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

Effects of conservative approaches for treating diastasis recti abdominis in postpartum women: A systematic review and meta-analysis

BACKGROUND

Verify the effects of conservative approaches for treating diastasis recti abdominis in postpartum women.

METHODS

PubMed, Embase, CENTRAL, CINAHL, SportDiscus, LILACS, and PEDro were searched, until March 15, 2024. The methodological quality of randomized clinical trials (RCTs) was assessed using the PEDro scale. Meta-analyses were conducted using the mean difference (MD) between groups for interrectus distance (IRD) in millimeters (mm).

RESULTS

After screening, 34 RCTs were included in the systematic review, of which 21 presented a low risk of bias. Very low certainty evidence demonstrated significant effects for IRD reduction in favor of abdominal exercises versus no intervention (MD = -6.82 mm) and for abdominal exercises plus multi-interventions versus abdominal exercises only (MD = -3.56 mm). Subgroup analyses demonstrated that significant IRD reduction occurs only with isotonic abdominal exercises (MD = -3.78 mm) and that the best co-intervention with abdominal exercises is electrical stimulation (MD = -4.43 mm).

CONCLUSION

Isotonic abdominal exercises, especially when combined with electrical stimulation, represent the best conservative treatment option for improving postpartum diastasis recti abdominis. However, due to the very low certainty of the evidence, these results should be interpreted with caution, and further well-designed RCTs with high methodological quality are needed to confirm these findings.

Intraobserver Reliability of Two-Dimensional Ultrasound Measurements of the Linea Alba in Parous Women During Different Abdominopelvic Exercises

OBJECTIVE

To assess the intraobserver reliability of Diastasis Recti Abdominis (DRA) measurement by ultrasonography during four specific abdominopelvic exercises, evaluating interrecti distance, Linea Alba (LA) thickness, and distortion index in parous women.

METHODS

Fifty-four parous women were assessed using ultrasound imaging for the LA. Four exercises were evaluated: crunch, abdominal drawing-in maneuver, pelvic floor muscle contraction, and one exercise based on the de Gasquet Method. Each exercise was performed three times. The ultrasound probe was placed 3 cm above and 2 cm below the umbilicus. Interrecti distance (IRD), distortion index, and LA thickness were measured and analyzed using ImageJ software by independent researchers. Intraobserver reliability was evaluated using the intraclass correlation coefficient (ICC) with a 95% confidence interval.

RESULTS

ICC values for the IRD ranged from 0.84 to 0.99 for the four exercises. The distortion index showed moderate to high reliability (ICC: 0.77-0.98), while LA thickness also demonstrated moderate to high reliability (ICC: 0.75-0.98).

CONCLUSION

The results demonstrate the reliability of ultrasound in measuring key parameters, including LA thickness, distortion, and IRD in women with DRA during various exercises. As a non-invasive tool, it supports evidence-based interventions in postpartum recovery and clinical practice.

Comparative Efficacy and Acceptability of Non-surgical Treatments with or without Exercise for Diastasis Recti Abdominis in Postpartum Women: A Network Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Diastasis recti abdominis (DRA), commonly occurring in postpartum women, is not only an aesthetic issue but is also highly associated with functional impairments. Various conservative treatment modalities have been employed in clinical practice to alleviate DRA. However, the comparative efficacy of these non-surgical treatments for improving the inter-recti distance (IRD) remains to be determined.

AIM

This current network meta-analysis (NMA) aims to compare the efficacy and acceptability of different non-surgical treatments with or without exercise for improving DRA in postpartum women.

METHODS

This NMA adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. ClinicalKey, Cochrane Library, CINAHL, Embase, PubMed, Web of Science, and ClinicalTrials.gov were systematically searched for randomized controlled trial (RCT) studies up to April 2024. The analysis included studies that met the following criteria: (1) postpartum women diagnosed with DRA defined as an IRD greater than 2 cm; (2) intervention: any non-surgical treatments for at least 2 weeks; (3) comparator: no-treatment control; and (4) outcome: changes in IRD and acceptability. The relative efficacy between the non-surgical treatments tested and the probability of treatments were evaluated.

RESULTS

Twenty-one RCTs comprising 1195 participants aged from 18 to 45 years old were included. The forest plot revealed that exercise coupling with neuromuscular electrical stimulation systems (NMES) [mean difference (MD) - 1.12 cm, 95% confidence interval (CI) - 1.66 to - 0.58], acupuncture (MD - 0.81 cm, 95% CI - 1.54 to - 0.08), corset (MD - 0.65 cm, 95% CI - 1.24 to - 0.06), and exercise alone (MD - 0.48 cm, 95% CI - 0.80 to - 0.16) led to significant reductions in IRD compared with control. Further, the treatment ranking indicated that the combination of NMES with exercise has the highest probability (91.0%) of being the best treatment for reducing IRD, followed by acupuncture with exercise (71.1%). Treatments combined with exercise demonstrated better rankings for reducing IRD than individual treatments without exercise. Acceptability did not significantly differ between the groups.

