1.1.2 Lecture - Pregnancy-PFM Anatomy-DRAM-Prolapse.pdf

Lecture 1 Pregnancy, PFM Anatomy, DRAM, Prolapse Amanda Adamson, PT, DPT, OCS, CAPP-Pelvic PHT...

Lecture 1 Pregnancy, PFM Anatomy, DRAM, Prolapse Amanda Adamson, PT, DPT, OCS, CAPP-Pelvic PHTH 727 School of Physical Therapy Lecture Outline Pregnancy Related Physiological Changes Pregnancy and Nutrition Pelvis & Pelvic Floor Anatomy, Associated Musculature Pelvic Dysfunction and Related Conditions Including as Postpartum Female Posture/Body Mechanics Awareness Diastasis Recti Prolapse PHTH 727 School of Physical Therapy 2 Weekly Learning Objectives: 1. Explain the impact of age, gender and hormonal changes on the musculoskeletal, neuromuscular, cardiovascular, pulmonary, urogenital, reproductive patient characteristics relevant to physical therapy care. (CO#18) 2. Describe basic changes to each body system associated with pregnancy, childbirth and postpartum periods and how these changes may impact a patient’s physical therapy care. (CO#18) PHTH 727 School of Physical Therapy 3 Sensitivity of information Victims of Sexual Assault/Domestic Violence May need to ask specific questions: sexual activity, urinary habits, etc. IMPORTANT BUT SENSITIVE How to ask about sensitive info Explain: role as professional, seeking to help and determine cause of pain Explain: reproductive, urinary, and GI causes may contribute to symptoms “Need to ask more questions” Any change in urinary habits, frequency, flow, burning Sexual changes Menstrual changes Any history of sexual or physical abuse Bowel changes, bloody stools, diarrhea, cramping Changes with food/eating Practice sensitive language Sex Intercourse Pass gas Bowel movement Stool/feces Diarrhea Penis Vagina Uterus Urine/void  Pregnancy & Normal Anatomical/Physiological Changes Pregnancy 1 Estrogen (E), progesterone (P) ↑ during pregnancy With human gonadotropin, responsible for most physiologic changes during pregnancy Physiological changes -> accommodate growing fetus Prepare mom for labor/delivery Every organ affected Postpartum: changes resolve, minimal residual effects PHTH 727 School of Physical Therapy 8 Blood1 50% increase in plasma volume by 34 weeks Nutritional demands: 2-3x increase for iron 10-20x increase for folate 2x increase for vitamin B12 All to meet needs of certain enzymes and demands of fetus Clotting factors increase – especially after delivery Increase risk for pregnancy, postpartum DVT ↑ venous stasis in lower limbs worse on left - compression of left iliac vein by left iliac artery and ovarian artery (on right, artery does not cross vein) PHTH 727 School of Physical Therapy 9 Urinary/renal1 Increase in renal blood flow (40-65%) and glomerular filtration rate (GFR, 50-85%) -> kidneys increase in length/size by 1-1.5 cm Increased flow may impede ability to filter protein, glucose Ureters relax, dilate (smooth muscle changes results from ↑ progesterone) changing their angle (curved) Can cause residual urine issues, increased urinary frequency, potential infection Pressure from uterus pressing against ureters/bladder Increased calcium absorption ↑ risk for kidney stones ↑ likelihood postpartum incontinence (involuntary urinary leaking) PHTH 727 School of Physical Therapy 10 Cardiovascular1 Increased blood volume Venous vasodilation Consider compression stockings Venous pressure increases Inferior Vena Cava pressure from uterus ↓ cardiac output -> decreased uterine blood flow -> potentially harm fetus Blood pressure changes http://www.birth.com.au/popup.asp?id=2-18 Lower in 1st & 2nd trimesters Normalizes again 3rd trimester HR ↑ slightly each trimester total of 10-20 bpm 40% increase in cardiac output PHTH 727 School of Physical Therapy 11 Cardiovascular PHTH 727 School of Physical Therapy 12 Pulmonary 20% ↑ in oxygen consumption1 However, respiratory rate minimally changes, despite c/o SOB during pregnancy (varied causes) More secretions in upper respiratory tract Ribs flare up and out later in pregnancy Then compressed eventually by uterus Chest circumference ↑ ~ 2 inches PHTH 727 School of Physical Therapy 13 Pulmonary1 Increases Decreases Depth of breath Expiratory reserve volume Tidal volume Residual volume Minute volume Functional residual volume Oxygen consumption (20%) Dyspnea Unchanged Respiratory Rate Nausea/vomiting 50-90% of pregnancies1 Thyroid is another potential Mechanism unclear cause1: Peaks end of 1st trimester hCG cross reacts with TSH, Usually resolves by week 20 stimulating thyroid gland hCG and oestrogen and progesterone may be involved Other potential causes1: H pylori infection GDF15, linked to greater Genetics symptoms Immune factors Nutritional deficiencies Increased pressure on stomach Gastrointestinal 1 Stomach displaced upward ↑ gastric pressure Esophageal sphincter tone decreased Reflux - Nausea/vomiting PHTH 727 School of Physical Therapy 16 Reproductive 2 Uterus ↑ in size Shifts from pelvic organ to abdominal organ ~ 30 lbs (range 25-35) weight gain: 2 lbs breast tissue 1.5 lbs placenta 2 lbs amniotic fluid, blood volume, fluid 2 lbs uterus 7 lbs maternal fat, protein, nutrients storage 7.5 lbs average baby weight 4 lbs blood volume 4 lbs fluid PHTH 727 School of Physical Therapy 17 Musculoskeletal Increased relaxin Causes ↑ ligament laxity -> prepare for delivery Result: decreased stability, ↑ risk injuries Contributes to low back pain, SI joint issues, pubic symphysis dysfunction 50-70% experience lumbar/pelvic pain during pregnancy3 PHTH 727 School of Physical Therapy 18 Musculoskeletal Abdominals are at a disadvantage Rectus Abdominis is stretched/pulled apart Diastasis of the Rectus Abdominis Muscle (Diastasis Recti or DR or DRAM) Greater than 2 finger-width gap Separation at linea alba Pelvic floor can drop about 2.5 cm http://bringingyoufitness.com/blog/diastasis-recitab-separation/ PHTH 727 School of Physical Therapy 19 Musculoskeletal Center of gravity shifts forward Anterior tilt of pelvis Increased lumbar lordosis (changes gait late in pregnancy) PHTH 727 School of Physical Therapy 20 Posture and Balance Compensations at: Spine Scapula Hips Knees Feet Muscle activity PHTH 727 School of Physical Therapy 21 Posture ↑ lordosis Lumbar Cervical – forward head ↑ kyphosis Thoracic Suboccipitals ↑ activity to support optic righting reflex Pubic symphysis and SI joints widen PHTH 727 School of Physical Therapy 22 Posture Scapula: Protraction Follows thoracic kyphosis Hips: ↑ external rotation Wider base of support for gait Knees: Hyperextension Feet: Weight shift to heels ↑ in flatfoot (widen/lengthens foot) PHTH 727 School of Physical Therapy 23 Pregnancy and Low back pain - treatment Multifactorial – do what helps: General exercise Core strength training for stability Postural alignment/education, positioning Pelvic floor stability strengthening Water aerobics Bracing as needed Manual therapy Yoga Don’t use heat/US/Estim over low back/uterus or hot yoga PHTH 727 School of Physical Therapy 24 Pregnancy & SI Joint Instability & Pelvic Pain Bracing? Exercise? Both? SI bracing (rigid or soft) with exercises may be better than exercise alone13 PHTH 727 School of Physical Therapy 25 Pregnancy and nerve palsies Due to pelvic