Postpartum Exercise and Diastasis Recti Abdominis
Condition: Diastasis Recti Abdominis; Diastasis Recti
MeSH terms: Diastasis, Muscle
Study type: Interventional

Summary: 
      Prevalence rates of diastasis recti abdominis (DRA) among postpartum women vary between 30% -
      68%. It has been postulated that DRA, in addition to being a cosmetic concern for many women,
      may reduce low- back and pelvic stability causing low back- and pelvic girdle pain and be
      related to pelvic floor dysfunctions such as urinary incontinence, anal incontinence and
      pelvic organ prolapse. Given the limited research data, there is currently no consensus on
      which abdominal exercises to recommend to narrow the diastasis.

      The purpose of this assessor blinded parallel group randomized controlled trial (RCT) is to
      evaluate the effect of abdominal muscle training on inter-recti distance (IRD) and prevalence
      of DRA.
    

Detailed description: 
      BACKGROUND:

      DRA is defined as an impairment with midline separation of the two rectus abdominis muscles
      along the linea alba. The condition affects a significant number of women during the
      antenatal- and postnatal period. Today there is a strong focus on the pregnant woman's
      appearance, especially through social media. Webpages and apps recommend how women should
      stay thin and get back into shape with "a flat tummy" at an early stage of the postpartum
      period. There are easily available advices on how to get rid of what is named "the mum's
      belly" (e.g.mammamage.se, breakingmuscle.com, befitmom.com, babybellybelt.com, tummyzip.com).
      A systematic review of the scientific literature has found none or very weak evidence behind
      any of these advices. DRA is diagnosed by measuring the distance between the median borders
      of the two rectus abdominis; IRD, and ultrasound has been found to have the best intra- and
      inter-tester reliability with Intraclass Correlation Coefficient (ICC) > 0.9.

      In a systematic review by Benjamin et al. (2014), 8 studies in treatment of DRA using
      abdominal exercises were found: four case studies, two retrospective observational studies,
      one quasi-experimental post-test study and one small RCT of a brief training intervention. A
      new search on Pubmed of July 2019 found six additional RCTs using abdominal exercises in
      treatment of DRA. The studies differ in methodological and interventional quality and results
      differ between studies. Given the limited research data, use of different outcome measures
      and cut-off point for diastasis in published studies, there is currently no consensus on
      which abdominal exercises to recommend to narrow the diastasis.

      AIMS:

      The aim of this study is to assess the effect of abdominal muscle training on IRD and
      prevalence of DRA in postpartum primi- and multiparous women.

      STUDY DESIGN AND METHODS:

      Before starting this RCT, an experimental cross-sectional study investigating the acute
      effect of different abdominal- and pelvic floor exercises on IRD in women with DRA will be
      conducted. Based on findings from the experimental cross-sectional study, we will choose
      exercises that narrow the IRD for the RCT's exercise program.

      Women will respond to an electronic questionnaire sent by email before they meet for the
      clinical assessments, before and after the intervention period. Women diagnosed with DRA
      giving informed consent are assessed at baseline with 2D ultrasound measurements of IRD,
      abdominal muscle strength tests and the Oswestry Low Back Disability Index (ODI), Pelvic
      Girdle Questionnaire (PGQ) and (Pelvic Floor Disability Index) PFDI-20. After baseline
      testing the participants are randomly allocated to either an exercise or control group.
      Randomization will be computer-generated, in blocks of 4 with concealed allocation.
      Randomization will be provided by a person not involved in assessments of outcome. The
      outcome assessor will be blinded for group allocation. After the 3 month training period,
      both the exercise and control group will be reassessed with 2D ultrasound, abdominal muscle
      strength and endurance tests and the ODI, PGQ and PFDI-20.
    

Intervention name(s): Abdominal muscle training
Intervention type(s): Other
Intervention description(s): The intervention starts 6-12 months postpartum and will last for three months with weekly follow-up through an exercise app. Before commencing the home-based program, women in the intervention group will have an individual session in how to perform the program with a physiotherapist. The intervention consists of a 10 min 5 days a week exercise program, including the following exercises; headlift, crunch and twisted crunch. General principles for strength training are followed: 3 sets of 8-12 contractions close to maximum. The participants will be provided with a smartphone app (Athlete Monitoring) to be reminded to exercise and to register adherence.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: An assessor blinded parallel group RCT
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: Postpartum; Abdominal Muscle Training; Exercise