LIMITATIONS AND IMPLICATIONS

This NMA encountered limitations due to participant variability, differing measurement methods, and sparse data, necessitating careful interpretation of findings regarding postpartum DRA interventions.

CONCLUSIONS

This NMA suggests NMES combined with exercise as the best treatment tested for DRA in postpartum women.

PROSPERO REGISTRATION

CRD42024541345.

International Delphi study of clinical and exercise professionals' opinion of physical activity prescreening and contraindications for participating in postpartum physical activity

OBJECTIVE

To establish expert consensus on prescreening and contraindications to moderate-to-vigorous intensity physical activity (MVPA) during the first year postpartum.

METHODS

A Delphi survey of clinical and exercise professionals working with postpartum women and people was conducted until consensus was reached (≥75% agreement). Round I consisted of questions about relative and absolute contraindications to MVPA. Rounds II and III included additional questions based on the thematic coding of open-ended responses from the previous rounds. The results were used to develop a postpartum MVPA preparticipation screening tool.

RESULTS

120 participants completed round I, 105 completed round II and 95 completed round III. Consensus was reached in 46/49 (94%) statements. Twenty-four relative contraindications to MVPA were identified: (loss of consciousness; neurological symptoms; kidney disease; calf pain or swelling suggestive of deep vein thrombosis; severe abdominal pain; vaginal bleeding not associated with menses; postpartum cardiomyopathy; caesarean section with symptoms that worsen with MVPA; unstable hypertension; eating disorder; malnutrition; anaemia; excessive fatigue; fractures or other significant musculoskeletal injuries; haemodynamic instability; breathing difficulties; acute systemic infection accompanied by fever, body aches, or swollen lymph glands; the new onset of chest pain, discomfort, and other angina-like symptoms with exertion; dizziness or lightheadedness during MVPA; new symptoms of heart disease, stroke; and other medical or physical conditions that may affect the ability to be physically active. Key biopsychosocial barriers to MVPA were identified.

CONCLUSION

This Delphi study recommends relative contraindications to MVPA for the first year postpartum that were incorporated into a postpartum MVPA pre-participation screening tool the Get Active Questionnaire for Postpartum.

Impact of exercise on musculoskeletal pain and disability in the postpartum period: a systematic review and meta-analysis

OBJECTIVE

To examine the impact of exercise on musculoskeletal pain (low back pain (LBP), pelvic girdle pain (PGP), lumbopelvic pain (LBPP) and bodily pain) and kinesiophobia during the postpartum period.

DESIGN

Systematic review with random effects meta-analysis.

STUDY ELIGIBILITY CRITERIA

Online databases were searched from database inception to 12 January 2024. Studies of all designs (except case studies) of any publication date or language were included if they contained information on the population (women and people 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 interventions (eg, electrotherapy, infrared irradiation, ultrasound; 'exercise+cointervention')), comparator (no exercise or different exercise measures) and outcome (symptom severity of LBP/PGP/LBPP, related disability, bodily pain and kinesiophobia).

RESULTS

37 studies (N=3769 participants) from 15 countries were included. Moderate certainty evidence showed that exercise-only interventions, including various strengthening exercises targeting the trunk muscles, were associated with a greater reduction in LBPP symptom severity (4 randomised controlled trials (RCTs), n=210; mean difference -2.21 points (on a 0-10 Visual Analogue Scale) 95% CI -3.33 to -1.08) and related disability (6 RCTs, n=296; standardised mean difference -1.17, 95% CI -1.92 to -0.43; large effect size) as compared with no exercise. Similar results were found for bodily pain (2 RCTs, n=318). Evidence was limited and inconclusive regarding the impact of exercise interventions on kinesiophobia.

CONCLUSION

Postnatal exercises, including a variety of muscular strengthening exercises targeting the trunk muscles, decrease the symptom severity of LBPP and related disability.

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.

Reliability of transversus abdominis thickness and inter-recti distance during forced expiration with limb adduction in primiparous women following vaginal delivery

INTRODUCTION

The postpartum period involves significant biomechanical changes that impact maternal health, particularly in the activation of the transversus abdominis (TrA) and the inter-recti distance (IRD), which may contribute to lumbo-pelvic pathologies. While lumbopelvic exercises are beneficial, it remains unclear whether upper or lower limb adduction combined with forced expiration is more effective in activating the TrA. Therefore, the primary objective of this study is to analyze changes in TrA thickness and IRD during four conditions. The secondary objective is to evaluate the intra-observer reliability of these ultrasound measurements.

