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R. V. Martinez
22.3.6 Postures that Increase Intraabdominal Pressure
andWorsen Diastasis
When the recti of the abdomen are activated, with
movements such as exing the trunk, pressure
throughout the abdominal compartment is
increased, causing damage to the linea alba, as it
cannot withstand the stress.
The vast majority of patients are unaware of
this and also the way the move worsens their
injury.
There are movements to avoid in order not to
cause hyperpressure:
• Efforts in abdominal exion, repetition of bad
movements in daily life, such carrying heavy
weights, as well as a multitude of movements
is maintained in exion in daily activities..
• Some sports that involve rotation of the trunk
and abdominal hyperpressure such as golf,
tennis, or certain yoga and pilate poses.
But there are also other alterations in our body
which can create harmful pressure, such as
chronic coughing, bouts of allergies, and constipation, all of which lead to apnea.
22.3.7 Evaluation oftheAbdominal
Muscle
We may assess abdominal diastasis by manual
palpation of the abdomen, taking into account the
number of ngers that t between the recti [3,
21]. This measurement offers satisfactory intra-
rater reliability [24], but poor interrater reproducibility [21, 24].
Calipers have shown high intrarater reliability
[22, 25] and a high degree of agreement with
ultrasonographic measurements taken above the
umbilicus [4, 10]. Ultrasound has proved accuracy and validity and is considered the gold standard in the evaluation of IRD [4, 23, 24].
Besides assessing IRD, ultrasonography
enables to evaluate the cross-sectional area of the
recti abdominis [23], offering fundamental data
for establishing a correct diagnosis.
22.4 Pretreatment Evaluation
22.4.1 Physical Examination/US
Examination
22.4.1.1 Manual Measurement ofIRD
Three measurement points will be checked for
manual control; it is considered that there is an
IRD, if there is a perceived inter-recti distance of
more than two ngers or if the patient presents a
mountain-like abdomen. This technique is
explained in the following lines and in the Video
22.1.
1. Body position of the patient for the
assessment
Patient is lying in supine, and knees are
supported to achieve relaxation of the abdominal muscles.
2. How to activate musculature for assessment
We will ask for a slight exion of the trunk
in the patient, without forcing and keeping the
shoulder blades in contact with the stretcher.
This will activate the recti abdomini and
enable us to evaluate the inter-recti distance.
22.4.2 Position oftheHand
intheAbdomen
1. Relaxed hand in the area, exerting no
pressure:
Fig. 22.1 Assessment above the umbilicus
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(a) Assessment above the umbilicus—Fig.
22.1
(b) Assessment at the umbilicus—Fig. 22.2
(c) Assessment below the umbilicus—Fig. 22.3
22.4.3 Ultrasonography
We position the transducer and locate the two
recti abdomini in the two areas that are to be analyzed for diastasis assessment: supraumbilical
and infraumbilical.
We will not be able to assess the umbilical
area via ultrasound because of image issues.
The patient is requested to slightly ex the
abdomen, evaluating the approximation of the
recti abdomini muscles, determining the distance
in centimeters.
Fig. 22.2 Assessment at the umbilicus
Fig. 22.3 Assessment below the umbilicus
In cases of very acute diastases, it may be
more complicated to establish an exact measurement, because if the separation is very pronounced, the two recti cannot be viewed in the
screen within the same shot.
A panoramic view may be necessary, if the
linear probe of the ultrasound machine allows it.
Ultrasound has shown accuracy and validity
and is considered the gold standard in the evaluation of IRD [4, 23, 24]. In addition to measuring
IRD, it allows to assess the cross- sectional area
of the recti abdomini [23]. (See Video 22.2).
In the abdominal assessment, we must take
into account how the alba line acts, as well as the
abdominal muscles since it is essential to assess it
for a correct recovery program (See Video 22.3).
22.5 Technique forRecovery
You can work with the three types of abdominal,
costal, or diaphragmatic and upper breaths to
become aware of the tissues of the abdomen and
the costal movement.
The person can be seated, place the hands rst
between the navel and pubis and breathe bringing
the air to this area and connect the movement
(Fig. 22.4) that occurs in these tissues when
breathing; then move to place the hands at the
costal level and feel the movement of the ribs
when inspiring and exhaling and nally placing
the hands at the upper level just below the clavicles and inspiring and letting the air out.
