task, with values similar to those seen in women
317 without DRA(FIGURE 5d). It is quite plausible that this subgroup of women with “mild” DRA
318 have no difficulty with functional task performance. Conversely, the women with high LA
319 distortion (distortion index>0.50cm) all had DRA and all generated low (< 50kPa) peak stiffness
320 in their LA during the semi-curl-up (FIGURE 5c). These data suggest that we may be able to
321 predict functional impariments based on a combination of IRD, LA stiffness and/or LA
322 distortion, and support the implementation of such a study as a logical next step.
14
323 Limitations
324 Before shear-wave elastography or the distortion index are used in a clinical context, full
325 reliability analyses are essential. Shear-wave elastography methods may be limited when women
326 have large IRDs because the field of view is limited to the width of the probe. While panoramic
327 impaging is and option18, it was challenging to get stable shear-wave elastography colourmaps
328 using panoramic imaging during dynamic tasks.
329 The results of the secondary analysis suggest that both age and parity may independently
330 influence the structure and function of the LA. Specifically, it appears that women who are older
331 have larger IRDs and demonstrate more LA distortion. Parity, however, appears to influence the
332 stiffness of the LA, regardless of age, suggesting that stresses on the LA during pregnancy
333 produce lasting strain. This result should be interpreted with caution, however as the sample was
334 small and there was a significant correlation between age and parity (r=0.746, p=0.000) which
335 may reflect a recruitment bias- older volunteers tended to be parous and to have DRA. While not
336 conclusive, this finding does provide impetus for future research to evaluate the interactions
337 among age, DRA and parity on the structure and mechanical function of the LA in women.
338
339 CONCLUSION
340 Our results support further research on the influence of LA distortion and LA stiffness in
341 evaluating the biomechanical implications of DRA. While IRD and LA distortion appear to be
342 uninfluenced by measurement location, the stiffness of the LA is not uniform along its length and
343 as such may need to be measured at multiple sites. Our results also confirm that LA distortion
344 observed during a semi-curl-up is a reflection of both the morphology and stiffness
345 characteristics of the LA and that LA distortion may best be measured during a semi-curl-up and
15
346 not a head lift. While LA distortion, computed through B-mode imaging, is more clinically
347 accessible than quantitative shear-wave elastography, it should not be interpreted as a direct
348 reflection of the extent to which the LA stiffens.
349
350 KEY POINTS
351 FINDINGS: Among women with DRA, while IRD is not significantly affected by measurement
352 site or task, LA stiffness is significantly affected by both of these factors, and LA distortion is
353 affected by the difficulty of the task. Both LA stiffness and IRD are significant predictors of how
354 much the LA distorts during a semi-curl-up task when women have DRA.
355 IMPLICATIONS: Shear-wave elastography may have utility in the development of best-
356 practice recommendations for women with DRA. A capacity to stiffen the LA may be a good
357 predictor of function and this is an important next step for this research.
358 CAUTION: We do not yet know the implications of LA stiffness or distortion on the symptoms
359 nor functional abilities of women with DRA.
360
16
361 REFERENCES
362
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20
TABLE 1. Demographic characteristics of the sample
Characteristics n=20
Age (years) 31 (8)

BMI (kg/m2) 25.28 (3.89)
Waist to hip ratio 0.80 (0.05)
Minutes of Moderate-Vigorous Physical Activity per week 144 (110)
Parity (number of children)
- 0 9 (45%)
- 1 1 (5%)
- 2 9 (45%)
- 3 1 (5%)
Abbreviations: BMI, body mass index; SD, standard deviation. Data are mean (SD) or
Numbers with percentages (%).

