The Effect of Core Exercise Using Online Videoconferencing Platform and Offline-Based Intervention in Postpartum Woman with Diastasis Recti Abdominis

Impact of postpartum exercise on pelvic floor disorders and diastasis recti abdominis: a systematic review and meta-analysis

OBJECTIVE

To examine the effect of exercise during the first year postpartum on pelvic floor disorders and diastasis recti abdominis.

DESIGN

Systematic review with random effects meta-analysis.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, SPORTDiscuss, Evidence-Based Medicine Reviews (Ovid), Scopus, Web of Science and ClinicalTrials.gov were searched until 12 January 2024.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies of all designs (except case studies) and languages were included if they contained information on the Population (individuals in the first year postpartum), Intervention (subjective or objective measures of frequency, intensity, duration, volume or type of exercise alone ('exercise-only') or in combination with other intervention (eg, biofeedback; 'exercise+co-intervention')), Comparator (no exercise or different exercise measures) and Outcome (symptom severity and risk of urinary incontinence, anal incontinence, pelvic organ prolapse, diastasis recti abdominis and sexual function).

RESULTS

65 studies (n=21 334 participants) from 24 countries were included. 'Moderate' certainty of evidence revealed that pelvic floor muscle training reduced the odds of urinary incontinence by 37% (seven randomised controlled trials (RCTs), n=1930; OR 0.63, 95% CI 0.41 to 0.97, I2 72%) and pelvic organ prolapse by 56% (one RCT, n=123; OR 0.44, 95% CI 0.21 to 0.91) compared with control groups. 'Low' certainty of evidence showed a greater reduction in inter-rectus distance measured at rest and during a head lift following abdominal muscle training compared with no exercise. Evidence on the effect of exercise on the risk of anal incontinence and diastasis recti abdominis, as well as the severity of anal incontinence, urinary incontinence, pelvic organ prolapse and sexual function, is limited.

CONCLUSION

Evidence supports the effectiveness of postpartum pelvic floor muscle training in reducing the odds of urinary incontinence and pelvic organ prolapse and postpartum abdominal exercise training in reducing inter-rectus distance.

PROSPERO REGISTRATION NUMBER

CRD42022359282.

Impact of Minimal Incision Repair of Rectus Abdominis Diastasis on Quality of Life and Stress Incontinence: A Prospective Study

Aim

This study evaluates the impact of the minimal incision repair of rectus abdominis diastasis (MIRRAD) procedure on physical activity, muscle strength, quality of life, and overall satisfaction in women with postpartum rectus abdominis diastasis (PP-RAD).

Methods

A cohort of 31 female patients, aged 20-50 years, diagnosed with PP-RAD unresponsive to conservative treatment, underwent the MIRRAD procedure. Assessments were conducted preoperatively and 1 year postoperatively, these included the Modified Abdominal Trunk Function Protocol (MATFP), Disability Rating Index (DRI), and Urinary Disability Index (UDI) questionnaires. Physical activity intensity was monitored using accelerometers.

Results

Significant improvements were observed in vigorous physical activities (Z = -2.352, p = 0.019), vector magnitude counts per minute (Z = -2.163, p = 0.031), and steps per minute (Z = -3.131, p = 0.002). DRI showed significant improvements in physical tasks like dressing, walking, and strenuous work (Z ranging from -2.705 to -4.603, p < 0.001). UDI indicated significant improvements in urinary symptoms, including reduced frequency (Z = -2.984, p = 0.003) and less urinary leakage (Z = -2.357, p = 0.018). MATFP demonstrated gains in back and abdominal muscle strength (Z = -4.321, p < 0.001) and trunk stability (Z = -3.991, p < 0.001).

Conclusion

The MIRRAD procedure significantly improves physical strength, trunk stability, and urinary function, enhancing daily activities and overall physical health in women with PP-RAD. Further research is recommended to evaluate long-term outcomes.

