|Year : 2020 | Volume
| Issue : 2 | Page : 278-280
Effect of postnatal physiotherapy during puerperal management of low back pain and diastasis recti
Ashwini Kale1, Asmita Suryawanshi2, Bharati Bellare3
1 Associate Professor, MGM's Institute of Physiotherapy, Aurangabad, India
2 Associate Professor, Dept of Radiology, MGM's Medical College and Hospital, Aurangabad, India
3 Retd. Professor, MGM School of Physiotherapy, Navi Mumbai, India
|Date of Submission||12-Jul-2020|
|Date of Decision||06-Aug-2020|
|Date of Acceptance||18-Aug-2020|
|Date of Web Publication||23-Dec-2020|
Dr. Ashwini Kale
MGM's Institute of Physiotherapy, Aurangabad, Maharashtra
Source of Support: None, Conflict of Interest: None
Association of low back pain (LBP) with diastasis recti (DR) is known and frequently encountered during obstetrical status. Exercise during puerperium is prohibited as per the Indian culture in maternal care. A 24-year-old primiparous woman developed LBP (visual analog scale 8) immediately after uneventful vaginal delivery, which jeopardized her functional independence. Examination revealed pathological DR showing interrectal distance (IRD) of 8.72 cm on Vernier caliper and 7.93 cm on transabdominal ultrasound (TAUS) at umbilical level. Physiotherapy limiting to isometric and functional activity was implemented on the patient from the 2nd postpartum day, which continued as home program up to 8 weeks. The patient reported complete resolution of LBP on the 12th postpartum day, whereas by the 8th week, her DR restored to physiological range with the reduction of IRD by 67.88% and 78% on caliper and TAUS, respectively. The case report concluded that culturally suitable postnatal physiotherapy was found to be effective in resolving postnatal LBP and restoration of DR.
Keywords: Diastasis recti, low back pain, postnatal physiotherapy
|How to cite this article:|
Kale A, Suryawanshi A, Bellare B. Effect of postnatal physiotherapy during puerperal management of low back pain and diastasis recti. Arch Med Health Sci 2020;8:278-80
|How to cite this URL:|
Kale A, Suryawanshi A, Bellare B. Effect of postnatal physiotherapy during puerperal management of low back pain and diastasis recti. Arch Med Health Sci [serial online] 2020 [cited 2021 Jan 18];8:278-80. Available from: https://www.amhsjournal.org/text.asp?2020/8/2/278/304710
| Introduction|| |
Rectus abdominis diastasis (diastasis recti [DR]) is a conventional term used to define split between the two rectus abdominis muscles, which usually develops as a result of undue pressure on the abdominal wall, imposing overstretch, thinning, and elongation of the linea alba. Pregnancy, second stage of labor, and abdominal obesity are the most common factors that impose the risk of DR. “Support system” of lumbar spine provides lumbar stabilization (LS) exactly like a custom-made lumbar corset and linea alba functions such as its anterior zip lock. Association of DR with low back pain (LBP) is well documented although not all the cases with DR develop LBP. Maternal care is generally offered with ethnokinship or with technocentric approach. Ethnokinship is based on the ancient traditional modes and widely followed in India. It strongly believes in complete bed rest during puerperium, leaving no scope for postnatal physiotherapy (PNP) (a technocentric approach), because exercises form major domain of PNP. Natural restoration of DR by period postnatally is known, but its total reversal to prenatal status is not guaranteed. Many women, who are asymptomatic during early postnatal stage, develop LBP in the later stage associated with sustained DR.
| Case Report|| |
A 24-year-old primiparous healthy female had full-term uneventful vaginal delivery. She had no health issues such as LBP, stress urinary incontinence, cough, or constipation during pregnancy. She also had no history of miscarriages or any major or minor abdominal surgeries. The patient complained severe LBP following delivery. The status continued on the 2nd postpartum day, and she was unable to assume proper position to breastfeed the baby and turning in bed was also difficult.
The testing procedure was thoroughly explained to the patient and she had given informed consent. The patient was supine on examination table and both legs exed at hips and knees. She was then instructed to perform trunk exion to the point when inferior angles of the scapulae were just off the table. Medial edges of the two rectus abdominis muscle were palpated, and measurement was taken by a Vernier caliper. Then, in relaxed supine posture, the distance between rectus muscles was measured by transabdominal ultrasound (TAUS) at the umbilical level. TAUS, being a gold standard for interrectal distance (IRD) measurement, was performed on the first assessment before treatment and on the 8th week posttreatment.
The ultrasound measurements were taken by a Diagnostic Ultrasound Unit Voluson E8 H48701RU US machine with a two-dimensional, high-frequency linear transducer, used in B-mode for imaging by a radiologist.
The patient was assessed in details by a physiotherapist, during which DR was identified showing IRD at the umbilical level as 8.72 cm on Vernier caliper and 7.93 cm on TAUS.
