Physiotherapy Theory and Practice

An International Journal of Physical Therapy

ISSN: 0959-3985 (Print) 1532-5040 (Online) Journal homepage: https://www.tandfonline.com/loi/iptp20

The impact of exercise therapy and abdominal

binding in the management of diastasis recti
abdominis in the early post-partum period: a pilot
randomized controlled trial

Nadia Keshwani, Sunita Mathur & Linda McLean

To cite this article: Nadia Keshwani, Sunita Mathur & Linda McLean (2019): The impact of
exercise therapy and abdominal binding in the management of diastasis recti abdominis in the early
post-partum period: a pilot randomized controlled trial, Physiotherapy Theory and Practice, DOI:
10.1080/09593985.2019.1675207

To link to this article: https://doi.org/10.1080/09593985.2019.1675207

Published online: 23 Oct 2019.

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PHYSIOTHERAPY THEORY AND PRACTICE
https://doi.org/10.1080/09593985.2019.1675207

The impact of exercise therapy and abdominal binding in the management of

diastasis recti abdominis in the early post-partum period: a pilot randomized
controlled trial
a b c
Nadia Keshwani, PT, PhD , Sunita Mathur, PT, PhD , and Linda McLean, PT, PhD
a
School of Rehabilitation Therapy, Queens University, Kingston, ON, Canada; bDepartment of Physical Therapy, University of Toronto,
Toronto, ON, Canada; cSchool of Rehabilitation Sciences, University of Ottawa, Ottawa, ON, Canada

ABSTRACT ARTICLE HISTORY

Purpose: To explore the feasibility of two physiotherapy interventions for the management of Received 23 March 2018
diastasis recti abdominis (DrA): abdominal binding and targeting trunk exercises. Revised 12 June 2019
Methods: A pilot randomized controlled trial (RCT) design was used to compare the effectiveness Accepted 5 September 2019
of exercise therapy and/or abdominal binding to no intervention on thirty-two primiparous KEYWORDS
women who presented with DrA in the early post-partum period. Feasibility was determined Physiotherapy; pregnancy;
based on study recruitment, compliance, and attrition rates as well as through computation of body image; abdominal
treatment effect sizes associated with each intervention compared to no intervention. Outcomes muscles; diastasis recti
included inter-rectus distance measured using ultrasound, body image, pain, urogynecological
symptoms, and function measured using questionnaires, and trunk flexion strength and endur-
ance measured using clinical tests.
Results: The recruitment rate was 3 participants/month. Intervention adherence rates were >50%
and the attrition rate was 16%. After 6 months, positive effects (Cohen’s d (d) = 0.2–0.5) on body
image were observed in both the abdominal binding alone and combination therapy groups.
A positive effect on trunk flexion strength (d = 0.7) was observed in the combination therapy
group.
Conclusion: The effect sizes suggest that physiotherapy interventions can positively impact body
image and trunk flexion strength. While a clinical trial investigating these interventions is feasible,
further preliminary investigation is recommended.

Introduction 2015; Verissimo et al., 2014); body image and body

satisfaction rates are lower in women with DrA
Diastasis recti abdominis (DrA), a separation of the
(Bolton, Pruzinsky, Cash, and Persing, 2003; de Brito
rectus abdominis heads through strain of the linea
et al., 2010, 2012) than those found in the general
alba, is primarily a sequelae of pregnancy and is esti-
population (Cash, 2000; Cooper, Taylor, Cooper, and
mated to be present in at least two-thirds of women
Fairburn, 1987; Keely, Swanson, and Denison, 2012;
immediately post-partum (Rett, Braga, Bernardes, and
Sperry, 2011). DrA may also be associated with abdom-
Andrade, 2009). The amount of separation present,
inal pain (Emanuelsson, Gunnarsson, Strigard, and
measured as the inter-rectus distance (IRD), improves
Stark, 2014; Keshwani, McLean, and Mathur, 2018;
naturally but appears to plateau by eight weeks post-
Litos, 2014; Nahas, Ferreira, and Mendes Jde, 2004;
partum (Coldron, Stokes, Newham, and Cook, 2008).
Parker, 2009; Zappile-Lucis, 2009), while evidence for
DrA can persist for decades after pregnancy in many
lumbopelvic pain and dysfunction (Dalal, Kaur, and
women (Spitznagle, Leong, and Van Dillen, 2007).
Mitra, 2014; Oneal et al., 2011; Parker, 2009; Santos
Women with DrA exhibit impaired abdominal mus-
et al., 2016; Taylor et al., 2018; Toranto, 1988, 1990)
cle strength (Hills, Graham, and McLean, 2018; Liaw
and urogynecological complaints (Spitznagle, Leong,
et al., 2011) and endurance (Liaw et al., 2011) com-
and Van Dillen, 2007; Taylor et al., 2018; Turan,
pared to women without DrA (Liaw et al., 2011). DrA
Colluoglu, Turkyilmaz, and Korucuoglu, 2011) is
also has cosmetic implications (Akram and Matzen,
inconsistent (Bø et al., 2017; Braekken, Majida,
2014; Keshwani, McLean, and Mathur, 2018; Rosin,
Ellström Engh, and Bø, 2009; Keshwani, McLean, and