Online vs. Supervised Training in Relieving Urinary Incontinence and Diastasis Recti Abdominis in Early Postpartum

Background/Objectives: The postpartum period is marked by numerous physical changes, often leading to pelvic floor disorders (PFD) such as urinary incontinence (UI) and diastasis recti abdominis (DRA). This study aimed to assess the occurrence of UI and DRA in postpartum women and evaluate the effectiveness of physiotherapy in managing UI and DRA. Methods: A total of 396 women, between the 3rd and 5th postpartum day, were randomized into three groups: control (GrCon), online exercise group (GrOnl), and supervised group (GrSup). GrCon received only education, whereas GrOnl and GrSup had three sessions with exercises with physiotherapist-online or supervised. Data were collected through questionnaires, ICIQ FLUTS, body posture assessments, and DRA measurements. Results: The results showed a significant reduction in UI and DRA symptoms across all groups, with the GrSup group showing the greatest improvement. UI symptoms decreased from 49% during pregnancy to 36.9% postpartum, with GrSup women reporting fewer urological complaints compared to the GrOnl and GrCon groups (p < 0.001). DRA incidence dropped from 76.2% in the early postpartum days to 23.4% at six weeks, with GrSup showing the lowest rates (9.8%). Notably, supervised physiotherapy resulted in a higher frequency (94.7%) and correct performance of PFME (72.2%) compared to the online and control groups. Conclusions: The study concludes that supervised physiotherapy is more effective than online sessions in managing postpartum UI and DRA, emphasizing the importance of guided exercise for better outcomes.

Differences in Abdominal and Lumbar Muscle Thickness and Contractile Function Between Nulliparous, Primiparous, and Multiparous Women 6 Months Postpartum

OBJECTIVE

The purpose of this study was to evaluate the differences between primiparous and multiparous women at 6 months postpartum and nulliparous women regarding the thickness (including thickness pattern) and contractile function of the abdominal and lumbar muscles.

METHODS

A cross-sectional observational study of 80 women, both primiparous (n = 29) and multiparous (n = 25), as well as including nulliparous as a comparison group (n = 26), was conducted. B-mode ultrasound imaging was used for the measurement of abdominal and lumbar muscle thickness in two conditions (resting and activation). Moreover, the contractile function of these muscles was determined by the thickness ratio.

RESULTS

Significant differences between groups were observed in abdominal muscle thickness. During activation, the obliques showed a lower thickness in both groups of postpartum women compared to nulliparous women, while lower values for the thickness for the transverse abdominis (TrA) were only observed in primiparous women. The thickness pattern observed in nulliparous women both in resting and in activation (internal oblique [IO] > external oblique [EO] > TrA) was also achieved among postpartum women, despite no statistical differences observed between IO and EO in these groups. No significant differences between groups were observed for contractile function, showing the TrA greater values, followed by IO and EO in both nulliparous and postpartum women.

CONCLUSIONS

This study suggests that the thickness (and the thickness pattern) of the abdominal muscles in women at 6 months postpartum differs from nulliparous, while for the lumbar muscles, it is comparable to nulliparous. However, despite the obliques being thinner in postpartum women, the abdominal muscles are functionally competent.

IMPACT

This is believed to be the first study to compare abdominal and lumbar muscles thickness and contractile function specifically between primiparous and multiparous women. Although at 6 months' postpartum abdominal thickness differs from nulliparous women, these muscles are functionally competent. These findings provide valuable insights for use in the development of postpartum interventions.

Ultrasonographic evaluation of diastasis recti abdominis and its association with pelvic floor dysfunction in postpartum women: a cross-sectional study of a two-year retrospective cohort

Objective

This study aims to evaluate the ultrasonographic findings of Diastasis Recti Abdominis (DRA) in postpartum women, explore associated risk factors, and assess the relationship between DRA and pelvic floor dysfunction.

Methods

This retrospective cross-sectional study included 143 parturient women diagnosed with DRA at our institution from January 2022 to December 2023. The study aimed to assess the ultrasonographic characteristics and clinical implications of DRA in postpartum women. The study participants were aged 21-43 years, carried a single fetus to term without instrumental delivery, and had no prior abdominal surgery. We excluded incomplete records and cases with congenital lumbar spine abnormalities or significant visceral disease. Ultrasound was employed to evaluate the DRA features, specifically the condition of the abdominal midline and echo types. A control group comprised 57 women who had normal deliveries without DRA. The primary outcome of this study was the measurement of rectus abdominis separation using ultrasonography. Secondary outcomes included the assessment of pelvic floor muscle function via electromyography (EMG), evaluation of pain levels, and the identification of risk factors associated with diastasis recti.