compression/trauma during delivery but can occur during pregnancy too Every 1 in 2600 deliveries Femoral N (L2-3) Weak quad/psoas Slight medial thigh sensory deficit Obturator N (L3-4) Weak abductors Ant/medial thigh slight sensory deficit Peroneal N (L4-5) Weak toe extensors, foot evertors Ant/lateral leg/dorsal foot sensory deficit PHTH 727 School of Physical Therapy 26 Pregnancy and Carpal Tunnel Due to postural/fluid changes 1-50% occurrence in pregnant women; 68% have bilateral Often reverses within 6 weeks postpartum Pain and paresthesia's at night in median N distribution Atrophy hand Nightime splint mobilization – in neutral Modify work activities/ergonomics Injection if persists PHTH 727 School of Physical Therapy 27 Pregnancy and Edema Leg edema can be early sign of pre-eclampsia BP over 140/90 mmHG after 20 weeks – tell physician Importance of PT to monitor BP at each visit S & S; dizziness, lightheaded, seeing spots, headache, light sensitivity CHF, seizures, maternal stroke, premature birth can result – MEDICAL EMERGENCY Higher weight gain increases risk Edema common however – 80% of pregnancies Evidence to treat edema with: Foot massage most days of week Compression stockings Water aerobics Water immersion – 45 mins PHTH 727 School of Physical Therapy 28 Break PHTH 727 School of Physical Therapy 29 Pregnancy & Nutrition Pregnancy and Nutrition Academy of Nutrition and Dietetics4: Appropriate weight gain Balanced diet Regular exercise Vitamin and mineral supplementation if recommended by physician Calories5: 2200-2900 calories when expecting if at healthy weight upon pregnancy 1st trimester: no additional calories 2nd trimester: additional 340 calories from non pregnant state 3rd trimester: 450 calories from non pregnant state PHTH 727 School of Physical Therapy 31 Pregnancy and Nutrition Supplements4: Folic acid: 400 micrograms (0.4 mg) Start before pregnancy, most important in first 28 days after conception Reduce neural tube defects (spina bifida) Others: calcium, iodine, vitamin B12, iron Balanced diet should suffice Check with physician on needs first ↑ water PHTH 727 School of Physical Therapy 32 Pregnancy and Nutrition Foods to Avoid4: Unpasteurized milk (soft cheeses, feta, queso blanco and fresco, Camembert, brie or blue-veined cheeses) Hot dogs, deli meats (unless they are heated until steaming hot) Raw and undercooked seafood/fish (sushi), eggs and meat Refrigerated pâté and meat spreads Refrigerated smoked seafood Caffeine Artificial sweeteners Alcohol Tobacco PHTH 727 School of Physical Therapy 33 Gestational Diabetes (GD) 5-9% of pregnancies6 Diabetes diagnosed 1st time during pregnancy/gestation High blood sugar Potential cause: placenta may block ability to effectively use insulin Routine urine test at 20 weeks gestation Usually normalizes after pregnancy Symptoms: frequent urination, thirst6 Risk factors: had it before, overweight, familial history of diabetes, PCOS, African American, Hispanic, Latino, American Indian, Alaska Native, Native Hawaiian, Pacific Islander6 Risk to baby if have it: high glucose -> larger birth weight, may have low blood sugar at birth, breathing issues, diabetes later?, obesity later? PHTH 727 School of Physical Therapy 34 Gestational Diabetes (GD) Estrogen (E), Progesterone (P), relaxin result in loose ligaments/joints, to prepare for delivery E and P are insulin antagonists Leads to insulin resistance Insulin levels are high during pregnancy as a result 45% of pregnant women unable to produce adequate insulin to overcome the action of E and P Diet (less carbs/soda/sugars)/exercise important