CONTACT Nadia Keshwani 8nk23@queensu.ca School of Rehabilitation Therapy, Queens University, 31 George Street, Kingston, ON K7L 3N6,
Canada
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/IPTP.
© 2019 Taylor & Francis Group, LLC
2 N. KESHWANI ET AL.
Mathur, 2018; Mota, Pascoal, Carita, and Bø, 2015b;
Sperstad et al., 2016).
Physiotherapeutic interventions for DrA typically
include exercise therapy and/or abdominal binders
(Keeler et al., 2012). A wide range of abdominal exer-
cises are prescribed (Keeler et al., 2012; Litos, 2014),
with a pervasive focus on transversus abdominis muscle
activation (Keeler et al., 2012). Such exercises have
theoretical merit as the connective tissue sheaths sur-
rounding the muscles of the lateral abdominal wall are
continuous with the linea alba (Rizk, 1980). As such,
activation of the muscles of the lateral abdominal wall,
including the transversus abdominis, can mechanically
load the linea alba (Lee and Hodges, 2016; Scott-
Conner and Dawson, 2009). Mechanical loading may
stimulate the formation and alignment of collagen
(Buckwalter and Grodzinsky, 1997; Kjaer et al., 2009),
thereby enhancing the capacity of the linea alba to
transfer loads across the midline. Although this hypoth-
esis remains unconfirmed, abdominal exercises per-
formed in the post-partum period may improve the
mechanical function of the linea alba.
Reports on the effect transversus abdominis activa-
tion specifically on IRD are inconsistent. Mota, Pascoal,
Carita, and Bø (2015a) reported that an abdominal
drawing-in maneuver, a common method of engaging
the transversus abdominis, resulted in an immediate,
transient increase in IRD when measured below the
umbilicus during the contraction compared to rest,
likely because of the transient mechanical and tensile
loading of the linea alba induced by the contraction.
However, a recent study by Tuttle et al. (2018) investi-
gating the effect of transversus abdominis activation
over a period of twelve weeks reported reductions in
IRD measured above the umbilicus, perhaps due to
connective tissue remodeling in response to loading.
As an alternative to exercise, abdominal binders used
in the early post-partum period may provide physical
support to the abdominal wall (El-Mekawy, Eldeeb, El-
Lythy, and El-Begawy, 2013), perhaps protecting newly
formed collagen as the linea alba undergoes repair.
Exercise therapy interventions and abdominal binding
interventions may also be used in isolation or in com-
bination (Benjamin, van de Water, and Peiris, 2014;
Keeler et al., 2012), the latter possibly resulting in an
additive effect.
Despite the widespread use of exercise therapy and
abdominal binding in rehabilitation programs for
DrA (Keeler et al., 2012), the impact of these inter-
ventions is unclear. Four studies have investigated the
impact of one or both of these conservative interven-
tions for DrA in the post-partum period (Acharry and
Kutty, 2015; El-Mekawy, Eldeeb, El- Lythy, and El-
Begawy, 2013; Tuttle et al., 2018; Walton et al., 2016),
the majority of which focused solely on a reduction in
magnitude of the IRD as the desired outcome, with-
out considering improvements in trunk function or
symptoms. Further, only one study, performed by
Tuttle et al. (2018) employed a control group that
received no intervention, while three used untested
interventions in a comparison group. The inclusion of
a nonintervention control group is essential to inform
the management of DrA in the early post-partum
period since IRD reduces naturally during that time
(Coldron, Stokes, Newham, and Cook, 2008). The
preliminary study by Tuttle et al. (2018) found that
over a twelve week period, an exercise program aimed
at transversus abdominis activation resulted in reduc-
tions in IRD measured above the umbilicus in ten
women with DrA compared to seven women in
a control group who received no intervention. The
results of this small study suggest that exercise ther-
apy may be a promising intervention to reduce IRD,
however, the authors note that more research on the
effect of conservative management on IRD is
required. Further, the effect of interventions on the
symptoms associated with DrA, not just on IRD
should be investigated. With reference to abdominal
binding, while it is commonly prescribed or advised
(Keeler et al., 2012), no studies have investigated the
effect of its use on the signs and symptoms associated
with DrA through comparison with a no-intervention
control group. Currently there is insufficient evidence
to support or refute the use of abdominal binding
and/or abdominal exercises for the management of
DrA (Benjamin, van de Water, and Peiris, 2014).
The primary aim of this pilot study was to assess
the feasibility of conducting a randomized controlled
trial (RCT) to investigate the efficacy of two phy-
siotherapy interventions, abdominal binding and/or
exercise therapy, delivered in the early post-partum
period, for the management of DrA. Our secondary
aim was to gain insight into the magnitude of the
effects of these two interventions through calculation
of treatment effect sizes associated with each inter-
vention when compared to no intervention on
a series of outcomes. Several outcomes including
IRD, trunk flexor strength and endurance, body
image, abdominal and lumbopelvic pain, urogyneco-
logical symptoms, low back dysfunction, and self-
perceived function, were selected based on the lit-
erature (Akram and Matzen, 2014; Dalal, Kaur, and
Mitra, 2014; Emanuelsson, Gunnarsson, Strigard,
and Stark, 2014; Liaw et al., 2011; Parker, 2009;
Santos et al., 2016; Spitznagle, Leong, and Van
Dillen, 2007).

Methods
This study was approved by Queen’s University (REH-
566-13) and University of Toronto (#30007) Health
Sciences Research Ethics Boards and was registered in
the National Institutes of Health Clinical Trials Registry
(NCT02268110). A single blinded, four-armed, rando-
mized controlled trial design was employed.
Participants
A total of 32 women were recruited through prenatal
education and prenatal fitness classes, and through
flyers placed in obstetrical clinics and birth centers in
Toronto, Canada. Potential participants were initially
screened by phone to determine eligibility. Women
were initially eligible if they were pregnant with their
first child and were between the ages of 18 and
35 years. Women were not eligible if they had a diag-
nosed neurological impairment known to impact mus-
cle activity, had any known connective tissue disorders,
had a history of persistent pain with intercourse prior
to pregnancy, or if they were unable to attend weekly
physiotherapy sessions during the 12 week intervention
period.
Eligible participants were contacted after their
anticipated delivery date at which time they were
excluded if they delivered by Cesarean section. For
those remaining eligible, their first visit to the labora-
tory at the University of Toronto was scheduled in their
third post-partum week.
Procedure
At the first session, after providing written, informed
consent, the presence of DrA was confirmed through
palpating the sulcus between the rectus abdominis
heads at four levels along the linea alba (i.e. superior
border of the umbilicus, 3 cm and 5 cm above it, and
3 cm below the inferior border of the umbilicus). In
order to facilitate palpation and better delineate the
rectus abdominis heads, the participant, positioned in
crook-lying with one pillow under their head, per-
formed a slight head lift. When performing the head
lift, the participant was instructed to keep her neck in
line with her spine and to gently lift her head off the
pillow, such that her head was still touching, but no
longer supported by, the pillow. If the physiotherapist
was able to place at least two fingers in the sulcus
(Noble, 1945) at one or more sites, DrA was confirmed
and the woman was deemed eligible to participate
(Figure 1) while those without DrA were excluded.
Eligible participants were then familiarized with the
PHYSIOTHERAPY THEORY AND PRACTICE 3
trunk flexion strength and endurance assessment pro-
tocols in order to optimize performance consistency
during the subsequent assessment.
Demographic data including age, delivery date,
degree of perineal tearing and/or episiotomy if
known, and breastfeeding/pumping status were
obtained through self-report. Physical activity level
was recorded using the International Physical Activity
Questionnaire (Craig et al., 2003) and participants
reported the frequency of performing any specific
abdominal or pelvic floor muscle exercises on custom
questionnaires. Height, weight, and waist circumfer-
ence were measured by a research assistant using stan-
dard procedures. Participants then completed the
questionnaires described below. Participants returned
within three days to undergo an abdominal ultrasound
imaging assessment to measure IRD and to have their
trunk flexion strength and endurance assessed.
Randomization
Eight participants were randomly assigned to each of
four groups: 1) exercise therapy alone; 2) abdominal
binding alone; 3) exercise therapy and abdominal bind-
ing (combination therapy); and 4) control (no inter-
vention), using a computerized, constrained, random
allocation. Randomization and revealment of group
assignment occurred after the first evaluation session,
and was carried out by one of the study investigators
(NK) who was not involved in data collection.
A separate research assistant who remained blinded to
group assignment was responsible for all assessments.
A registered sonographer with over 15 years of experi-
ence in gynecological, obstetrical, and musculoskeletal
imaging performed all ultrasound imaging assessments,
and a registered physiotherapist with over 10 years of
experience administered all questionnaires and per-
formed the abdominal muscle function evaluation.
The sonographer received over 30 hours of hands-on
training on the imaging protocol by a study investigator
(NK) and the physiotherapist received over 15 hours of
hands-on instruction on administration of the ques-
tionnaires and on the functional evaluation procedures.
Interventions
Exercise therapy
Weekly individualized sessions were provided by
a registered physiotherapist who had post-graduate train-
ing and experience in women’s health. This physiothera-
pist was not involved in any of the evaluations. Over the
12-week intervention period, women received advice on
postural correction and movement mechanics, and were
4 N. KESHWANI ET AL.