During the whole exercise, one of the hands
can be left on the abdomen to feel if abdominal
tension is produced at any time when the air is
drawn (Fig.22.5).
Dene the physical space of the abdomen so
that the person knows the place that occupies his
abdomen and the muscles that she has to activate.
In short, become aware of the real space that your
abdomen occupies and integrate it not only at the
intellectual level but at the sensory-motor level.
You can perform various exercises that involve
activation of the abdomen; usually the area that is
most difcult to identify and feel is the lower
abdomen area; to wake up this area, you can perform the following exercise: lie down in supine
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R. V. Martinez
position, you are instructed to inspire and when
exhaling to contract the lower abdomen from
pubis upward, as practice is acquired in this exercise, it can also be performed in sitting and
standing.
We explain how to perform a simple exercise
to activate the transverse muscle during the entire
gluteus lift movement. We will get activation of
the abdominal area and functional recovery of the
abdomen (Figs.22.6 and 22.7).
We should always check and assess the condition of the diaphragm in the patient; if there is
tension, it should be treated.
As the diaphragm has been indicated in the
exploration section, the diaphragm can be
blocked both in inspiration and in expiration.
Fig. 22.4 Starting posture
Fig. 22.6 Lying posture for abdominal control
Fig. 22.5 Palpation of the oblique and transverse
muscles
Fig. 22.7 Posture lying down for muscle activation and
abdominal work
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There may also be restriction in one hemidiaphragm and not in the other.
This blockage can affect the functionality of
the abdomen and may limit or hinder its recovery.
Once the exploration has been carried out, these
tensions can be worked with manual tension
relaxation techniques, such as costal ange
maneuvers and/or diaphragmatic breathing
release and reprogramming exercises.
During the session, the different abdominals
alternate, such as the straight and oblique abdominals, as well as the oblique abdominals between
them, and this allows the bers of the muscles to
move by sliding which improves their exibility
and sensitivity.
You can also perform lumbopelvic stabilization by saying how to work the body’s ability to
control the position of the pelvis and trunk in different postures and movements.
As an example: stand with arms along the
body with about 45 degrees of separation, as leg
is raised and from this posture a self-elongation is
made, the arms push towards the ground and the
leg that is raised performs a front-to-back swing
always attending to the abdomen as if there is no
bulge.
Remember that classic abdominal exercises
are contraindicated both in the existence of
diastasis and in the postpartum due to its
harmful effect on the pelvic oor.
22.8 Conclusions
The treatment of diastasis is not only an aesthetic
issue, the correct functioning of the abdomen is
important both for the pelvic oor and for the
individual’s posture. Its assessment is not limited
only to measure this diastasis but to assess all the
elements that inuence the abdomen as well as
understand the functionality of the abdomen.
There are also many techniques that can be
applied for treatment.
As indicated at the beginning of the articles,
many women come to the physiotherapy ofce
without a diagnosis of diastasis, sometimes it is
the woman herself who suspects the existence of
a diastasis. It is important to inform and “selfdiagnoses” “herself.”
It would be necessary to nd a channel so
that assessment of the abdomen was always
done in a postpartum; if needed it can be referred
to a physiotherapist for treatment. Ideally, a
physiotherapist should evaluate every woman
who has given birth. Today, this seems complicated but at least health professionals who evaluate women after childbirth should know by the
diagnosis of diastasis and its effects on the body
in order to refer the person to a physiotherapist
for recovery.
References
22.6 Post-treatment Care
The entire recovery program should be based on
eliminating possible excess pressure at the
abdominal level that can manage an increase in
pressure with the consequent damage at the tissue level.
22.7 Complications
After carrying out a program for abdominal
recovery and learning everything necessary for
abdominal care, we must take into account that a
new pregnancy will cause new abdominal diastasis that should be treated in the future.
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Aust J Physiother. 1997;43(2):109–14.
Non-surgical Abdominal
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Treatments
BeatrizBeltrán Redondo
23
Take-Home Points
• Non-surgical abdominal treatments are suitable for patients who do not need signicant
reshaping in an area.
