Effects of Transverse Abdominis Activation and Rectus Abdominis Strengthening on Inter-rectus Distance and Core Stability
NCT ID: NCT07253844
Last Updated: 2025-11-28
Study Results
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Basic Information
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NOT_YET_RECRUITING
NA
33 participants
INTERVENTIONAL
2025-11-25
2026-05-30
Brief Summary
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Detailed Description
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Diastasis Rectus Abdominis (DRA) is a prevalent postpartum musculoskeletal condition characterized by the separation of the rectus abdominis muscles along the linea alba, resulting in impaired trunk stability, abdominal weakness, and postural dysfunction. Despite its high prevalence, DRA remains underdiagnosed and undertreated, particularly in developing countries where structured rehabilitation protocols are lacking. Physiotherapy-based interventions focusing on abdominal muscle retraining and core stability have been shown to improve outcomes; however, the relative effectiveness of Transverse Abdominis (TrA) activation, Rectus Abdominis (RA) strengthening, and their combined approach remains uncertain.
Objectives:
This randomized controlled trial aims to compare the effects of TrA activation, RA strengthening, and their combination on inter-rectus distance (IRD) and core stability among postpartum women with DRA.
Methods:
This three-arm, parallel-group randomized controlled trial will be conducted at the Pakistan Society for the Rehabilitation of the Disabled (PSRD) Hospital, Lahore, Pakistan. A total of 33 postpartum women aged 20-40 years, diagnosed with DRA (6 months to 2 years postpartum), will be recruited using non-probability convenience sampling. Participants will be randomly assigned into three groups (n = 11 per group):
Group A (TAA): Transverse Abdominis Activation exercises
Group B (RAS): Rectus Abdominis Strengthening exercises
Group C (TAA + RAS): Combined TrA activation and RA strengthening protocol
Each participant will undergo a 6-week intervention program, including three supervised sessions per week for 3 weeks, followed by a 3-week home exercise program. Each session will last 30-45 minutes and will be supervised by a licensed physical therapist at PSRD.
Outcome Measures:
Primary Outcome: Change in Inter-Rectus Distance (IRD), measured via real-time ultrasound imaging (7.5 MHz linear probe) at three anatomical sites (4.5 cm above, at, and 4.5 cm below the umbilicus), pre- and post-intervention.
Secondary Outcome: Core stability, assessed using a Pressure Biofeedback Unit (PBU) during the abdominal drawing-in maneuver (ADIM) in crook-lying position. Participants will aim to reduce pressure by 6-10 mmHg from a 40 mmHg baseline and sustain the contraction for 10 seconds; the mean of three trials will be recorded.
Randomization and Blinding:
Participants will be randomized using Randomized Allocation Software (Version 1.0) in a 1:1:1 ratio. Due to the exercise-based nature of the interventions, blinding of participants and therapists is not feasible; however, the outcome assessor will remain blinded to group assignments, ensuring a single-blind design.
Data Analysis:
Statistical analysis will be performed using SPSS version 26. Data will first be tested for normality using the Shapiro-Wilk test. A two-way mixed ANOVA will be applied to assess both within-subject effects (time: pre vs. post) and between-subject effects (group: TAA, RAS, TAA+RAS), as well as the interaction effect (time × group) on IRD and core stability outcomes. Post-hoc pairwise comparisons with Bonferroni correction will identify specific between-group differences. Statistical significance will be set at p \< 0.05 with a 95% confidence interval.
Expected Clinical Significance:
It is hypothesized that TrA activation exercises will lead to a greater reduction in IRD and improvement in core stability compared to RA strengthening alone. The combined exercise group (TAA + RAS) is expected to demonstrate the most comprehensive benefits due to synergistic activation of both deep and superficial abdominal muscles. The study outcomes are anticipated to provide evidence-based guidance for physiotherapists in postpartum rehabilitation, contributing to the development of standardized, non-invasive exercise protocols for DRA management and improved quality of life in postpartum women.
Conditions
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Study Design
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RANDOMIZED
PARALLEL
TREATMENT
SINGLE
Study Groups
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Group A (Transverse abdominis activation)
Transverse Abdominis activation exercises
Group A (TAA) will perform abdominal drawing-in maneuvers (ADIM) in crook lying, side lying, and quadruped positions. They will be instructed to gently draw the belly button inward toward the spine without moving the pelvis or rib cage, emphasizing breathing coordination and pelvic floor co-activation. In the supervised phase, participants will perform 3 sets of 10 repetitions, with each contraction held for 10-20 seconds, and a rest interval of 3 minutes between sets
Group B (Rectus abdominis strengthening)
Rectus Abdominis Strengthening exercises
Group B (RAS) will perform exercises in supine lying with knees bent, including partial curl-ups, reverse crunches, pelvic tilts, and leg raises with abdominal bracing. The command will be tighten your abdominals as if bracing for a punch, and lift without straining your neck. Each supervised session will include 3 sets of 10-15 repetitions per exercise, progressing in difficulty using added resistance if tolerated, with a 3-minute rest interval between sets
Group C (Transverse abdominis activation +rectus abdominis strengthening)
combined protocol of both transverse abdominis activation and rectus abdominis strengthening.