Assessed for eligibility (n=89)

Excluded (n= 57)

♦ Did not meet inclusion criteria at initial
contact i.e. during pregnancy (n= 17)
♦ Declined to participate (n= 15)
♦ Delivered via C-section (n= 17)
♦ DrA (-) at 3 weeks postpartum (n= 5)
♦ Other reasons (eg. planned to be
away during study period) (n= 3)

Randomized (n=32)

Allocated to intervention Allocated to intervention Allocated to intervention Allocated to control

Group 1 (n= 8) Group 2 (n=8) Group 3 (n= 8) Group 4 (n= 8)

Lost to follow-up (n=1;
family emergency)
Discontinued intervention
(n=1; same as above)
Lost to follow-up (n= 0)
Discontinued intervention
(n= 0)
Lost to follow-up (n=1;
declined returning for
follow-up)
Discontinued intervention
(n=1; same as above)
Lost to follow-up (n=1)
Relocated to another
province
Discontinued intervention
(n= 0)

Analysed (n= 7) Analysed (n= 8) Analysed (n= 7) Analysed (n= 7)

Lost to follow-up (n=1) Lost to follow-up (n= 0) Lost to follow-up (n=1) Lost to follow-up (n=0)
Relocated to another Relocated to another
country country

Analysed (n= 6) Analysed (n= 8) Analysed (n= 6) Analysed (n= 7)

1

Figure 1. Participant flow diagram. Abbreviations: Group 1, exercise therapy alone; Group 2, abdominal binding alone; Group 3,
combination of exercise therapy and abdominal binding; Group 4, no intervention; DrA, diastasis recti abdominis.

prescribed a progressive daily home abdominal exercise
program, which included isolated activation of the trans-
versus abdominis muscles, bent knee leg lifts in crook
lying while maintaining a neutral lumbopelvic spine,
eccentric trunk flexion exercises starting in sitting using
a sheet/towel to support the abdominal wall during the
exercise, and side planks with progressive variations.
Details of the exercise therapy sessions including prescrip-
tion parameters are provided in the Appendix. Real-time
ultrasound imaging, visual inspection, and palpation were
used to ensure correct performance of the exercises and to
progress them.
instructed women to wear it during waking hours,
except while bathing, for the entire 12 week interven-
tion period.
Combination therapy
Women received the abdominal binder and the home-
based exercise program, and attended weekly phy-
siotherapy sessions as described above.
Control group
Women received no education or intervention.

Abdominal binding Outcome measures and follow-up

The physiotherapist provided and fitted an abdominal Exercise therapy adherence and abdominal binder use
binder (Postnatal FITsplintTM, MomBod Fitness) and were monitored using online self-report logs, and

participants received daily e-mail reminders to com-
plete the log. Participants were asked to return for
two follow-up evaluations, one immediately following
the intervention period (i.e. at 12 weeks) and one
6 months after the end of the intervention period.
All outcome assessments were administered by the
research assistants, who remained blinded to group
assignment initially and at all follow-up visits. For
each outcome, the difference between the value
obtained at the initial evaluation and the follow-up
was calculated for use in the statistical analyses. The
outcomes included the following measures.
Inter-rectus distance
A trans-abdominal ultrasound imaging assessment was
performed by the registered sonographer. Images were
acquired at four locations along the linea alba with parti-
cipants in supine and while relaxed. IRD was measured at
the same sites used for the palpation assessment described
above. A GE LogiqTM e portable ultrasound imaging
system was used in B-mode, interfaced with a two-
dimensional, high frequency (4–13 MHz) linear transdu-
cer (12.7 mm width, 47.1 mm length). Panoramic imaging
was used when needed (Keshwani, Mathur, and McLean,
2015). This ultrasound imaging protocol produces excel-
lent test-retest reliability (Keshwani and McLean, 2015)
and criterion-related validity (Mendes et al., 2007) in
women with DrA. The mean IRD across five images
acquired at each measurement site was computed and
the largest mean IRD at the initial assessment, regardless
of measurement site, was used as baseline for comparison.
Trunk flexion strength and endurance
Trunk flexion strength was graded (zero to five) using
Daniels and Worthingham’s procedure (Hislop, Avers,
and Brown, 2013). Static trunk flexion endurance was
tested by adopting the most challenging position that
was achieved in the strength test, and instructing the
participant to hold that position as long as possible.
Standardized verbal encouragement was provided by
the assessor, and the holding time was determined
using a stopwatch. Three repetitions of the static endur-
ance test were performed with at least 3 minutes of rest
between trials; the best (i.e. longest holding time) of the
three trials was used to represent the participant’s
endurance. The same position used to evaluate trunk
flexion endurance at the initial evaluation was used in
subsequent evaluations, even if the participant’s
strength grade improved between evaluations.
PHYSIOTHERAPY THEORY AND PRACTICE 5
Pain intensity
Abdominal, low back, and pelvic pain were quantified
separately using 100 mm horizontal visual analogue
scales (VAS) with “no pain” and “worst pain imagin-
able” as anchors (Boonstraa et al., 2008). Participants
were asked to rate their current pain, and also the worst
intensity of pain they had experienced in the past
24 hours. Participants were placed in a standardized
seated position when completing these VAS scales.
Urogynecological complaints
The short form Pelvic Floor Distress Inventory and the
short form Pelvic Floor Impact Questionnaire (Barber
et al., 2011; Barber, Kuchibhatla, Pieper, and Bump,
2001; Barber, Walters, and Bump, 2005) were adminis-
tered with one modification. The original instructions
ask participants to consider their symptoms in the last
three months. This time period was not considered
appropriate for women three weeks post-partum, and
was therefore removed. Each questionnaire is scored
from 0 to 300, where higher scores indicated greater
distress and negative impact on quality of life.
Disability due to low back pain
Disability due to low back pain was determined using the
modified Oswestry Disability Index, whereby the question
about sex life was replaced with an item surrounding home-
making activities (Davidson, 2008; Fritz and Irrgang, 2001).
The total score is expressed as a percentage (0 to 100%) with
higher values representing greater disability. Participants
were placed in a standardized seated position when com-
pleting this questionnaire.
Body image
Body image was evaluated using the Appearance
Evaluation and Body Areas Satisfaction subscales of the
Multidimensional Body-Self Relations Questionnaire
(Brown, Cash, and Mikulka, 1990). For the latter, the
item relating to satisfaction with one’s waist/stomach
was evaluated separately because it was of particular inter-
est. Scores range from one to five, where higher scores
indicate more positive body image and greater satisfaction
with the appearance of one’s stomach/waist, respectively.
Both subscales have adequate internal consistency
(Cronbach’s alpha = 0.73 to 0.88) and test-retest reliability
(correlation coefficient = 0.74 to 0.91) (Cash, 2000).
Perceived function
Overall perceived post-partum function was evaluated
using the Inventory of Functional Status After Childbirth
6 N. KESHWANI ET AL.
Questionnaire (Fawcett, Tulman, and Myers, 1988) which
includes five domains: 1) household responsibilities; 2)
social and community activities; 3) baby care; 4) self-care;
and 5) work if applicable. The average across all scales
yields a total score ranging from 1 to 4, with lower scores
indicating lower functional status.
Data analyses
Statistical analyses were performed using IBM SPSS
Statistics (v.22). Data were first tested for normality
using the Kolmogorov-Smirnov test (α = 0.05) with
a Lilliefors Significance correction. Effect sizes were
calculated for each outcome and intervention through
comparison with the control group, at each of the two
follow-up points (12 weeks and 6 months) using the
difference from baseline each group experienced.
Cohen’s d was calculated for normally distributed
data. Where scores were not normally distributed,
a nonparametric equivalent to Cohen’s d (r) was calcu-
lated (Field, 2009) using Equation 1:
z of the umbilicus in 6 women.
r ¼ pffiffiffi ;
n
where z is the Mann-Whitney U test statistic con-
verted to a z score, and n is the combined sample
size of the intervention and control groups.
Effect sizes (d or r) were classified as none (< 0.2), small
(≥ 0.2), medium (≥ 0.5), or large (≥ 0.8). Where d or r was
≥0.2, effects were then classified as clinically meaningful if
the difference in the amount of change experienced by the
intervention group compared to the control group was
greater than the established minimal detectable change
(MDC) for objective outcomes or the minimal clinically
important difference (MCID) for subjective outcomes.
Because the MCID had not been established for the
Multidimensional Body-Self Relations Questionnaire nor
Table 1. Minimal detectable change or minimal clinically important difference values for each outcome.
Outcome Measure
IRD (cm)
Trunk flexor strength
Trunk flexor endurance (s)
VAS pain scale (cm)
Abdominal pain
Low back or pelvic pain
Modified Oswestry Index (%)
PFDI
PFIQ
MBSRQ
Appearance evaluation
Body areas satisfaction (stomach/waist)
IFSAC
Abbreviations: IRD, inter-rectus distance; VAS, visual analogue scale; PFDI, Pelvic Floor Distress Inventory; PFIQ, Pelvic Floor Impact Questionnaire; MBSRQ,
Multi-Dimensional Body-Self Relations Questionnaire; IFSAC, Inventory of Functional Status after Childbirth.
the Inventory of Functional Status after Childbirth, clini-
cally meaningful changes were defined a-priori. For the
Body Areas Satisfaction score for the stomach or waist,
an improvement by at least one was deemed meaningful.
Similarly, an improvement by one on at least one item on
the Appearance Evaluation subscale was deemed mean-
ingful. For the Inventory of Functional Status After
Childbirth, a change of one in any of the four primary
domains was deemed to be meaningful. Table 1 lists the
MDC/MCID values for each outcome.
Results
Participant characteristics are presented in Table 2. Group
outcome measure scores collected at baseline are pre-
sented in Table 3. No significant differences between
groups (one-way analysis of variance or Kruskal-Wallis
test depending on normality, α = .05) were found for any
baseline scores. Of the 29 women whose baseline data
were included in the 12 week time point analyses, IRD
was largest at the superior border of the umbilicus in 23
women and was largest at 3 cm above the superior border
(1)
Recruitment, adherence, and attrition rates
Recruitment occurred between May 2014 and June 2015.
Eighty-eight women were assessed for eligibility
(Figure 1) before reaching our target of 32 participants,
resulting in a recruitment rate of three participants per
month. Three participants dropped out before the
12 week evaluation and an additional two participants
dropped out before the 6-month evaluation (Figure 1),
resulting in attrition rates of 9% and 16%, respectively.
Adherence was 60% for the abdominal binder, where, on
average, women donned the binder for 9 hours out of
a possible 15 waking hours and was 73% for the exercise
MDC or MCID value Source (if applicable)
0.29 Keshwani and McLean, 2015
1 Mahony et al., 2009
35 Moreland et al., 1997
16 Gallagher, Bijur, Latimer, and Silver, 2002;
19 Hagg, Fritzell, and Nordwall, 2003
8.4 Fritz and Irrgang, 2001; Childs and Piva, 2005
45 Barber, Walters, and Bump, 2005
36 Barber, Walters, and Bump, 2005
0.14
1
0.25
 PHYSIOTHERAPY THEORY AND PRACTICE 7