• Non-surgical abdominal treatments require
little or no downtime, no general anesthesia or
incisions, they do not leave scars, and side
effects are minimal for most patients.
• Results can last if the patient maintains his/her
weight; thus, it is essential to have a healthy
lifestyle.
23.1 Introduction
During pregnancy, endocrinological, immunological, metabolic, and vascular changes may
affect abdominal skin [1] and have an impact on
women’s life [2]. These changes include formation of new stretch marks (striae gravidarum), lax
skin, and localized fat accumulation [3, 4].
Reference procedures to substantially reduce
these alterations are invasive techniques, such as
liposuction or abdominoplasty. Thus, non-invasive procedures can be the most suitable options
Supplementary Information The online version contains
supplementary material available at https://doi.org/
10.1007/978- 3- 030- 43840- 1_23.
B. Beltrán Redondo (*)
Clínica Dra. Beatriz Beltrán, Barcelona, Spain
for the aesthetic recovery of the abdominal
tissue.
Interest in non-invasive approaches has grown,
thus non-surgical abdominal treatments are
increasing as well. Due to the high demand for
safer procedures with faster recovery, fewer side
effects and less discomfort, new modalities have
been developed to address body contouring from
a less invasive perspective.
23.2 Abdominal Fat Reduction
Currently, liposuction is already the most common and effective procedure for body contouring, but given its invasive nature and inherent
risks, there has been continuous research for the
development of non-invasive methods [5]. Nonsurgical treatments for abdominal fat reduction
are comparatively new in the eld of excess fat
removal and include minimally invasive treatments that selectively break down fat cells in specic areas to reduce the size of subcutaneous fat
pockets (fat deposits that sit beneath the skin, but
above the muscle) [6
touring currently represents the fastest growing
area of aesthetic medicine.
The four leading non-invasive techniques
available for reducing localized subcutaneous
adipose tissue are cryolipolysis, radiofrequency
(RF), low-level laser therapy (LLLT), and highintensity focused ultrasound (HIFU) [6, 7].
]. Non- invasive body con-
© Springer Nature Switzerland AG 2023
M. Gomes-Ferreira, J. Olivas-Menayo (eds.), Post-maternity Body Changes,
https://doi.org/10.1007/978-3-030-43840-1_23
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B. Beltrán Redondo
23.2.1 Cryolipolysis
The cryolipolysis technology, developed in the
1990s, is an effective alternative to invasive treatments for silhouette remodeling [5, 8, 9] and different studies have proven its efcacy and safety
[6, 7]. Cryolipolysis is a technique in which controlled cold exposure is performed in the selective destruction of fat cells [10]. The rst study in
animal models was carried out by Manstein etal.,
renowned dermatologists from the Massachusetts
Hospital [9].
Scientic basis: The principle of cryolipolysis is based on the effect of controlled local cooling of the skin (at temperatures low enough to
freeze fat cells) that can induce selective damage
and subsequent loss of subcutaneous fat without
harming the overlying skin [11]. Cryoadipolysis
takes advantage of differences in cold-sensitivity
of different cell types, being adipocytes the most
susceptible cells. This is because adipocytes contain excess of triglycerides that crystallize under
temperature around 10°C [12, 13]. On the other
hand, the surrounding cells contain more water
(Table 23.1), which freezes below −5 °C [9].
These facts make the adipose tissue more susceptible to cold than other tissues such as muscle,
nerves, and skin [4, 5]. When fat cells are cooled,
cryolipolysis produces crystallization of the cytoplasmic lipids within the adipocytes. However,
the destruction of adipocytes does not affect
serum lipid levels or liver function tests signicantly [10]. Cold induces an inammatory
response that causes programmed death (apoptosis) of adipocytes [14]. Apoptosis causes cellular
contraction, maintenance of organelle integrity,
blistering of the membrane surface, condensation/fragmentation of nuclear chromatin, without
negatively affecting the neighboring cells [12],
and gradual decrease of the subcutaneous fat
layer. Because skin, muscle, and nerve tissues
freeze at a lower temperature than fat, they
remain unharmed [5, 15, 16]. Its effects are not
immediate, although a statistically signicant
reduction can be achieved within approximately
2months from application [17].