METHODS

This cross-sectional study, conducted with a sample of 32 participants, assessed TrA thickness (primary outcome) and IRD (secondary outcome), quantified under four conditions: (1) resting position, (2) forced expiration, (3) forced expiration with upper limb adduction, and (4) forced expiration with lower limb adduction. Differences between the four conditions were analyzed using repeated measures ANOVA. The intra-observer reliability of these measurements was evaluated using intraclass correlation coefficients (ICC).

RESULTS

A total of 32 primiparous women between January and April 2024 were included in this study with a mean postpartum period of 9 ± 2.33. Significant variations in TrA thickness were observed across conditions (p < 0.001). Differences were noted between resting and forced expiration (MD = -0.17, p < 0.001) and forced expiration with lower limb adduction (MD = -0.20, p < 0.001) on both sides. For the right TrA, forced expiration differed from upper limb adduction (MD = -0.04, p = 0.007), while no difference was found between upper and lower limb adduction (MD = -0.005, p > 0.05). For IRD, no significant differences were detected across conditions, including resting and lower limb adduction (MD = -0.018, p = 0.727). Excellent intra-examiner reliability was demonstrated for all ultrasound measurements (ICC (1,3) 0.92-0.99).

CONCLUSIONS

There were no significant differences in TrA thickness between forced expiration isolated and when combined with adduction exercises. The high ICC values confirm the robustness of ultrasound measurements for TrA and IRD, highlighting the potential for future research in postpartum rehabilitation strategies.

Effect of hypopressive and conventional abdominal exercises on postpartum diastasis recti: A randomized controlled trial

BACKGROUND

Diastasis recti abdominis (DRA) is the separation of the rectus abdominis muscles along the linea alba, often occurring during pregnancy due to hormonal and mechanical changes. While DRA usually resolves post-childbirth, some women experience persistent issues. Exercise may help reduce the inter-rectus distance, though more research is needed.

OBJECTIVES

Analyze the immediate and long-term effects of hypopressive and conventional abdominal exercises on inter-rectus distance (IRD) in postpartum women, focusing on parity differences.

METHODS

Twenty-eight women who met specific inclusion criteria were randomly assigned to either the hypopressive group (n = 14) or the conventional group (n = 14). The exercise programs for both groups lasted 6 weeks. Ultrasound measurements were taken of the IRD at two locations above the umbilicus, 2 cm (AB2) and 5 cm (AB5), before and after exercise programs.

RESULTS

The IRD decreased after both exercise programs compared to baseline measurements in AB2 (mean difference: 3.06 mm, 95% CI: 1.06 to 5.05) and in AB5 (mean difference: 2.88 mm, 95% CI: 1.59 to 4.17), confirming the long-term effect of exercise. No differences were found between the application of the conventional exercise program or the hypopressive exercises, indicating that both had a similar positive effect. Regarding the immediate effect, after the performance of both programs, the IRD was greater during rest compared to abdominal contraction. This effect was more pronounced at AB5 location (mean difference: 1.00mm, 95% CI: 0.97 to 1.89). Conventional exercises result in a reduction during resting condition (mean difference: 4.52mm, 95% CI: 2.62 to 6.79), whereas with hypopressive exercises, the reduction occurs during muscle contraction (mean difference: 3.43mm, 95% CI: 1.21 to 5.65). With regard to parity, multiparous women benefit most from the application of exercise programs.

CONCLUSION

A reduction in IRD has been achieved with the implementation of both exercise programs in postpartum women, with multiparous women benefiting the most. Specifically, at 5 cm above umbilicus, conventional exercises result in a reduction during the rest condition, whereas with hypopressive exercises, the reduction occurs during muscle contraction.

TRIAL REGISTRATION

Clinical trial registration: NCT05439668.

Immediate effects of corrective exercise versus curl-up in women with diastasis recti abdominis

BACKGROUND/AIM

It is still unclear what types of exercise, beneficial to prevent and/or decrease diastasis recti abdominis (DRA). This study purposed to examine immediate effects of corrective exercise versus curl-up exercise on interrecti distance (IRD) and linea alba (LA) distortion in women with DRA.

MATERIALS AND METHODS

Twenty-three women with DRA were included. The IRD and the LA distortion (with distortion index formula) were measured with ultrasound imaging at rest, during curl-up and corrective exercise.