Table 2. Baseline group characteristics of participants who completed their 12 week follow-up evaluation (n = 29).
Group 1 Group 2 Group 3 Group 4
Exercise therapyAbdominal binding Combination Control
(n = 7) (n = 8) (n = 7) (n = 7)
Age (years) [Mean (SD)] 31(3) 32(2) 31(3) 32(2)
Time since delivery (days) [Mean (SD)] 22(2) 22(2) 23(2) 22(2)
BMI (kg/m2) [Mean (SD)] 23.5(2.4) 25.9(2.5) 24.1(3.7) 25.5(2.2)
Waist circumference (cm) [Mean (SD)] 81.7(7.9) 83.1(6.0) 82.1(10.0) 85.6(6.5)
Weight (kg) [Mean (SD)] 65.2(5.8) 66.2(7.9) 65.3(13.4) 70.3(5.7)
Height (cm) [Mean (SD)] 166.9(6.2) 159.0(6.1) 166.0(7.1) 166.1(4.6)
Degree of perineal tearing [Median (IQR)] 1 (2) 2 (1) 2 (1) 2 (1)
PFMT performance (# participants) 5 7 3 2
Singleton pregnancy (# participants) 7 8 7 7
Abdominal exercise performance (# participants) 1 1 1 0
Curl-ups/sit-ups 0 0 0 0
Pilates 0 1 0 0
Breastfeeding (# participants) 7 8 7 7
Moderate activity (MET-mins/wk) [Median (IQR)] 240 (540) 60 (248) 105 (270) 240 (960)
Vigorous activity (MET-mins/wk) [Median (IQR)] 0 (0) 0 (0) 0 (0) 0 (0)
Means and standard deviaions (SD) are presented for normally distributed data and medians and interquartile ranges (IQRs) are presented for non-normal
data. Two participants were unsure of the degree of perineal tearing they experienced. Abbreviations: BMI, body mass index; PFMT, pelvic floor muscle
training; MET, metabolic equivalent task; MET-mins/wk, minutes of metabolic equivalent tasks performed in a week.

therapy program, where, on average, women reported
that they had completed the prescribed number of sets
and repetitions of each exercise 73% of the time. All
participants in the exercise therapy alone and combina-
tion therapy groups attended at least 10 out of 12 phy-
siotherapy sessions. Adherence to each intervention in
the combination group was similar to the interventions
delivered alone (abdominal binder: 64%, vs. 53%; exer-
cise therapy: 77% vs. 70%, respectively).
Effect sizes
The baseline values of pain, and disability due to low
back pain were very low (Table 3). Calculating effect
sizes on these low values was deemed to be inappropri-
ate. The relevant effect sizes associated with each inter-
vention are displayed in Tables 4 and 5, where data
collected at the 12 week and at the 6 month follow-ups
are presented separately for parametric and non-
parametric data. Differences in the mean/median
improvement experienced by each intervention group
compared to the control group are also displayed. Small
to medium positive, clinically meaningful effects deter-
mined through comparison with the values presented
in Table 1 were found only for body image and trunk
flexion strength in response to abdominal binding
alone or to the combination of exercise therapy and
abdominal binding. At the 6 month follow-up,

Table 3. Group outcome measures scores at baseline (n = 29).

Group 1 Group 2 Group 3 Group 4
Exercise therapy Abdominal binding Combination Control
(n = 7) (n = 8) (n = 7) (n = 7)
IRD (cm) [Median (IQR)] 2.54 (0.59) 3.80 (1.38) 2.57 (1.92) 3.00 (1.38)
Trunk flexor strength [Median (IQR)] 4 (1) 4 (1) 3 (1) 4 (1)
Trunk flexor endurance (s) [Median (IQR)] 9.3 (19.2) 4.3 (11.0) 7.9 (8.1) 5.7 (7.0)
Abdominal pain VAS (mm) [Median (IQR)]
Current 0 (0) 0 (4) 0 (2) 0 (2)
Worst in 24 hours 0 (0) 3 (8) 0 (6) 0 (3)
Low back pain VAS (mm) [Median (IQR)]
Current 0 (3) 0 (6) 2 (6) 2 (4)
Worst in 24 hours 1 (4) 5 (16) 1 (7) 3 (13)
Pelvic pain VAS (mm) [Median (IQR)]
Current 0 (0) 1 (4) 0 (2) 0 (21)
Worst in 24 hours 0 (8) 2 (7) 0 (3) 0 (10)
PFDI [Mean (SD)] 26.6(11.3) 39.8(28.2) 44.7(35.5) 56.9(32.9)
PFIQ [Mean (SD)] 12.2(8.6) 34.5(52.3) 27.4(36.6) 24(30.2)
Modified Oswestry Index (%) [Median (IQR)] 0 (4) 4 (11) 6 (6) 6 (22)
IFSAC [Mean (SD)] 3.1(0.4) 3.1(0.4) 3.1(0.3) 2.9(0.4)
MBSRQ [Median (IQR)]
Appearance evaluation 4.14 (0.57) 3.64 (1.46) 3.71 (1.15) 3.57 (0.86)
Body areas satisfaction (waist/stomach) 3 (2) 3 (3) 2 (2) 1 (3)
Mean and standard deviation (SD) are presented for normally distributed data and medians and interquartile ranges (IQRs) are presented for non-normal data.
Abbreviations: IRD, inter-rectus distance; VAS, visual analogue scale; PFDI, Pelvic Floor Distress Inventory; PFIQ, Pelvic Floor Impact Questionnaire; IFSAC,
Inventory of Functional Status after Childbirth; MBSRQ, Multidimensional Body-Self Relations Questionnaire.
8 N. KESHWANI ET AL.