to PREVENT12 insulin may be needed PHTH 727 School of Physical Therapy 35 Anatomy Pelvis and Pelvic Floor Musculature Video – 10 minutes Anatomy Review-Pelvis Starts less stable than males as: Female: Shallow, wide Bones thin, lighter More round/oval Outlet larger Coccyx more flexible/straighter Male: Deep, narrow Male is heavier, thicker https://quizlet.com/330204282/male-vs-female-pelvic-girdle-diagram/ Heart shaped Outlet small Coccyx less flexible/curved PHTH 727 School of Physical Therapy 37 Pelvic Diaphragm: Coccygeus LEVATOR ANI: Pubococcygeus Iliococcygeus Puborectalis Think of name and where attaches Source: http://legacy.owensboro.kctcs.edu/GCaplan/anat/Notes/API%20Notes%20J%20Muscles%20of%20the%20Vertebrae%20&%20Abdomen.htm PHTH 727 School of Physical Therapy 38  not part of a typical DPT degree/education www.mayoclinicproceedings.org S. S. Faubion, L. T. Shuster, A. E. Bharucha. Recognition and Management of Nonrelaxing Pelvic Floor Dysfunction. Mayo Clin Proc. Feb 2012;87:187-193. doi:10.1016/j.mayocp.2011.09.004 PHTH 727 School of Physical Therapy 39 From text: https://books.google.com/books?id=lwDGDgAAQBAJ&pg=PA71&lpg=PA71&dq=Faubion,+Shuster+Recognition+and+managemen t&source=bl&ots=jaqkgQEg19&sig=SJ1hSPy6QCEbMo2mmCVMpndUClk&hl=en&sa=X&ved=0ahUKEwiWn- XXrL_XAhWBKyYKHUP5BpkQ6AEISTAF#v=onepage&q=Faubion%2C%20Shuster%20Recognition%20and%20management&f=false PHTH 727 School of Physical Therapy 40  Pelvic Floor Anatomy Important muscles that function during Urogenital sexual climax diaphragm – deeper muscles Pelvic diaphragm PHTH 727 School of Physical Therapy 41  https://www.semanticscholar.org/paper/Pelvic-floor-muscle-function-during-gait-Avni/bb1ffcaea6e063ce04d66eb3f8112282809968e8 Pelvic Floor Anatomy PHTH 727 School of Physical Therapy 42  Source: https://static1.squarespace.com/static/5589f6aee4b0cdce3add755a/t/565ba9cde4b02fbb0a4b21c0/1448847828844/MaleVsFemaleMuscles PHTH 727 School of Physical Therapy 43 PHTH 727 School of Physical Therapy 44 Pelvic Diaphragm a.k.a. coccygeus + levator Ani (pubococcygeus, ilioococcygeus, puborectalis) Supports bowel, bladder and uterus Striated muscle but run by the autonomic nervous system (ANS) (except in crisis) 70% slow twitch, 30% fast twitch7 Resting tone keeps anorectal angle, bladder angle Loops around urethra to keep it closed to prevent leaking Relaxation of this tone encourages emptying ANS inhibits tone to allow opening of the outlet and urination PHTH 727 School of Physical Therapy 45  Pelvic Floor Anatomy PHTH 727 School of Physical Therapy 46 Urogenital Diaphragm Anterior pubic bone to rectum Transverse perineal muscles Interrupted by vagina and urethra in females, penis in males Fast acting fibers Fatigue quickly Sexual importance – proprioception, orgasm/erection Contracting here repeatedly can increase circulation to clitoris and penis and enhance sexual function Can provide back up for incontinence control (not endurance) PHTH 727 School of Physical Therapy 47 Other Muscles7: Associated muscles (hip movements) – Piriformis, obturator internus Facilitatory muscles (abdominals/hip movements) – Thigh adductors, gluteals, tranversus abdominis, obturator internus *Common correlation between hip/back pain and pelvic floor dysfunction Good reminder to treat the whole patient…these areas may contribute to PFM/pelvic floor issues or pain PHTH 727 School of Physical Therapy 48 Obturator Internus Fascial attachment to pelvic diaphragm (levator ani, therefore activates it) Active at 0-40° hip flexion and 90° hip flexion Active in walking with each step Hip external rotation (pulls