Group C (TAA+RAS) will perform a hybrid protocol integrating both TrA activation and RA strengthening exercises. Each session will begin with ADIM in crook lying, side lying, and quadruped positions, followed by RA exercises including curl-ups, pelvic tilts, and leg raises. The command will be to activate your deep core with breathing, then strengthen your outer abdominals through controlled movements. Each supervised session will consist of 3 sets of 10 repetitions for TrA exercises (10-20 seconds hold) and 3 sets of 10-15 repetitions for RA exercises, with a rest period of 3 minutes between all sets.
Interventions
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combined protocol of both transverse abdominis activation and rectus abdominis strengthening.
Group C (TAA+RAS) will perform a hybrid protocol integrating both TrA activation and RA strengthening exercises. Each session will begin with ADIM in crook lying, side lying, and quadruped positions, followed by RA exercises including curl-ups, pelvic tilts, and leg raises. The command will be to activate your deep core with breathing, then strengthen your outer abdominals through controlled movements. Each supervised session will consist of 3 sets of 10 repetitions for TrA exercises (10-20 seconds hold) and 3 sets of 10-15 repetitions for RA exercises, with a rest period of 3 minutes between all sets.
Transverse Abdominis activation exercises
Group A (TAA) will perform abdominal drawing-in maneuvers (ADIM) in crook lying, side lying, and quadruped positions. They will be instructed to gently draw the belly button inward toward the spine without moving the pelvis or rib cage, emphasizing breathing coordination and pelvic floor co-activation. In the supervised phase, participants will perform 3 sets of 10 repetitions, with each contraction held for 10-20 seconds, and a rest interval of 3 minutes between sets
Rectus Abdominis Strengthening exercises
Group B (RAS) will perform exercises in supine lying with knees bent, including partial curl-ups, reverse crunches, pelvic tilts, and leg raises with abdominal bracing. The command will be tighten your abdominals as if bracing for a punch, and lift without straining your neck. Each supervised session will include 3 sets of 10-15 repetitions per exercise, progressing in difficulty using added resistance if tolerated, with a 3-minute rest interval between sets
Eligibility Criteria
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Inclusion Criteria
* Multigravida
* Delivered a singleton pregnancy via vaginal breech or instrumental delivery
Exclusion Criteria
* Abdominal and pelvic hernias or severe musculoskeletal conditions
* Patients with abdominal and pelvic surgery
* Patients with disc herniation
20 Years
40 Years
FEMALE
No
Sponsors
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Lahore University of Biological and Applied Sciences
OTHER
Responsible Party
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Principal Investigators
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Muhammad tariq Shafi, BSPT,tDPT
Role: STUDY_CHAIR
Lahore University of Biological and Applied Sciences
Locations
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Lahore University of biological and applied sciences
Lahore, Punjab Province, Pakistan
Pakistan Society for Rehabilitation of Differently Abled
Lahore, Punjab Province, Pakistan
Countries
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Central Contacts
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Facility Contacts
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References
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Benjamin DR, Frawley HC, Shields N, van de Water ATM, Taylor NF. Relationship between diastasis of the rectus abdominis muscle (DRAM) and musculoskeletal dysfunctions, pain and quality of life: a systematic review. Physiotherapy. 2019 Mar;105(1):24-34. doi: 10.1016/j.physio.2018.07.002. Epub 2018 Jul 24.
Olsson A, Woxnerud K, Kiwanuka O, Sandblom G, Stackelberg O. The TOR concept (training, operation, and rehabilitation) applied to a cohort of postpartum women with training-resistant symptomatic rectus diastasis: evaluation 1 year after surgery. BJS Open. 2023 Jan 6;7(1):zrac162. doi: 10.1093/bjsopen/zrac162.
Gluppe SL, Hilde G, Tennfjord MK, Engh ME, Bo 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 Apr 1;98(4):260-268. doi: 10.1093/ptj/pzy008.
Pascoal AG, Dionisio S, Cordeiro F, Mota P. Inter-rectus distance in postpartum women can be reduced by isometric contraction of the abdominal muscles: a preliminary case-control study. Physiotherapy. 2014 Dec;100(4):344-8. doi: 10.1016/j.physio.2013.11.006. Epub 2014 Jan 18.
Berg-Poppe P, Hauer M, Jones C, Munger M, Wethor C. Use of exercise in the management of postpartum diastasis recti: a systematic review. The Journal of Women's & Pelvic Health Physical Therapy. 2022;46(1):35-47.
Other Identifiers
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UBAS/ERB/FoRS/25/025
Identifier Type: -
Identifier Source: org_study_id
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