Table 4. Changes from, 1) baseline to immediately after the 12-week intervention (n = 29) and 2) baseline to after 6 months
(n = 27), in normally distributed outcomes.
Assessment time Mean (SD) change from Improvement difference Cohen’s d effect
point Outcome measure Group baseline intervention – control size
12 weeks
PFDI 1, Exercise 2.3 (20.7) −20.3 − 0.9 (large)
2, Abdominal −19.3 (26.2) +1.3 +0.1
Binding
3, Combination −18 (35.8) +0.0 +0.0
4, Control −18 (24.9)
Appearance evaluation 1, Exercise −0.39 (0.38) −0.26 − 0.6 (med)†
2, Abdominal 0.14 (0.36) +0.27 +0.6 (med)†
Binding
3, Combination 0.23 (0.52) +0.36 +0.7 (med)†
4, Control −0.13 (.54)
IFSAC 1, Exercise 0.4 (0.1) −0.2 − 0.9 (large)
2, Abdominal 0.6 (0.3) +0.0 +0.0
Binding
3, Combination 0.6 (0.2) +0.0 +0.0
4, Control 0.6 (0.3) +0.0
6 months
IRD (cm) 1, Exercise −0.93 (0.88) −0.38 − 0.4 (small)†
2, Abdominal −1.34 (0.34) +0.03 +0.0
Binding
3, Combination −1.24 (0.73) −0.07 − 0.1
4, Control −1.31 (1.08)
Appearance evaluation 1, Exercise 0.09 (0.40) +0.05 +0.1
2, Abdominal 0.30 (0.38) +0.26 +0.5 (med)†
Binding
3, Combination 0.19 (0.51) +0.15 +0.3 (small)†
4, Control 0.04 (0.60)
IFSAC 1, Exercise 0.6 (0.24) +0.0 +0.0
2, Abdominal 0.7 (0.31) +0.1 +0.3 (small)
Binding
3, Combination 0.6 (0.56) +0.0 +0.0
4, Control 0.6 (0.37)
Trunk flexor endurance (s) 1, Exercise 16.0 (12.4) +7.0 +0.7 (med)
2, Abdominal 14.6 (17.6) +5.6 +0.4 (small)
Binding
3, Combination 14.2 (12.4) +5.2 +0.5 (med)
4, Control 9.0 (7.3)
Values are presented as change from baseline after either 12 weeks or 6 months: Positive change indicates improvement except for the PFDI and for IRD,
where a negative change indicates improvement. Improvement difference intervention – control: These values indicate the difference observed in the
intervention group less the difference observed in the control group. In all cases, a positive value indicates that the intervention group experienced
a greater improvement than the control group, and as such, positive effects sizes are favorable. † indicates a clinically meaningful effect. Abbreviations: SD,
standard deviation; PFDI, Pelvic Floor Distress Inventory; IFSAC, Inventory of Functional Status after Childbirth questionnaire; IRD, inter-rectus distance.

a negative, small, but clinically meaningful effect on
IRD was found in the exercise therapy alone group.
Changes in relevant participant characteristics after
12 weeks and 6 months are displayed in Table 6.
Discussion
Our recruitment (3 participants/month), retention
(91% at 12 weeks, 84% at 6 months) and treatment
adherence rates (> 50%) suggest that an RCT investi-
gating the treatment efficacy of physiotherapeutic inter-
ventions for DrA is feasible, but would likely require
a multi-center approach. At the 6 month follow-up,
exercise therapy alone was not associated with
a positive, clinically meaningful effect on any of the
outcomes, while abdominal binding alone had
a positive clinically meaningful effect on women’s atti-
tudes toward their physical self, and satisfaction with
the appearance of their stomach/waist. None of the
interventions appeared to have any impact, positive or
negative, on urogynecological symptoms or on overall
function. Abdominal binding in combination with
exercise therapy was associated with positive, clinically
meaningful effects not only on both body image out-
comes, but also on trunk flexion strength. Although the
results of this pilot study suggest that physiotherapeutic
interventions can positively impact body image com-
plaints and abdominal muscle function among women
with DrA, several considerations must be taken into
account before a larger RCT is initiated.
Only one other pilot study has investigated the effect
of exercise therapy on IRD through comparison with
a control group that received no intervention, and
those authors found significant reductions in IRD mea-
sured 4.5 cm above the umbilicus immediately after the
twelve-week intervention period in ten women who
 PHYSIOTHERAPY THEORY AND PRACTICE 9

Table 5. Group median changes from, 1) baseline to immediately after the 12-week intervention (n = 29) and 2) baseline to after
6 months (n = 27), in non-normally distributed outcomes.
Assessment time Median (IQR) change from Improvement difference Nonparametric
point Outcome measure Group baseline intervention – control effect size
12 weeks
IRD (cm) 1, Exercise −0.59 (0.32) −0.42 − 0.2 (small)†
2, Abdominal −0.92 (0.94) −0.09 +0.0
Binding
3, Combination −0.81 (1.03) −0.20 − 0.1
4, Control −1.01 (1.19)
PFIQ 1, Exercise −5 (9) +0 +0.1
2, Abdominal −7 (66) +2 +0.2 (small)
Binding
3, Combination −5 (62) +0 +0.2 (small)
4, Control −5 (24)
BAS (stomach/waist) 1, Exercise −1 (1) −1 − 0.4 (small)†
2, Abdominal 1 (2) +1 +0.1
Binding
3, Combination 0 (1) +0 − 0.1
4, Control 0 (2)
Trunk flexor strength 1, Exercise 0 (1) +0 +0.2 (small)
2, Abdominal 1 (0) +1 +0.7 (med)†
Binding
3, Combination 1 (1) +1 +0.6 (med)†
4, Control 0 (1)
Trunk flexor endurance (s) 1, Exercise 2.39 (11.14) −4.05 − 0.4 (small)
2, Abdominal 9.25 (26.10) +2.81 +0.2 (small)
Binding
3, Combination 12.18 (16.07) +5.74 + 0.1
4, Control 6.44 (15.57)
6 months
PFDI 1, Exercise −14.5 (24.3) −7.5 − 0.4 (small)
2, Abdominal −13.0 (43.5) −9.0 − 0.2 (small)
Binding
3, Combination −16.0 (55.0) −6.0 − 0.1
4, Control −22.0 (55.0)
PFIQ 1, Exercise −9.5 (9.3) −0.5 +0.0
2, Abdominal −5.0 (74.8) −5.0 − 0.1
Binding
3, Combination −0.5 (68.0) −9.5 − 0.2 (small)
4, Control −10.0 (14)
BAS (stomach/waist) 1, Exercise 1 (2) +1 +0.0
2, Abdominal 1 (2) +1 +0.2 (small)†
Binding
3, Combination 1 (2) +1 +0.2 (small)†
4, Control 0 (2)
Trunk flexor strength 1, Exercise 1 (1) +0 +0.5 (med)
2, Abdominal 1 (0) +0 +0.4 (small)
Binding
3, Combination 2 (1) +1 +0.7 (med)†
4, Control 1 (1)
Values are presented as change from baseline after either 12 weeks or 6 months: Positive change indicates improvement except for IRD, the PFDI, and the
PFIQ, where a negative change indicates improvement. Improvement difference intervention – control: These values are presented as the difference
observed in the intervention group less the difference observed in the control group. In all cases, a positive value indicates that the intervention group
experienced a greater improvement than the control group, and as such, positive effects sizes are favorable. † indicates a clinically meaningful effect.
Abbreviations: IQR, interquartile range; IRD, inter-rectus distance; PFIQ, Pelvic Floor Impact Questionnaire; BAS, body areas satisfaction; PFDI, Pelvic Floor
Distress Inventory.