TABLE 2. Inter-rectus distance, mean and peak linea alba stiffness and linea alba
distortion recorded from n=20 women
SITE INTER- MEAN PEAK DISTORTION

RECTUS STIFFNESS STIFFNESS INDEX
DISTANCE (kPa) (kPa) (UNITLESS)
(cm)
REST SBU 2.39 30.49†* 51.34†* 0.41*
(1.29) (18.42) (46.43) (0.36)
3SBU 2.59 27.00†* 41.94* 0.51*
(1.47) (14.76) (29.88) (0.53)
5SBU 2.54 35.21††* 52.59††* 0.51*
(1.45) (17.91) (30.66) (0.58)
HEAD LIFT SBU 2.29 33.57†** 55.54†** 0.52
(1.26) (24.59) (51.43) (0.47)
3SBU 2.47 36.28†** 62.21** 0.61
(1.39) (27.50) (54.29) (0.69)
5SBU 2.43 40.97††** 65.76††** 0.54
(1.33) (30.20) (58.79) (0.58)
SEMI CURL- SBU 2.27 36.14†*** 64.86†*** 0.55**
UP (1.15) (29.95) (55.91) (0.47)

3SBU 2.30 46.87†*** 79.64*** 0.63**
(1.15) (37.52) (62.16) (0.66)
5SBU 2.36 50.45††*** 85.14††*** 0.60**
(1.00) (37.00) (61.45) (0.60)
All values are presented as mean (standard deviation). Image sites were the superior border of the
umbilicus (SBU), 3 cm above the superior border of the umbilicus (3SBU) and 5 cm above the superior
border of the umbilicus (5SBU). Significant differences in outcomes between tasks are indicated,
whereby outcomes measured during tasks marked with * are significantly different from those measured
during tasks marked with **, and outcomes measured during tasks marked with ** are significantly
different from outcomes measured during tasks marked with ***. Similarly, outcomes at sites marked
with † are significantly different from those at sites marked with ††.
TABLE 3. Univariate linear regression analysis results
Regressions IRD range R R2 Slope Intercept p-value

IRD SCU vs IRD rest All data 0.966 0.933 0.8 0.38 <0.001*
IRD <2.2cm 0.135 0.02 0.40 0.12 0.750
IRD >2.2cm 0.894 0.80 0.55 1.01 <0.001*
Mean stiffness at rest All data -0.601 0.362 -8.05 52.38 0.005*
vs IRD rest
IRD <2.2cm 0.075 0.01 4.4 36.55 0.860
IRD >2.2cm -0.589 0.35 -7.97 51.53 0.044*
Peak stiffness at rest All data -0.406 0.165 -11.16 78.29 0.075
vs IRD rest
IRD <2.2cm 0.311 0.10 37.13 10.01 0.454
IRD >2.2cm -0.608 0.37 -21.37 115.0 0.036*
Mean LA stiffness All data -0.654 0.428 -17.35 92.38 0.002*
during SCU vs IRD
rest IRD <2.2cm -0.108 0.01 -10.59 81.99 0.799
IRD >2.2cm -0.639 0.41 -20.09 102.0 0.025*

Peak LA stiffness All data -0.577 0.333 -25.17 143.0 0.008*
during SCU vs IRD
rest IRD <2.2cm 0.288 0.08 47.71 42.3 0.489
IRD >2.2cm -0.677 0.46 -37.52 187.0 0.016*
Mean LA Stiffness All data -0.707 0.500 -41.98 72.0 <0.001*
during SCU vs DI
IRD <2.2cm -0.908 0.82 -321.0 121.0 0.002*
IRD >2.2cm -0.682 0.47 -34.69 64.16 0.015*
Peak LA Stiffness All data -0.694 0.481 -67.78 118.0 0.001*
during SCU vs DI
IRD <2.2cm -0.769 0.60 -460.0 181.0 0.026*