RESULTS

The IRD, measured at above and below umbilicus, and the distortion index were different between the measurements at rest, during curl up and correction exercise (p < 0.05). In corrective exercise, the change in the IRD at above umbilicus decreased more than rest (p = 0.009) and curl-up (p = 0.004). The change in the IRD at below umbilicus decreased more in corrective exercise than rest (p = 0.033) and curl-up (p = 0.028). The distortion index increased more in corrective exercise than rest (p = 0.006). The index increased more in curl-up than rest (p = 0.029).

CONCLUSION

The corrective exercise may be helpful in the treatment of DRA. Moreover, different muscle contractions that will provide the LA distortion should be taken into account in the treatment of DRA.

Utilizing machine learning to analyze trunk movement patterns in women with postpartum low back pain

This paper presents an analysis of trunk movement in women with postnatal low back pain using machine learning techniques. The study aims to identify the most important features related to low back pain and to develop accurate models for predicting low back pain. Machine learning approaches showed promise for analyzing biomechanical factors related to postnatal low back pain (LBP). This study applied regression and classification algorithms to the trunk movement proposed dataset from 100 postpartum women, 50 with LBP and 50 without. The Optimized optuna Regressor achieved the best regression performance with a mean squared error (MSE) of 0.000273, mean absolute error (MAE) of 0.0039, and R2 score of 0.9968. In classification, the Basic CNN and Random Forest Classifier both attained near-perfect accuracy of 1.0, the area under the receiver operating characteristic curve (AUC) of 1.0, precision of 1.0, recall of 1.0, and F1-score of 1.0, outperforming other models. Key predictive features included pain (correlation of -0.732 with flexion range of motion), range of motion measures (flexion and extension correlation of 0.662), and average movements (correlation of 0.957 with flexion). Feature selection consistently identified pain, flexion, extension, lateral flexion, and average movement as influential across methods. While limited to this initial dataset and constrained by generalizability, machine learning offered quantitative insight. Models accurately regressed (MSE < 0.01, R2 > 0.95) and classified (accuracy > 0.94) trunk biomechanics distinguishing LBP. Incorporating additional demographic, clinical, and patient-reported factors may enhance individualized risk prediction and treatment personalization. This preliminary application of advanced analytics supported machine learning's potential utility for both LBP risk determination and outcome improvement. This study provides valuable insights into the use of machine learning techniques for analyzing trunk movement in women with postnatal low back pain and can potentially inform the development of more effective treatments.Trial registration: The trial was designed as an observational and cross-section study. The study was approved by the Ethical Committee in Deraya University, Faculty of Pharmacy, (No: 10/2023). According to the ethical standards of the Declaration of Helsinki. This study complies with the principles of human research. Each patient signed a written consent form after being given a thorough description of the trial. The study was conducted at the outpatient clinic from February 2023 till June 30, 2023.

Comparison of Health Parameters in Postpartum Diastasis Recti: A Randomized Control Trial of SEMG Biofeedback-Assisted Core Strengthening Exercises with Kinesiotaping vs. Non-Assisted Exercises

Current medical treatments for diastasis recti often involve exercises to strengthen the core muscles, along with abdominal binders or supports. However, there is limited evidence comparing the effectiveness of surface electromyography (SEMG) biofeedback-assisted core strengthening exercises combined with kinesiotaping to other approaches. This study aimed to assess the impact of three interventions on core strength, inter-rectus distance, and quality of life in postpartum women with diastasis recti. The interventions included core strengthening exercises with kinesiotaping and SEMG biofeedback-assisted core strengthening with kinesiotaping. This randomized controlled trial (NCT05897255) included 24 postpartum women divided into three groups. We measured inter-rectus distance, quality of life using the Short Form Health Survey 36, and core strength using the McGill torso battery test. The SEMG biofeedback provided auditory and visual cues. We used one-way analysis of variance to compare outcomes between groups, while a t-test for within-group analysis. Both the SEMG biofeedback-assisted and non-assisted core strengthening exercises with kinesiotaping groups showed significantly greater improvements in energy, bodily pain, general health, physical functioning, and limitations due to physical problems than the core strengthening group. Additionally, the SEMG biofeedback-assisted group demonstrated a greater reduction in inter-rectus distance. There were no statistically significant differences in core strength improvement among the three groups. Core strengthening exercises with SEMG-assisted kinesiotaping were superior to core strengthening alone in reducing inter-rectus distance, enhancing physical function, energy levels, and general health, and decreasing bodily pain and limitations due to physical problems. Core strength improvements were similar across all groups.