received the intervention compared to seven noninter-
vention controls (Tuttle et al., 2018). Specific to our
exercise therapy alone intervention, we did not detect
a positive effect on IRD. In fact, we detected a negative,
small but clinically meaningful effect of exercise on IRD,
meaning that women in the exercise therapy alone group
experienced slightly less improvement in IRD than those
in the control group who represented natural recovery.
Differing results may be due to differences in the study
samples, as Tuttle et al. (2018) included both primi- and
multi-parous women and, although not stated, presum-
ably women who had given birth vaginally as well as
through Cesarean section while the inclusion criteria for
the current study stipulated that women must have been
primiparous and must have given birth vaginally. The
timeframe during which the intervention was adminis-
tered also differed between the two studies: 6 to 12 weeks
post-partum (Tuttle et al., 2018) and 3 to 4 weeks post-
partum (current study). Differing results may also have
been due to the exercises performed. Tuttle et al. (2018)
10 N. KESHWANI ET AL.

Table 6. Participant characteristics after 12 weeks and 6 months.

12 weeks 6 months
Group Group Group Group Group Group Group Group
1 2 3 4 1 2 3 4
(n = 7) (n = 8) (n = 8) (n = 8) (n = 6) (n = 8) (n = 6) (n = 7)
Weight change from baseline (kg) [Median (IQR)] −2.7 −2.1 −1.4 −4.1 −6.6 −5.1 −6.6 −6.5
(1.2) (2.5) (2.6) (3.2) (10.4) (5.0) (4.1) (8.2)
BMI change from baseline (kg/m2) [Median (IQR)] −1.1 −0.9 −0.6 −1.5 −2.5 −2.1 −2.4 −2.5
(0.5) (1.0) (0.9) (1.2) (3.7) (1.6) (1.3) (3.1)
Waist circumference change from baseline (cm) [Median (IQR)] −2.0 −4.1 −4 .0 −5.0 −7.8 −7.3 −8.1 −6.0
(7.1) (5.3) (7.5) (6.5) (11.8) (4.0) (9.3) (3.8)
PFMT (# participants) 3 3 2 4 3 4 2 5
Abdominal exercises (# participants) 3 3 4 3 4 5 4 2
Curl up/sit- up 0 2 0 0 0 3 0 2
Pilates 0 1 0 1 1 3 0 1
Moderate physical activity (MET-mins/wk) [Median (IQR)] 465 770 810 720 1045 694 1260 450
(2340) (2458) (1103) (1545) (871) (1358) (1155) (1905)
Vigorous physical activity (MET-mins/wk) [Median (IQR)] 0 140 960 240 1070 280 810 0
(720) (1140) (2160) (660) (1557) (880) (1142) (645)
None of the variables were normally distributed. Abdominal exercises: At the 12 week follow-up, participants in an exercise therapy group were asked to
consider abdominal exercises that they were performing outside of the prescribed exercise therapy program. Abbreviations: IQR, interquartile range; BMI,
body mass index; PFMT, pelvic floor muscle training current performance; MET, metabolic equivalent task; Group 1, exercise therapy; Group 2, abdominal
binding; Group 3, exercise therapy and abdominal binding; Group 4, no intervention.

prescribed transversus abdominis exercises but did not
advise women on, nor monitor, other abdominal exer-
cises performed outside of the prescribed exercises.
Mota, Pascoal, Carita, and Bø (2015a) reported an
immediate, transient decrease in IRD compared to rest
when an abdominal crunch was performed. It is possible
that participants in Tuttle et al.’s study (2018) who
performed the prescribed exercises also performed
other abdominal exercises that may have contributed
to IRD reductions, perhaps abdominal curl up/sit-ups.
Performance of additional abdominal exercises is unli-
kely to have impacted our results, as no participants in
either the exercise therapy alone nor control groups
reported performing abdominal curl-ups or sit-ups at
the 12 week follow-up (Table 6). In any event, while IRD
is a reliable and valid measure of DrA severity, the results
of the current study suggest that the intervention we
employed is unlikely to decrease IRD. By definition,
the IRD is not equivalent to the path length of the linea
alba. As such, results based on changes in IRD may be
misleading when IRD is interpreted as a reflection of the
extent of change in the morphology of the linea alba. No
studies have investigated the effect of an intervention
comprising abdominal curl up/sit-ups on the signs and
symptoms associated with DrA. Before a larger RCT is
undertaken, further research is necessary to determine if
different exercise programs (for example, abdominal
curl-ups, transversus abdominis training, or others) are
associated with more positive effects on outcomes when
compared to a no-intervention control group. Negative
effects should also be monitored, as it has been reported
that abdominal curl-ups can cause increases in intra-
abdominal pressure (Simpson et al., 2016) and bladder
base depression in parous women (Barton, Serrao,
Thompson, and Briffa, 2015), which, in turn, may
increase the incidence or severity of urogynecological
complaints.
With regards to urogynecological complaints, in the
current study, although exercise therapy and abdominal
binding were associated with negative effects on urogy-
necological function, none of these effects were mean-
ingful when interpreted within the context of
established MCIDs. The exercise program did not con-
tain high impact exercises (e.g. running and jumping
jacks) and purposely excluded activities (e.g. abdominal
curl-ups/sit-ups) that may increase intra-abdominal
pressure and may therefore result in, or worsen, uro-
gynecological complaints (Barton, Serrao, Thompson,
and Briffa, 2015; Fozzatti et al., 2012). Moreover, the
abdominal binders used in the current study were unli-
kely to evoke or exacerbate urogynecological symptoms
through causing an increase in intra-abdominal pres-
sure. Zhang et al. (2016) reported that while rigid
binders do cause increases in intra-abdominal pressure,
elastic binders do not. The Postnatal FITsplint, while
not specifically tested, is unlikely to have changed intra-
abdominal pressure because it is flexible and elastic.
That said, further research is needed to determine the
impact of individual abdominal binders on intra-
abdominal pressure and urogynecological symptoms.
Very low baseline levels of musculoskeletal pain and
disability due to low back pain were found in our
sample. Because of these low values, it was not appro-
priate to calculate the effect sizes associated with these
outcomes. The low levels of baseline pain and dysfunc-
tion found in our sample may have been a reflection of
the relatively young, physically active, primiparous
sample that was recruited. It is possible that older, less