Application: Cryolipolysis targets subcutaneous fat, which is the fat that is above the muscle,
which can be treated and reduced effectively and
is not pronounced in obese patients with considerable skin accidity [18]. This is not the case
with visceral fat, which is the fat surrounding the
organs under the abdominal muscles, making it
difcult to remove [19]. This procedure can
selectively focus on and reduce subcutaneous fat
while leaving the surrounding structures intact
[5, 7]. Cryolipolysis is a body contouring procedure not intended as a method for weight loss
(Fig. 23.1). Treatments take 35–60 min to perform, and patients usually need one or two sessions. Clinical efcacy data have shown fat
reduction across multiple treatment locations,
such as the submental area, arms, anks, abdomen, and inner and lateral thigh [10, 20,
21]. This
chapter focuses on the abdomen and anks.
Despite being a safe technique, special attention
should be given to patient selection and prepara-
Fig. 23.1 Example of cryolipolysis device
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tion in order to obtain the expected result and
ensure patient satisfaction [22].
Expected results: Cryolipolysis is considered
a safe and effective procedure, with high patient
satisfaction rates [22]. Usually, there is about
25% decrease in the thickness of the subcutaneous fat layer within 90days after treatment and in
some patients results can be maintained in the
long term (between 6 and 9years after treatment)
(Fig.23.2) [8, 13]. The decrease in the number of
adipocytes results in a lower capacity to store fat
in the treated area. Being a targeted treatment that
only affects cooled subcutaneous fat [9], body fat
that is not cooled by the applicator will not be
affected, being distributed evenly. Cryolipolysis
is not dependent on the operator, which should be
considered an advantage of the technique,
although long-treatment sessions are an important disadvantage. See Video 23.1 [17].
Post-treatment care: There typically is minimal recovery time after and patient will be able to
return to her normal daily routine immediately
after the procedure. Since it is common for the
treated area to feel bloated and to look swollen
for the rst 3weeks after the treatment, wearing
compression tights or yoga pants may be of help
for feeling good during this period. Prevent
weight gain; it will help to maintain the achieved
results. Avoid the use of anti-inammatory medications such as ibuprofen, naproxen, and Celebrex
for 6weeks after the treatment. The inammatory response in your body is the mechanism
which removes the fat cells, and inhibiting the
body’s ability to get a response may slow the
progress of your result. Moisturize the area with
moisturizer and sunscreen.
Contraindications for treatment: Patients
with cold-sensitive conditions such as Raynaud’s
Syndrome or any disease related to cryoglobulinemia, cold agglutinin disease, paroxysmal cold
hemoglobinuria, cold urticaria, severe varicose
vein dermatitis, or loss of skin continuity due to
prolonged exposure to the localized cold inducer.
The literature also cites some other conditions
with positive rheumatoid factor (Sjögren’s
Syndrome, lupus, vasculitis, rheumatoid arthritis,
hepatitis C) [22].
Side effects: Expected side effects are temporary erythema, mild swelling, tingling, bruising,
and transient numbness that usually resolve
within 14 days after treatment [8]. Serious or
lasting side effects are extremely rare.
23.2.2 Low-Level Laser Therapy
(LLLT)
Numerous studies have shown laser therapy’s
ability to induce a variety of cellular reactions in
non-photosynthetic cells [23–26], and increasing
evidence suggests that laser therapy may alter
cellular bioenergetics, inuencing intracellular
functional-biochemical properties and producing
a diverse and observable clinical effect [27]. In
the last decade, the use of LLLT as an adjuvant of
liposuction for non-invasive body remodeling,
cellulite reduction, and improvement of the blood
lipid prole began to be investigated, and LLLT
can also help in autologous fat transfer procedures by improving the viability of adipocytes.
However, the underlying mechanism seems to be
unclear [28].
Scientic basis: It is based on experiences
that the application of a 635-nm laser leads to the
formation of small temporary openings in the
adipocyte membrane, which allows fat to be
released into the interstitial space without
destruction of the cells. As a result, a reduction in
the thickness of the subcutaneous adipose tissue
occurs. It seems that this mechanism is a consequence of the photoexcitation process of cytochrome c oxidase in the respiratory chain of
mitochondria [29–31].