pelvic floor up like a hammock) and abduction of flexed hip *Common correlation between hip/back pain and pelvic floor dysfunction causing urinary issues and pelvic pain PHTH 727 School of Physical Therapy 49  Source: http://legacy.owensboro.kctcs.edu/GCaplan/anat/Notes/API%20Notes%20J%20Muscles%20of%20the%20Vertebrae%20&%20Abdomen.htm PHTH 727 School of Physical Therapy 50 Obturator Internus Piriformis Hip palpation PHTH 727 School of Physical Therapy 51 PHTH 727 School of Physical Therapy 52 Summary of Role of Pelvic Floor Muscles Support the pelvic organs in relaxed state Support intra-abdominal pressure Work core and pelvic floor simultaneously Sphincteric – tone/pressure close off canals to support continence Sexual function - proprioception, orgasm/erection PHTH 727 School of Physical Therapy 53 The Postpartum Female Posture and Body Mechanics What postures are postpartum moms typically in? What MSK issues result after pregnancy (already talked about)? What activities do they perform often? Our interventions for mom and dad Consider: Crib Stroller Changing table Highchair Breastfeeding positions/accessories Floor playing Dish cleaning/bottle cleaning Exercise/activity – for female, slow return to normal activity over 6-16 weeks PHTH 727 School of Physical Therapy 55 Concerns Postpartum Posture/Body mechanics Nursing Lifting Diastasis of the Rectus Abdominis Muscle (DRAM) Prolapse Nutrition Incontinence Ligamentous Laxity/ Musculoskeletal Pain (SI joint, low back) Pelvic Pain, Coccyx Pain/Coccydynia Pain with intercourse/trigger points/spasm, sensitivity Stress Sleep Deprivation Varicose Veins Nerve Compression Scarring PHTH 727 School of Physical Therapy 56 Diastasis Recti Abdominal separation that typically results from pregnancy ~53%8 ~66-100% during 3rd trimester8 Often will improve within first 8 weeks postpartum but up to a year Potential Risk factors Pregnancy, multiple pregnancies Excessive abdominal exercises after 1st trimester Poor lifting habits Obesity Effects8: Appearance/self-esteem Low back or abdominal pain Prolapse Difficulty with lifting/just feel weak in core https://radium-aesthetics.com/what-every-new-mum-should-know-about-postpartum-diastasis-recti/ Poor postural alignment Lumbopelvic instability, pelvic floor weakness (incontinence) PHTH 727 School of Physical Therapy 57 Break? PHTH 727 School of Physical Therapy 58 Lab Diastasis Recti Assessment Finger width assessment: 2 inches above, at, below navel Observation with head/shoulder blade lift from supine, knees at 90, fingertips touch knees Greater than 2 finger widths, + Source: https://vestnik.szd.si/index.php/ZdravVest/article/view/2450/2877#figures for DRA (or greater than 2.7cm at umbilicus8) Digital Calipers Source: https://www.jospt.org/doi/10.2519/jospt.2013.4449 PHTH 727 School of Physical Therapy 60 Diastasis Recti/Diastasis Rectus Abdominis/DRA Assessment Ultrasound – gold standard9 Calipers when used are more accurate above the umbilicus than when used below the umbilicus, ultrasound preferred when available over calipers9 Source: https://www.jospt.org/doi/10.2519/jospt.2013.4449 PHTH 727 School of Physical Therapy 61 Diastasis Recti Assessment Doming Hard/solid – over-exertion, holding breath/improper breathing -> internal pressure is too much AVOID Soft – didn’t activate “right” muscles https://www.healthypostnatalbody.com/blog/diastasis-recti-does-a-doming-stomach-mean-you-should-stop-the- exercise/ OKAY but need to fix Chip bag analogy PHTH 727 School of Physical Therapy 62 Source: Back Front https://www.google.com/url?sa=i&url= https%3A%2F%2Fwww.youtube.com%2 