Having strong belief in ethnokinship, to obtain patient's acceptance and compliance for PNP, the standard dynamic exercises for PNP were excluded. Breathing, pelvic floor muscle exercises, and abdominal hollowing with pressure biofeedback for LS were retained since they were isometric. Each activity was performed under strict supervision of the physiotherapist till its correct method was ensured. PNP intervention commenced on the 2nd postpartum day with patient education about adverse effects of increased Increased Intra abdominal pressure (IIAP) on the abdominal wall and its association with functions such as coughing, straining while defecation, and lifting during puerperium. The patient was also taught protective technique of the abdominal wall bracing during urge to cough. On the 5th day, the patient's LBP reduced slightly (visual analog scale [VAS] 6), and with Abdominal corset (AC) on, she could walk with walker, assume and sustain adequate position for breastfeeding, and perform shifting activity in crook lying. Before discharge on the 5th day, the patient was advised to continue with the same protocol at home. The postdischarge feedback was carried out telephonically on a weekly basis. By the end of the 1st week, the patient reported about a substantial reduction in LBP (VAS 4). On the first follow-up on the 12th day postpartum, her LBP had totally subsided and was comfortable during activities of daily living with AC on. On examination, DR was reduced by 47% (4.56 cm) on caliper. Functional activities including shifting the body ( SB) were added, in which the buttocks were lifted just to clear the base by weight-bearing on hands while sustaining lumbar spine in neutral position and progression in long sitting were given. Telephonic weekly follow-up enabled regular feedback from the patient. A positive report was thus received on the enhancement of health status and compliance of prescribed instructions. The patient reported that she could perform all the activities of SB without AC by 3-week postpartum and was comfortable with all the activities of self and baby care without AC by 6 weeks. After 8 weeks, during the second follow-up, reduction in IRD was found to be 67.88% (IRD 2.8 cm) on caliper and 78% (IRD 1.74 cm) on TAUS. The patient was advised to continue with PNP till 6 months.
[Table 1] and [Figure 1]a and [Figure 1]b show the reduction of IRD caliper and TAUS, respectively.
|Figure 1: (a) Interrectal distance on the first assessment on transabdominal ultrasound. (b) Interrectal distance on final assessment posttreatment on transabdominal ultrasound|
Click here to view
|Table 1: Interrectal distance measurement on the first assessment and after 8 weeks of treatment|
Click here to view
| Discussion|| |
IRD beyond 2.7 cm at the umbilical level is considered pathological DR. Even though beneficial effects of PNP are well documented, it is not popular in India probably because of prevailing culture of ethnokinship and also due to a lack of referrals from obstetricians. In this study, the commencement of PNP intervention with patient education enables good acceptance and compliance of intervention. Exercises included in PNP were isometric and hence were not objectionable. This culturally acceptable experimental model of PNP implemented during puerperium not only established highly encouraging result in achieving its easy acceptance and compliance but also proved its effectivity in early resolution of LBP and timely reversal of DR to a physiological range.
| Conclusion|| |
In this case report, individual need-based and culturally suitable PNP protocol was found to be very effective in resolving postnatal LBP and restoration of DR to physiological range.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
We would like to thank MGM's Medical College and Research Centre.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Polden M, Mantle J. Continence and Incontinence, Physiotherapy in Obstetrics and Gynaecology. 1st
ed. New Delhi, India: Jaypee; 2007. p. 370.
Belisa D, Armèle D, Andréa L, Vitor CB, Manuela LP, Thayse NS. Abdominal muscle electrical activity during labor expulsive stage: A cross-sectional study. Brazi J Phys Ther 2011;15:445-51.
Hautakangas T, Palomäki O, Eidstø K, Huhtala H, Uotila J. Impact of obesity and other risk factors on labor dystocia in term primiparous women: A case control study. BMC Pregnancy Childbirth 2018;18:304.
Bellare B, Rajan P, Pandit U. Health of the abdominal capsule in the obstetrical and gynaecological context. In: Bellare BV, editor. Textbook of Prevention Practice and Community Physiotherapy. 1st
ed. New Delhi: Jaypee Brothers; 2018. p. 224-6.
Lo T, Candido G, Janssen P. Diastasis of the recti abdominis in pregnancy: Risk factors and treatment. Physiother Can 1999;51:32-44.
Posmontier B, Horowitz JA. Postpartum practices and depression prevalences: Technocentric and ethnokinship cultural perspectives. J Transcult Nurs 2004;15:34-43.
Hsia M, Jones S. Natural resolution of rectus abdominis diastasis. Two single case studies. Aust J Physiother 2000;46:301-7.
Benjamin DR, van de Water AT, Peiris CL. Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: A systematic review. Physiotherapy 2014;100:1-8.
Gluppe SL, Hilde G, Tennfjord MK, Engh ME, Bø K. Effect of a postpartum training program on the prevalence of diastasis recti abdominis in postpartum primiparous women: A randomized controlled trial. Phys Ther 2018;98:260-8.
Kale A, Bellare B. Awareness about exclusive role of postnatal physical therapy: A preliminary survey conducted on obstetricians at Aurangabad, Maharashtra. Indian J Physiother Occup Ther 2019;13:27-30.