Application: LLLT is intended to treat the
abdomen and anks for fat reduction and can be
used on other areas. The treatment, which usually
takes 25min per area, is typically painless and
patients only feel a warming sensation.
Expected results: The rst experiments with
LLLT that supposedly produced the aforementioned effect showed that the application of
635nm of 10-mw intensity for 6min produced a
fat reduction of approximately 99% [31],
although later studies, such as Brown’s etal., did
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B. Beltrán Redondo
Fig. 23.2 Abdominal
fat reduction with one
cryolipolysis session,
before (a) and results at
3months (b)
a
b
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not support these ndings [28]. Results are
noticeable after about 6weeks and nally after
about 12weeks. Research by Decorato etal. [32]
showed that a single treatment with a 1060-nm
diode laser on the anks resulted in an average fat
reduction of 13% at the 6-week follow-up, which
was maintained at 12weeks. Bass and Doherty
found a 16% reduction in fat thickness of the
abdomen 12weeks post-treatment [33]. In a separate pilot study comparing hyperthermic laser
lipolysis with cryolipolysis, there were no statistically signicant differences in outcome when
measuring fat reduction of the anks (24% versus
22%, respectively) [32].
Post-treatment care: Usually patients resume
normal activities immediately after treatment,
without downtime, pain, or the need of compression garments.
Contraindications for treatment: Patients
with active deep vein thrombosis or thrombophlebitis, hemorrhagic conditions, local malignancy, recently radiated tissue, skin disease (e.g.,
eczema), and tuberculosis. Also, precautions
need to be taken in patients with impaired cognition or communication and in patients with infection [34].
Side effects: Side effects of the diode laser
include discomfort during treatment, burns, temporary nodules, and prolonged tenderness [33].
23.2.3 Non-thermal Pulsed
Ultrasound
The pulsed, focused ultrasound system is an
innovative technology that delivers bursts of
pulsed focused ultrasound to non-thermally and
selectively destroy targeted subcutaneous fat
cells [35]. Ultrasound fat reduction uses highly
focused sonic waves to break down fat cell walls
in the treatment area, thereby releasing the fat
inside to be metabolized by the body and reducing the size of a fat deposit [6].
Scientic basis: Depending on the acoustic
parameters used, ultrasound energy can induce a
wide range of biological effects that can be intelligently crafted to cause positive outcomes in the
targeted tissues. While low levels of ultrasound
can produce benecial, reversible cellular effects,
higher levels of ultrasound energy (such as highintensity focused ultrasound) can quickly raise
the temperature of the targeted tissues, causing
instantaneous coagulative cell necrosis [35]. The
pulsed focus ultrasound system achieves fat cell
reduction in a non-thermal fashion. The ultrasound energy transmits through the skin, creating
rapid pressure changes that cause the fat cells to
break down while leaving surrounding tissues
unharmed [36]. The pulsed, focused ultrasound
energy delivers results with a non-thermal cavitation effect that only targets the adipose tissue in
the subcutaneous fat layer while controlling the
temperature elevation (i.e., less than 0.5 °C
increase) in the targeted tissues. The selective
destruction of adipocytes leaves the surrounding
collateral tissues in the treatment area unharmed.
This approach is likely, partially responsible for
its favorable safety prole [35].
Application: Treatments are intended for use
on the abdomen and anks. Patients usually need
one to three sessions spaced 2weeks apart. Its
combination with other cosmetic therapies, such
as radiofrequency, mechanical adipose destruction and/or injectable lipolysis, has shown promising results [37].
Expected results: Ultrasonography measurement showed a mean reduction of 0.5mm of subcutaneous fat thickness that persisted for at least
3days after treatment. One multicenter clinical
study showed that a single treatment performed
on the abdomen, thighs, and anks led to a mean
reduction of approximately 2cm in the treatment
area circumference 2 weeks after the session,
maintaining these results at the 12-week followup visit [38]. Three non-thermal, pulsed ultrasound treatments can safely and signicantly
reduce abdominal fat [35].
Post-treatment care: No special posttreatment care is required, and no downtime is
needed.
Contraindications for treatment: Infections
and open skin lesions in the target area and the
presence of active metallic implants, such as
pacemakers or debrillators in the treatment area.
Precautions must be taken when the patient has
keloids, implants, permanent dermal llers, and
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