Fwatch%3Fv%3DwKN2NYiqAPY&psig=A OvVaw1DMy10OzlwmggFKRCF44_C&us t=1668870502294000&source=images &cd=vfe&ved=0CAwQjRxqFwoTCPi24K WBuPsCFQAAAAAdAAAAABAO Source: https://www.athletespotential.co m/athletes-potential- blog/optimizing-function-of-the- diaphragm-the-pelvic-floor Diastasis Recti Interventions: Newest thoughts: It will not re-adhere You can reduce size of the DR with exercise and assisted approximation8 You can still improve the core over time Core strengthening with correct technique (avoid bulging abdomen as much as possible, chip bag analogy) With addition of pelvic floor muscle strengthening Neuromuscular re-education https://babybellyband.com/product/diastasis-recti-postpartum-wrap/ Work proper transverse abdominal contraction coordination with breathing Abdominal binder/belly band Log roll, consider postures and proper activation of TrA Surgery? May only provide cosmetic improvement Education: exercise before/during pregnancy may reduce DR risk/severity10 PHTH 727 School of Physical Therapy 64 Diastasis Recti Interventions: Neuromuscular re-education Proper breathing technique Transverse abdominal contraction coordination with breathing With towel approximation With elbow press With posterior pelvic tilt With pelvic clock 12-6, 3-9, full clock https://babybellyband.com/product/diastasis-recti-postpartum-wrap/ With arm movement With arm/leg movement PHTH 727 School of Physical Therapy 65 DRAM - Correct Abdominal Exercises Start treatment where they are at and progress form there, avoiding bulging as much as can As do the exercises, assure breathing properly and can assist when able with bracing/towel pull to approximate muscles towards midline Deep transverse abdominal contraction With TheraBand extension/horizontal abduction With dead bug With SLR lowering With dbl leg lift With dbl leg lowering Side plank Other core exercises but FORM/TECHNIQUE is CRITICAL PHTH 727 School of Physical Therapy 66 DRAM - Core Exercises cont. Assessment Observation of core at other positions Seated drawing in; with leg movement, arm movement, weighted/resisted Standing drawing in; with leg movement, arm movement, weighed/resisted Leg lift from wall, in supine (bottom near wall), ↑ distance from wall, weighted/resisted PHTH 727 School of Physical Therapy 67 Pelvic Floor Disorders (including those in postpartum female) Pelvic Floor Disorders11 Pelvic floor disorders are conditions in which muscle and ligaments of the pelvic floor are weakened and lose their ability to support Most common include: Prolapse Urinary incontinence Fecal incontinence All can be related to pelvic floor muscle (PFM) dysfunction Prolapse Pelvic Organ Prolapse – Descent/laxity/decreased support of internal pelvic organs – About half of women with children7 – High association with other pelvic floor weakness and disorders like stress incontinence and overactive bladder PHTH 727 School of Physical Therapy 70 Prolapse11 3 most common: Cystocele – bladder, anterior vaginal wall bulges into vagina Rectocele – rectum, posterior vaginal wall bulges into vagina Uterine – uterus falls into vagina Varying degrees Prolapse11 S&S: Lump in vaginal area Pain/pressure – feels like something falling out Painful intercourse Back pain Abdominal cramping Better when lying down Worse with prolong stand, cough, strain (rectal pain with BM) Urinary incontinence or fecal issues  Prolapse PHTH 727 School of Physical Therapy 73  Prolapse - Uterine 1st degree: some descent 2nd degree: descent beyond cervix and into introitus/vaginal canal 3rd degree: protrude through vaginal opening