fit, and/or multiparous women may report more pain
or dysfunction associated with DrA. Low levels of pain
and dysfunction may also have been associated with
sampling bias; it is possible that women with higher
levels of pain and dysfunction were not motivated,
willing, or able to participate. Specific to the symptom
of abdominal pain, using anchors of “no pain” and
“worst pain imaginable” on the Visual Analogue Scale
may not have been ideal. Emanuelsson et al. (2016)
reported that among 57 women with DrA, all reported
concurrent abdominal “discomfort” but 75 percent of
them reported no abdominal “pain” or “pain” that was
easy to ignore on the Ventral Hernia Questionnaire. It
is possible that anchors describing discomfort instead
of pain would have resulted in higher symptom scores.
With regards to dysfunction, a more individualized
measure such as the Patient Specific Functional Scale
(Stratford, Gill, Westaway, and Binkley, 1995) may
have yielded different results. In any event, our results
cannot be generalized to women with DrA who report
greater amounts of abdominal, low back, or pelvic pain,
or greater amounts of dysfunction. Further exploratory
work is recommended to determine if measures of
discomfort and/or dysfunction are relevant for other
samples of women with DrA such as those who present
with higher levels of pain, who are multiparous, whose
DrA has persisted for longer than four months, who
delivered via Cesarean section, and/or who are of older
maternal age.
To our knowledge, the current study is the first to
consider the effects of physiotherapy interventions on
psychosocial implications of DrA. Immediately after
the intervention period, exercise therapy alone had
a small to medium, negative, clinically meaningful
effect on body image (both overall and specific to the
stomach/waist); that is, women who were randomized
to the exercise therapy alone group had lower satisfac-
tion with their body than women who received no
intervention. This effect was no longer present at the
6-month follow-up. It is unclear why this occurred. It is
unlikely that IRD was moderating body image, as the
negative effect on body image disappeared by the
6 month follow up despite that the exercise therapy
alone group still displayed smaller reductions in IRD
than the control group. The exercise protocol did not
focus on weight loss activities (e.g. diet, aerobic exer-
cise), and the control group had no limitations put
upon them regarding their engagement in exercise. It
is possible that the control group engaged in more
weight loss activities than the exercise therapy alone
group between the initial evaluation and the 12-week
follow up evaluation (Table 6). We asked participants
about their breastfeeding status only at the initial
PHYSIOTHERAPY THEORY AND PRACTICE 11
evaluation, not at the follow-up evaluations.
Differences in breastfeeding status at follow-up may
also have affected weight loss (Baker et al., 2008).
These factors may contribute to changes in body
image satisfaction in the post-partum period and
should be investigated as confounders in future
research.
Although no positive effect on body satisfaction with
the waist/stomach was found with abdominal binder
use at 12 weeks, participants who received an abdom-
inal binder reported greater improvements in satisfac-
tion with their waist/stomach at the 6-month follow up
when compared to the control group. This effect was
not present immediately after the intervention period,
and did not occur concurrently with any differences in
weight loss, waist circumference, or body mass index
(Table 6) between groups. It is possible that the impact
of the abdominal binder on the appearance of the
stomach/waist may not have been visible until some
threshold amount of post-partum weight loss had
occurred, explaining why this effect was present at the
6-month follow-up but not immediately after the inter-
vention period. Further work is required to test the
moderating influence of weight loss before initiating
a larger trial. Regardless, abdominal binding, alone
and in conjunction with the exercise therapy program
used in the study, did have a positive effect on body
image and body satisfaction compared to no interven-
tion. Because there is no established MCID for the
Multidimensional Body-Self Relations Questionnaire,
interpretation of the Appearance Evaluation and Body
Areas Satisfaction outcomes derived from the
Multidimensional Body-Self Relations Questionnaire
should be done with caution. To the best of our knowl-
edge, the Multidimensional Body-Self Relations
Questionnaire is the only body image questionnaire
whose reliability and validity has been established,
which is why this particular measure was chosen.
Before the effect of interventions on body image should
be investigated in a future trial, the MCID of the
chosen questionnaire must be established.
At the 12 week follow-up, only the abdominal binding
alone and combination therapy groups experienced
a positive, clinically meaningful change relative to the
control group on trunk flexion strength. One other
study has investigated post-partum changes in abdominal
muscle function, where both exercise alone and abdom-
inal binding alone were associated with significant
improvements in strength compared to baseline, with
exercise therapy being associated with greater strength
improvements than abdominal binding (El-Mekawy,
Eldeeb, El- Lythy, and El-Begawy, 2013). Although the
exercise program used in the current study included
12 N. KESHWANI ET AL.
eccentric rectus abdominis strengthening, it did not
include the abdominal curl-ups used in other protocols,
which may have led to differences in results. By the
6-month follow-up, only the combination therapy group
retained its clinically meaningful treatment effect on
trunk flexion strength. This effect cannot be attributed
to abdominal exercises performed between the 12-week
and 6-month follow-ups, as, after the intervention period,
the number participants performing abdominal exercises
on their own was similar among all intervention groups
(Table 6). It is possible that the exercise therapy per-
formed in the early post-partum period promoted col-
lagen formation at the linea alba, providing a stronger
fixation point for the muscles of the lateral abdominal
wall to enhance stability during a sit-up task (Escamilla
et al., 2010), while concurrent abdominal binding may
have provided protection to newly formed collagen,
resulting in the better trunk flexion strength outcomes
in the combination therapy group. It is also possible that
the binder may have held the muscles of the abdominal
wall in a shortened position, thus improving performance
through remodeling of the muscles themselves (i.e. redu-
cing the number of sarcomeres in series) or their
embedded or surrounding connective tissue. More
research is needed to determine the mechanism(s)
through which an abdominal binder might lead to
improvements in abdominal muscle function. New
forms of ultrasound imaging techniques, specifically,
shear wave elastography to assess linea alba stiffness
(Beamish, Green, Nieuwold, and McLean, 2019), and
emerging technologies such as resonant reflection spec-
troscopy to assess sacromere length (Young et al., 2017)
may be useful in evaluating these proposed mechanisms
in future work. Interestingly, we did not find any other
positive effects in the combination therapy group at
6 months that could be attributed to trunk flexion
strength. Prospective studies conducted by Lee et al.
(1999) and Cho et al. (2014) reported that trunk flexion
strength may play a role in the development of low back
pain and is negatively associated with pain severity. As
such, it is possible that changes in symptoms or function
as a result of trunk flexion strength were not detected here
but could emerge later on. The test-retest reliability of
using isokinetic dynamometry to measure abdominal
muscle strength in women with DrA has been established
(Stark, Emanuelsson, Gunnarsson, and Strigard, 2012)
and as such may be a better measure of abdominal muscle
strength in a future trial as it may be more sensitive to
change than the discrete values obtained through the
clinical strength test employed in the current study.
Although we assessed only trunk flexion, measurement
of trunk rotation force using dynamometry, or clinical
strength tests that concurrently challenge the obliques
may also be of value (Hills, Graham, and McLean, 2018).
At baseline, all of the participants were breastfeed-
ing, and most were engaging in some amount of mod-
erate physical activity, had relatively low BMIs, and
presented with IRDs of approximately 3 to 4 cm. As
such, this sample is not likely representative of the
general population of primiparous women with DrA.
The higher levels of physical activity and low BMIs
found in this sample may have been a result of the
recruitment strategies used. Women were recruited
from several facilities, one of which was prenatal fitness
classes. Although recruitment at this location could
have led to sampling bias as these women were enga-
ging in physical activity during pregnancy, this does not
appear to be the case because only three of the 32
women who participated were recruited from
a prenatal fitness class. Recruitment bias may have
occurred simply due to the nature of the study.
Potential participants were aware that they may be
randomized to an exercise intervention; therefore, it is
possible that individuals who were more likely to want
to engage in physical activity decided to enroll. Such
recruitment and sampling biases should be considered
in future trials with an aim of generating a sample that
is more representative of the population of women with
DrA. This can be accomplished through relying on
more neutral recruitment sites, for example, prenatal
education classes, family medicine, obstetrical and mid-
wifery clinics and social media. Perhaps providing
more education regarding the type of exercise (i.e. not
high intensity cardiovascular training) would also be
useful in preventing this type of recruitment bias.
Although the use of several outcomes provided
a robust dataset including both objective and patient-
oriented outcomes, it comes with an increased the risk
of type II error. We attempted to account for the large
number of outcomes by interpreting all results within the
context of effect sizes relative to the MDC/MCID.
Further, due to the low baseline scores found on the
VASs for pain and the Modified Oswestry Disability
Index, we did not evaluate the effect sizes associated
with our interventions on these outcomes. These out-
comes may, however, be meaningful among women
with DrA who report higher levels of pain. Lastly, because
of the small sample of relatively young, active, first-time
mothers who underwent vaginal deliveries and were
breastfeeding at the time of the initial assessment, and
the assessments and interventions occurring in the early
post-partum period, the results should be interpreted
within this context of limited generalizability.
Nonetheless, the lessons learned through this pilot RCT