Results

In the observation group, ultrasound revealed widened abdominal midlines in 122 cases (85.31%), discontinuity in 21 cases (14.68%), and various echo types indicating unequal, narrow band-like moderate, and slightly strong fibrous echoes. Significant differences were found in rectus abdominis separation and levator ani muscle hiatus area, with both being larger in the observation group compared to the control group (p < 0.05). Advanced maternal age, higher parity, higher pre-pregnancy BMI, and cesarean delivery were identified as significant risk factors for DRA occurrence in the logistic regression analysis.

Conclusion

DRA is prevalent among postpartum women with specific ultrasonographic profiles indicating considerable abdominal muscle separation. The study highlights the importance of ultrasound in diagnosing DRA and suggests that certain demographic and delivery method factors increase the risk of this condition. These findings could guide clinicians in early diagnosis and intervention, potentially improving outcomes for affected women.

Health Perceptions and Practices of a Telewellness Fitness Program: Exploratory Case Study

Background

During the COVID-19 pandemic, many people lacked access to group fitness opportunities due to elevated risk of infection, lockdown, and closure of exercise facilities. Additionally, many people experienced higher than average rates of mental health burden (eg, anxiety and stress). To help address these needs, an existing in-person community exercise class, taught by a faculty member from an academic medical center, transitioned to an online synchronous (OS) physical fitness class via the Zoom (Zoom Video Communications) videoconferencing platform. As such, the instructor advertised the OS fitness classes through an existing email list of community members and university faculty, staff, students, or alumni email listservs. This telewellness intervention sought to create a sense of community, build social support, and promote physical and mental wellness during the COVID-19 pandemic.

Objective

Our aim was to determine the perceived mental and physical health benefits of attending an OS fitness class for community members, including health care workers. We also assessed the use and functionality of related technologies necessary for delivering and attending the fitness classes.

Methods

An online survey questionnaire was created and tested to collect quantitative and qualitative data for an exploratory study. Data were collected to evaluate the fitness class, motivation, perceived health benefits, and related technologies. A convenience sample of people who had participated in the OS fitness classes was recruited for this study via an emailed recruitment flyer.

Results

A total of 51 participants accessed and completed the survey questionnaire. Survey participants consisted of 28 of 51 (55%) with a university affiliation, 17 of 51 (33%) with no university affiliation, and 6 of 51 (12%) who declined to state. The largest group of participants reporting full-time employment (18/51, 35%) also reported university affiliation with the academic medical center. In this group, 13 of 51 (25%) participants reported full-time employment, university affiliation, and doctoral degrees. High overall exercise class satisfaction was observed in the survey responses (mean 4.0, SD 1). Data analyses revealed significant perceived value of both mental and physical health benefits as motivating factors for participating in the OS fitness class. Challenges were identified as not being able to receive individual feedback from the instructor and the inability of some participants to see if they were in sync with the rest of the class.

Conclusions

Results provide preliminary support for the use of online videoconferencing fitness platforms to promote wellness and facilitate group exercise in the community during times of high infection risk. Future studies should continue to explore perceived benefits, mental and physical wellness, best practices, and the design of related technologies.

Advancements in Postpartum Rehabilitation: A Systematic Review

Postpartum rehabilitation plays a crucial role in promoting maternal health and well-being following childbirth. This systematic review aims to explore recent trends and advancements in postpartum rehabilitation interventions across various categories. A comprehensive search was conducted on PubMed and Embase databases, yielding a total of 358 search results. After applying strict inclusion and exclusion criteria, 20 relevant studies were selected for detailed analysis. These studies were categorized into four distinct categories: exercise-based techniques, technology integration, medical interventions, and multi-modal approaches. Within the exercise-based technique category, pelvic floor exercises, trunk stabilization exercises, and physiotherapy emerged as the most commonly utilized interventions. Studies in this category typically involved population sizes ranging from n = 20 to 200 participants, with study durations spanning from six weeks to 12 weeks. In the technology integration category, predominant techniques included electrical stimulation, biofeedback, acupuncture, and vibrating vaginal balls. Population sizes ranged from n = 50 to 200 participants, with study durations ranging from three days to three months. Only one study was identified in the medical intervention category, which investigated the use of intrathecal analgesia and continuous ropivacaine after cesarean section, involving 200 participants. Multimodal approaches encompassed various combinations of technology, artificial intelligence, image processing, and exercise-based interventions, with population sizes ranging from n = 10 to 500 participants and study durations ranging from six weeks to 12 months. This systematic review provides insights into the diverse landscape of postpartum rehabilitation interventions, highlighting the prominence of exercise-based techniques and the growing utilization of technology integration. While medical interventions remain limited, multimodal approaches show promise in optimizing postpartum care outcomes. Continued research and innovation in this field are warranted to further refine rehabilitation strategies and improve maternal health outcomes following childbirth.