Prolapse Signs and Symptoms? Has your doctor or health care provider informed you that you have a prolapsed pelvic organ such as your bladder, uterus or rectum? Do you usually have a bulge or something falling out that you can see or feel in your vaginal or rectal area? Do you have pain/discomfort with intercourse or sitting? Low back pain? PHTH 727 School of Physical Therapy 75 Prolapse Treatment Surgery, mesh or suspension/sling procedures (bladder/uterus), hysterectomy (uterus) Pessary – see pics above PT: pelvic floor muscle training, biofeedback posture constipation remedies, water intake, fiber intake regular exercise manual support techniques to perineum (femmeze-pic to right) behavior modifications (no valsava, bearing down; avoid significant trunk flexion, improper core exercises with breath holding, use a pillow prop for gravity assisted help during intercourse, double void) PHTH 727 School of Physical Therapy 76 Summarize/Think/Share ??? PHTH 727 School of Physical Therapy 77 References 1. Soma-Pillay P, Nelson-Piercy C, Tolppanen H, Mebazaa A. Physiological changes in pregnancy. Cardiovasc J Afr. 2016. Mar-Apr; 27(2):89-94. Accessed July 31, 2024. Doi: 10.5830/CVJA-2016-021 2. Weight gain during your pregnancy. American Pregnancy Association. Accessed July 31, 2024. Available at: https://americanpregnancy.org/healthy-pregnancy/pregnancy-health- wellness/pregnancy-weight-gain/ 3. Martins RF, Silvia JLP. Treatment of pregnancy-related lumbar and pelvic girdle pain by the Yoga Method: A Randomized Controlled Study. J Altern Complement Med. 2014;20(1):24-31. 4. Nutrition during pregnancy. Johns Hopkins Medicine. Accessed July 31, 2024. Available at: https://www.hopkinsmedicine.org/health/wellness-and-prevention/nutrition-during- pregnancy 5. Ellis E. Healthy weight during pregnancy. Academy of Nutrition and Dietetics. Published July 9, 2019. Accessed July 31, 2024. Available at: https://www.eatright.org/health/pregnancy/prenatal-nutrition/healthy-weight-during-pregnancy 6. About gestational diabetes. U.S. Centers for Disease Control and Prevention. Published May 15, 2024. Accessed July 31, 2024. Available at: https://www.cdc.gov/diabetes/about/gestational-diabetes.html 7. American Physical Therapy Association Section on Women’s Health, Physical Therapy Pelvic Level I Course Manual, 2007. 8. Acharry N, Kutty RK. Abdominal exercise with bracing, a therapeutic efficacy in reducing diastasis-recti among postpartal females. Int J Physiother Res 2015;3(2):999-1005. Doi: 10.16965/ijpr.2015.122 9. Chiarello CM, McAuley JA. Concurrent validity of calipers and ultrasound imaging to measure interrecti distance. JOSPT. 2013;43(7):439-514. Accessed July 15, 2024. Available at: https://www.jospt.org/doi/10.2519/jospt.2013.4449 10. Benjamin DR, van de Water AT, Peiris CL. Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: A systematic review. Physiotherapy. 2014;100(1):1-8. Doi: 10.1016/j.physio.2013.08.005 11. Goodman CC & Fuller Kendra S. Pathology: Implications for the Physical Therapist. 4th ed. St. Louis, MO: Saunders/Elsevier; 2015:995-1055. 12. Guo X-Y, Shu J, Fu X-H, Chen X-P, Zhang L, Ji M-X, Liu X-M, Yu T-T, Sheng J-Z, Huang H-F. Improving the effectiveness of lifestyle interventions for gestational diabetes prevention: a meta-analysis and meta-regression. BJOG 2019; 126: 311–320. doi.org/10.1111/1471-0528.15489 13. Bertuit J, Van Lint C, Rooze M, Feipel V. Pregnancy and pelvic girdle pain: Analysis of pelvic belt on pain. Journal Of Clinical Nursing [serial online]. January 2018;27(1-2):e129- e137. PHTH 727 School of Physical Therapy 78