are highly relevant to work evaluating the effects of dif-
ferent conservative interventions in DrA management.
Conclusion
The recruitment, adherence, and attrition rates found
through this pilot RCT suggest that an RCT investigat-
ing the conservative management of DrA is feasible but
would likely have to be a multi-center endeavor. Our
preliminary results suggest that it may be possible to
improve body image and trunk flexion strength with
physiotherapy interventions. However, different exer-
cise programs may generate different results on IRD
and on other signs and symptoms associated with DrA.
More pilot work is advised before undertaking an RCT
on the physiotherapy management of DrA.
Acknowledgment
The abdominal binders used in this study (Postnatal
FitSplintTM) were provided in-kind by Mombod Fitness.
Funding
This work was supported by Queen’s University [Senate
Advisory Research Committee Grant]; CURA Physical
Therapies [Edmonton, Canada]; Physiotherapy Foundation of
Canada [365140]. Dr. Keshwani received funding from the
Canadian Institutes of Health Research [Doctoral Research
Award] during the execution of this study.
Disclosure statement
The authors declare no conflict of interest.
ORCID
Nadia Keshwani http://orcid.org/0000-0002-4602-9584
Sunita Mathur http://orcid.org/0000-0001-5564-9796
Linda McLean http://orcid.org/0000-0003-0343-5168
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Appendix: Exercise Therapy Specifications
Exercise therapy session protocol
● Total treatment time: 12 weeks
● Frequency of one-on-one sessions with a physiotherapist:
once per week
● Total number of treatment sessions: 8 to 12 (assumed each
participant would have four weeks where a scheduled visit
was either not possible or canceled)
● Duration of each session: First session 1 hour, subsequent
sessions 30–45 minutes
Exercise session details
Session 1: All participants first began with exercise 1,
involving transversus abdominis muscle (TA) isolation in
crook-lying. The physiotherapist first determined the best
cue for eliciting an isolated TA contraction (with the least
amount of co-engagement from the internal/external obli-
ques) using palpation, visual inspection, and ultrasound ima-
ging. Potential visual/verbal cues for TA engagement
included placing finger tips medial and inferior to the ante-
rior superior iliac spine and 1) imagining the belly was
a trampoline and fingers are people, and trying to gently
pull the trampoline away from the fingers; 2) imagining
finger tips are the flame on a candle, and gently pulling the
belly away from the warmth of the candle; 3) gently drawing
the belly button slightly inwards and slightly upwards toward
the heart. The participant practiced the exercise until she
could correctly perform 10 repetitions of exercise 1, with
full relaxation after every contraction.
● Home exercise program: TA isolation in crook-lying (10
repetitions, 3 sets per day; rest period of 2 breaths between
repetitions)
Session 2: Provided that exercise 1 was being performed
correctly, the participant progressed exercise 1 by holding the
contraction for two breaths before releasing (in crook-lying).
The participant was also instructed to start engaging TA
using their cue in other positions (sitting, standing). If exer-
cise 1 was not being performed correctly, the physiotherapist
spent the session reviewing the original exercise. She did not
progress the exercise as indicated until exercise 1 was being
performed correctly.
● Home exercise program (provided that previous exercise
was being performed correctly): TA hold x 2 breaths
(crook-lying; 10 repetitions, 3 sets per day; rest period of
2 breaths between repetitions) and TA isolation in sitting/
standing
Session 3: Provided that the participant could hold TA in
crook-lying for two full breaths (tested using ultrasound
imaging, visual inspection, and palpation), this exercise was
progressed by adding unilateral leg lifts. If the participant
could not hold TA in crook-lying for two full breaths, the
physiotherapist spent the session reviewing this exercise. She
did not progress the exercise until it was performed correctly.
● Home exercise program (provided that previous exercises
were being performed correctly): TA activation during
concurrent leg lifts (crook-lying start position; 10 repeti-
tions per leg, 3 sets per day; rest period of 1 breath between
repetitions), and TA engagement with daily activities in
sitting and standing.
Session 4: Provided that the participant could engage TA
in sitting, the physiotherapist taught her to eccentrically load
the rectus abdominis muscle with support in sitting. If the
participant could not engage TA in sitting (tested using visual
inspection, palpation, and ultrasound imaging), the phy-
siotherapist spent the session reviewing this exercise. She
did not progress to eccentric rectus abdominis loading until
the participant was able to engage TA in sitting.
● Home exercise program (provided that previous exercises
were being performed correctly): TA lean back with sheet
(sitting; 3 breath hold; 10 repetitions, 3 sets per day; rest
x 1 breath) and continue TA engagement with daily activ-
ities in sitting and standing.
Session 5: Provided that the participant could hold TA
activation during eccentric rectus abdominis loading, the
physiotherapist added an exercise designed to strengthen
the obliques. She did not teach this exercise unless the parti-
cipant could hold TA activation throughout eccentric rectus
abdominis loading. If the participant could not do this, the
physiotherapist spent the session reviewing this exercise. She
did not add a side plank until the participant was performing
the eccentric rectus abdominis loading exercise correctly.
● Home exercise program (provided that previous exercises
were being performed correctly): Side plank (knees bent; 5
repetitions each side, 1 set per day; rest period of 2 breaths
between repetitions), continue TA lean back with sheet (as
above), continue TA engagement with daily activities.
Sessions 6 to 12: The subsequent sessions were used to
play “catch up” with the exercises in those participants who
were having difficulties performing the exercises correctly.
Those participants requiring more than one session to learn
each exercise progressed to the exercises listed under Session
5 by the 12th treatment session. For those participants whose
exercises were progressed as expected (described above), the
side plank exercise was progressed in Sessions 6–12. Options
for progression included increasing the hold time if perform-
ing the exercise with knees bent (goal of 5 full breaths on
each side), performing the exercise with straight legs as
opposed to bent knees, and externally rotating the top hip
so that the top foot was resting on the bottom thigh, and by
exchanging forearm contact with palm contact on the
ground.