IRD >2.2cm -0.712 0.52 -64.71 116.0 0.008*
DI vs IRD rest All data 0.887 0.787 0.40 0.44 <0.001*
IRD <2.2cm 0.135 0.02 0.04 0.12 0.750
IRD >2.2cm 0.894 0.80 0.55 1.01 <0.001*
DI vs IRD during All data 0.874 0.764 0.47 0.57 <0.001*
SCU
IRD <2.2cm 0.689 0.48 0.17 0.08 0.059
IRD >2.2cm 0.857 0.73 0.64 1.12 <0.001*
Each regression is presented for the sample as a whole (n=20) then by Diastasis recti abdominis (DRA)
cohort defined by an IRD>2.2cm at 3cm above the umbilicus AND a mean IRD>2.2cm. Abbreviations:
IRD, inter-rectus distance; LA, linea alba; DI, distortion index; SCU, semi curl-up. * denotes significant
regressions.
FIGURE 1. Ultrasound image of the linea alba
An image of the linea alba in a nulliparous woman positioned in supine and at rest acquired
using the SupersonicTM Aixplorer® ultrasound system coupled with a high frequency (10MHz)
linear probe (Model SL15-4). Left panel: B-mode ultrasound image. Right panel: Same image
with tissues labelled. RA = rectus abdominus, LA = linea alba. SC = subcutaneous fatty layer.
The red arrow indicates the inter-rectus distance (IRD).
FIGURE 2: Measurement of Linea Alba Distortion Iand Linea Alba Stiffness
a) B-mode image of the linea alba in a woman with diastasis recti abdominis. b) Shear wave elastography
colour map acquired in the region of the linea alba in a nulliparous woman without diastasis recti
abdominis (corresponding B-mode image in panel d below). c) Same image as in a, where the green line
denotes the inter-rectus distance while the yellow line indicates the posterior boundary of the linea alba.
These lines generate the area used in the numerator in the calculation of the distortion index. d) B-mode
image of the linea alba recorded concurrently with the shear-wave elastography colourmap in panel b.
The blue region indicates the region of interest traced by the user to reflect the borders of the linea alba.
The mean and peak stiffness values within this region, determined by the on-board software of the
Supersonic Aixplorer Ultrafast Ultrasound system, were used as outcome measures in the analysis.
FIGURE 3: Cohort, measurement site and task effects on Inter-Rectus Distance, Distortion
Index and Linea Alba Stiffness.
a) b)
))
c) d)
Inter-rectus Distance (a), Distortion Index (b), Mean Linea Alba Stiffness (c) and Peak Linea Alba
Stiffness (d) are plotted by cohort, measurement site and task. Abbreviations: DRA= diastasis recti
abdominis, HL = head lift maneuver, SCU = semi-curl-up maneuver, SBU = superior border of the
umbilicus, 3SBU =3 cm above the superior border of the umbilicus, 5SBU = 5 cm above the superior
border of the umbilicus. Significant differences were tested at α= 0.05 with Bonferroni correction applied.
Significant cohort effects are indicated by *. Significant measurement site effects are indicated by ‡.
Significant task effects are indicated by †.
FIGURE 4: Sample of linea alba morphology and stiffness images derived from shear wave
elastography (SWE) ultrasound imaging.
a) b)
c) d)
e) f)
g) h)
B-mode images of the linea alba are indicated on the left panels with corresponding shear-wave
elastography images immediately to the right in each case. Tthe legend at the top right shows
that areas of low stiffness are represented by blue, with progressively higher stiffness represented
by warmer coulours ranging from turquoise to yellow to red. The upper four panels (a-d) are
images of the linea alba recorded from a nulliparous woman with no diastasis recti abdominis
(DRA), a and b were acquired at rest and c and d were acquired during a semi-curl-up. The lower
four panels (e-h) are images of the linea alba acquired from a parous woman who met the study
criteria for DRA, while she was at rest (e,f) and performing a sami-curl-up(g,h). Note the high
stiffness of the linea alba when the nulliparous woman performed the semi-curl-up (d), where
peak stiffness reached 118kPa. In the parous woman, note the larger inter-rectus distance
(2.63cm) at rest (e) and the posterior distortion of the linea alba during the semi-curl-up (g)
where there was no apparent increase in linea alba stiffness (h).
FIGURE 5. Scatter plots and trend lines for outcome measures
a) Scatter plot of inter-rectus distance (IRD) recorded at rest vs. IRD recorded during a head lift
(red) and semi-curl-up (blue). b) Scatter plot of mean vs peak linea alba stiffness recorded at rest
(blue), during a head lift (green) and during a semi-curl-up maneuver (red). c) Scatter plot of
IRD recorded at rest and linea alba distortion measured during a semi-curl-up maneuver. The
women without diastasis recti abdominis are indicated in blue, while those with diastasis recti
abdominis are indicated in red. d) Scatter plot of the distortion index vs peak linea alba stiffness
recorded during a semi-curl-up. Women without diastasis recti abdominis are indicated in blue
while those with diastasis recti abdominis are indicated in red. Note that the regression line for
women without diastasis recti abdominis (blue) is not significant.