Pregnant women may exercise both abdominal and pelvic floor muscles during pregnancy without increasing the diastasis recti abdominis: a randomised trial

QUESTION

What is the effect of a 12-week abdominal and pelvic floor muscle exercise program during pregnancy on the inter-recti distance (IRD) in women with diastasis recti abdominis immediately after the 12-week intervention period and at follow-up 6 weeks postpartum?

DESIGN

An exploratory, parallel-group, randomised controlled trial with concealed allocation, assessor blinding and intention-to-treat analysis.

PARTICIPANTS

Ninety-six pregnant women aged ≥ 18 years, either primigravida or multigravida, in gestation week 24 with an IRD of ≥ 28 mm measured at rest and/or a protrusion on initial assessment.

INTERVENTION

The experimental group participated in a 12-week abdominal and pelvic floor muscle exercise program during pregnancy. The control group received no intervention.

OUTCOME MEASURES

Change (mm) in IRD 2 cm above and below the umbilicus at rest from pre-intervention to immediately post-intervention and to 6 weeks follow-up measured with ultrasonography.

RESULTS

The IRD increased for both groups from baseline to immediately after the intervention and decreased from after the intervention to the follow-up at 6 weeks postpartum. The IRD was smallest for both groups at the follow-up. At 2 cm above the umbilicus, the intervention effect was 2 mm (95% CI -2 to 7) immediately after the intervention and -1 mm (95% CI -4 to 3) at follow-up. At 2 cm below the umbilicus, the intervention effect was -5 mm (95% CI -10 to 0) immediately after the intervention and 0 mm (95% CI -4 to 4) at follow-up.

CONCLUSION

Abdominal and pelvic floor muscle training during pregnancy have a negligible effect on the IRD immediately after 12 weeks of intervention and at 6 weeks post-partum.

REGISTRATION

NCT04960800.

Clinical and exercise professional opinion of return-to-running readiness after childbirth: an international Delphi study and consensus statement

Female athletes have identified a lack of guidance as a barrier to successfully returning to running postpartum, and existing guidelines are vague. Our aim was to define the current practice of determining postpartum run-readiness through a consensus survey of international clinicians and exercise professionals in postpartum exercise to assist clinicians and inform sport policy changes.A three-round Delphi approach was used to gain international consensus from clinicians and exercise professionals on run-readiness postpartum. Professionals who work with postpartum runners participated in an online survey to answer open-ended questions about the following postpartum return-to-running topics: definitions (runner and postpartum), key biopsychosocial milestones that runners need to meet, recommended screening, timeline to initiate running, support items, education topics and factors that contribute to advising against running. Consensus was defined as ≥75% participant agreement.One hundred and eighteen professionals participated in round I, 107 participated in round II (response rate 90.6%) and 95 participated in round III (response rate 80.5%). Responses indicated that, following a minimum 3-week period of rest and recovery, an individualised timeline and gradual return to running progression can be considered. Screening for medical and psychological concerns, current physical capacity, and prior training history is recommended prior to a return to running.This study proposes recommendations for the initial guidance on return-to-running postpartum, framed in the context of current research and consensus from professionals. Future research is needed to strengthen and validate specific recommendations and develop guidelines for best practice when returning-to-running after childbirth.

Rehabilitations for maternal diastasis recti abdominis: An update on therapeutic directions

Diastasis recti abdominis (DRA) affects a significant number of postpartum women, while its treatments are still under debate. This study aimed to systematically evaluate the effectiveness of rehabilitation training programs for postpartum DRA treatment. Four databases were systematically searched to identify eligible studies published up to February 1, 2023. We followed the PRISMA for scoping reviews guideline in this study. The characteristics and the main findings of the included studies were extracted. Sixteen studies enrolling 1129 women during the ante- and/or postnatal period were included. The common rehabilitation training for DRA included physical exercise, non-exercise physical therapy, acupuncture, and electrotherapy. The presence of DRA could be diagnosed by ultrasound, caliper, or palpation, of which ultrasound had the best reliability. Besides, these assessments could also be used for evaluating the therapeutic efficacy after the rehabilitation training programs. Several studies concluded that patients with DRA could be effectively improved by specific interventions. But a few included studies revealed rehabilitation training might be not more effective than no interventions when treating DRA. For example, some investigators did not recommend physical exercise for DRA patients due to this intervention during pregnancy kept the linea alba less stressed by maintaining abdominal tone, strength, and control, and therefore might aggravate DRA. However, it should be noted that this evidence was derived from limited studies (16/60, 27 % papers) with small samples. To some extent, women with postpartum DRA can benefit from the specific rehabilitation regimen by alleviating postpartum inter-rectus distance. Further research is still warranted to propose strategies for improving postpartum DRA.