Effects of telerehabilitation-based respiratory and corrective exercises among the elderly with thoracic hyper-kyphosis: a clinical trial

BACKGROUND

Aging is associated with changes in the musculoskeletal system, including increased susceptibility to spine malalignments. Utilizing corrective exercises with a therapeutic emphasis can be beneficial in the elderly with thoracic spine hyperkyphosis.

OBJECTIVE

This study aimed to investigate the effects of six weeks of telerehabilitation-based respiratory and corrective exercises on quality of life, disability, thoracic kyphosis, craniovertebral angle, shoulder angle, cranial angle, and chest expansion in the elderly with thoracic spine hyperkyphosis.

METHODS

In this clinical trial, a total of 40 participants aged 60 and above with thoracic hyperkyphosis were randomly divided into the control (N = 20) and experimental (N = 20) groups. The experimental group performed the corrective exercises for six weeks (3 sessions per week). The control group performed general stretching exercises during the same time period. We measured the outcomes of quality of life, disability, thoracic kyphosis, craniovertebral angle, shoulder angle, cranial angle, and lung expansion before and after the intervention. Analysis of covariance (ANCOVA) was employed to analyze the data. A P-value ≤ 0.05 was considered statistically significant.

RESULTS

Quality of life (P < 0.001, Effect Size (ES): 0.44), chest expansion (P < 0.001, ES: 0.56), thoracic kyphosis angle (P < 0.001, ES: 0.31), craniovertebral (P < 0.001, ES: 0.33), cranial (P < 0.001, ES: 0.38), and shoulder (P = 0.005, ES: 0.20) angles were significantly improved in the experimental group as compared with controls. However, no statistically significant difference was observed between the two groups in terms of physical ability (P = 0.251, ES: 0.04).

CONCLUSION

It is therefore recommended that online corrective exercises be used in the rehabilitation protocol to improve the quality of life, posture, chest expansion, and disability in the elderly with thoracic kyphosis.

Diastasis Recti Abdominis Rehabilitation in the Postpartum Period: A Scoping Review of Current Clinical Practice

INTRODUCTION AND HYPOTHESIS

Despite exercise being the standard approach to diastasis recti abdominis (DRA) rehabilitation, there is no consensus on the most effective exercise routine and adjunct modalities for reducing DRA and improving functional parameters. The present study is aimed at investigating evidence for DRA rehabilitation in postpartum women, as well as knowledge gaps and areas for future research.

METHODS

For this scoping review a systematic search was conducted in MEDLINE, AMED, CINAHL, Embase, ScienceDirect, Scopus, and PEDro up to November 2022. Selection criteria included studies investigating exercise therapy interventions both with and without adjunct modalities for postpartum DRA. Sample characteristics, diagnostic criteria, program design, and outcome measures were recorded. Critical appraisal of clinical trials was performed using PEDro classification.

RESULTS

Twenty-eight studies were included: 14 clinical trials, 3 case series, and 11 observational studies. DRA exercises that focused on deep and superficial muscles, pelvic floor muscles, respiratory maneuvers, functional exercises, or alternative interventions (yoga, suspension training, hypopressive exercise) and adjunct modalities showed promising results in reducing the inter-recti distance and related dysfunction. However, there was great variability in diagnostic criteria and methods, DRA severity, time post-birth, and exercise program design.

CONCLUSIONS

Reviewed studies provide valuable insights into exercise therapy, but it is important to recognize their limitations, as variability in diagnostic criteria, sample characteristics, and exercise program design hinder the generalizability of the findings. Further high-quality research is needed to strengthen the evidence in this area and provide reliable recommendations for clinical practice.