Dra Vs Sin Dra

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TITLE: DIFFERENCES IN LINEA ALBA STIFFNESS AND LINEA ALBA DISTORTION

BETWEEN WOMEN WITH AND WITHOUT DIASTASIS RECTI ABDOMINIS: THE

First author: Nicole Beamish (PT, PhD)

Second author: Natasha Green (PT,

Third author: Elyse Nieuwold (PT, MScPT)

Fourth author: Linda McLean (BScPT,

Corresponding author: Linda McLean;

of Ottawa Health Sciences and Sciences Research Ethics Board (H05-16-11).

2 STUDY DESIGN: cross-sectional, observational cohort

3 BACKGROUND: The biomechanical implications of diastasis recti abdominis (DRA) are

28 and is seen in 33%-74% of women in the postpartum period.2,5,24,31,37,38 While a clinical

30 mode ultrasound (FIGURE 1) is more precise, and has demonstrated excellent

32 impact of DRA in women.1,5,10,12,17,23,29,33,35,39

51 strain14,20,26 and during isometric contraction.3,4,14 Shear-wave elastography may help us to

59 the functional implications of these outcomes.

64 distortion are different between women with and without DRA.

68 all volunteers provided written informed consent before participating.

76 estimated to be adequate to detect a moderate negative correlation (r=-0.60).

81 if they reported being pregnant, having a history of abdominal, gynecological or urological

85 Evaluator qualifications and training

88 physiotherapist received 5 hours of training on shear-wave elastography at the LA by the senior

90 author consulted during imaging when questions/difficulties arose.

96 Supersonic™ Aixplorer ® UltrafastTM ultrasound system (SuperSonic Imagine, Aix-en-

116 Data Processing

124 measurement sites.

139 examination findings, and each other’s results.

151 Data Analysis

154 normality using the Shapiro-Wilk test.

159 were used where indicated.

173 the primary outcomes.

175 Sample characteristics

176 Twenty women participated; demographic data are reported in TABLE 1.

178 The impact of DRA status, measurement site and task

193 without DRA demonstrated no difference in distortion among tasks.

203 umbilicus that it was as the other sites.

204 Relationships amongst IRD, LA distortion and LA stiffness

213 the linear regressions between peak and mean LA stiffness.

228 relatively unaffected by DRA status (FIGURE 5d).

237 the model fit:

238 𝐷𝑖𝑠𝑡𝑜𝑟𝑡𝑖𝑜𝑛 = −0.043 + 0.3261 ∗ 𝐼𝑅𝐷 − 0.00279 ∗ 𝑠𝑡𝑖𝑓𝑓𝑛𝑒𝑠𝑠

251 regression analyses.

261 Inter-rectus distance

278 within raters.

286 shear-wave elastography to investigate LA biomechanical function, and the relationships

298 indeed be an objective for rehabilitation.

299 Relationships among IRD, LA stiffness and LA distortion

321 predict functional impariments based on a combination of IRD, LA stiffness and/or LA

328 using panoramic imaging during dynamic tasks.

348 reflection of the extent to which the LA stiffens.

350 KEY POINTS

359 nor functional abilities of women with DRA.

376 Wilkins; 1990.

453 dysfunction-are they related. J Womens Health Phys Therap. 2009;33(2):15-22.

Age (years) 31 (8)

Numbers with percentages (%).

SITE INTER- MEAN PEAK DISTORTION

UP (1.15) (29.95) (55.91) (0.47)

Regressions IRD range R R2 Slope Intercept p-value

IRD >2.2cm -0.639 0.41 -20.09 102.0 0.025*

IRD <2.2cm -0.769 0.60 -460.0 181.0 0.026*

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