Curl-up exercises improve abdominal muscle strength without worsening inter-recti distance in women with diastasis recti abdominis postpartum: a randomised controlled trial

QUESTION

What is the effect of a 12-week, home-based, abdominal exercise program containing head lifts and abdominal curl-ups on inter-recti distance (IRD) in women with diastasis recti abdominis (DRA) 6 to 12 months postpartum? What is the effect of the program on: observed abdominal movement during a curl-up; global perceived change; rectus abdominis thickness; abdominal muscle strength and endurance; pelvic floor disorders; and low back, pelvic girdle and abdominal pain?

DESIGN

This was a two-arm, parallel-group, randomised controlled trial with concealed allocation, assessor blinding and intention-to-treat analysis.

PARTICIPANTS

Seventy primiparous or multiparous women 6 to 12 months postpartum, having a single or multiple pregnancy following any mode of delivery, with a diagnosis of DRA (IRD > 28 mm at rest or > 25 mm during a curl-up).

INTERVENTION

The experimental group was prescribed a 12-week standardised exercise program including head lifts, abdominal curl-ups and twisted abdominal curl-ups 5 days a week. The control group received no intervention.

OUTCOME MEASURES

The primary outcome measure was change in IRD measured with ultrasonography. Secondary outcomes were: observed abdominal movement during a curl-up; global perceived change; rectus abdominis thickness; abdominal muscle strength and endurance; pelvic floor disorders; and low back, pelvic girdle and abdominal pain.

RESULTS

The exercise program did not improve or worsen IRD (eg, MD 1 mm at rest 2 cm above the umbilicus, 95% CI -1 to 4). The program improved rectus abdominis thickness (MD 0.7 mm, 95% CI 0.1 to 1.3) and strength (MD 9 Nm, 95% CI 3 to 16) at 10 deg; its effects on other secondary outcomes were trivial or unclear.

CONCLUSION

An exercise program containing curl-ups for women with DRA did not worsen IRD or change the severity of pelvic floor disorders or low back, pelvic girdle or abdominal pain, but it did increase abdominal muscle strength and thickness.

REGISTRATION

NCT04122924.

Technical aspects of inter-recti distance measurement with ultrasonographic imaging for physiotherapy purposes: the scoping review

BACKGROUND

Inter-recti distance (IRD) measurement using musculoskeletal USI has been used in physiotherapy research, in particular, to investigate pregnancy-related diastasis recti abdominis (DRA) and to seek its effective treatment methods. Severe and untreated diastasis may result in the formation of umbilical or epigastric hernias.

OBJECTIVE

This study aimed to systematically map physiotherapy-related research articles that included descriptions of IRD measurement procedures using USI to present their similarities and differences, and formulate recommendations on the procedure.

DESIGN

A scoping review was conducted according to PRISMA-ScR guidelines, including 49 of 511 publications from three major databases. Publications were selected and screened by two independent reviewers whose decisions were consulted with a third reviewer. The main synthesized data items were: the examinees' body position, breathing phase, measurement sites, and DRA screening methods. The final conclusions and recommendations were the result of a consensus between seven reviewers from four research centers.

RESULTS

Studies used 1-5 measurement sites that were differently determined. IRD was measured at the umbilicus (n = 3), at its superior (n = 16) and/or inferior border (n = 9), and at different levels: between 2 and 12 cm above the umbilicus, or a third of the distance and halfway between the umbilicus and xiphoid (n = 37); between 2 and 4.5 cm below the umbilicus or halfway between the umbilicus and pubis (n = 27). Different approaches were used to screen subjects for DRA.

CONCLUSIONS

The discrepancies between the measurement procedures prevent between-study comparisons. The DRA screening method should be standardized. IRD measurement protocol standardization has been proposed.

CRITICAL RELEVANCE STATEMENT

This scoping review indicates that the inter-recti distance measurement procedures using ultrasound imaging differ between studies, preventing between-study comparisons. Based on the results synthesis, the measurement protocol standardization has been proposed.

KEY POINTS

The inter-recti distance measurement procedures using USI differ between studies. Proposed standardization concerns body position, breathing phase, measurements number per location. Determination of measurement locations considering individual linea alba length is suggested. Recommended locations: umbilical top, ½ of umbilical top-xiphoid, ¼ of umbilical top-xiphoid/pubis distances. Diastasis recti abdominis diagnostic criteria are needed for proposed measurement locations.