Research Review By Dr. Ceara Higgins©

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Date Posted:

August 2016

Study Title:

Effects of exercise and Kinesio taping on abdominal recovery in women with caesarean section: a pilot randomized controlled trial

Authors:

Gursen C, Inanoglu D, Kaya S, et al.

Author's Affiliations:

Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Hacettepe University, Ankara, Turkey; School of Physiotherapy and Rehabilitation, Mustafa Kemal University, Hatay, Turkey.

Publication Information:

Archives of Gynecology and Obstetrics 2016; 293: 557–565.

Background Information:

During pregnancy and the postpartum period, hormonal changes lead to weakness and hypotonicity of the abdominal muscles as well as increased elasticity of the ligaments and connective tissues. This results in a lack of support around the waist, which can lead to pain and/or disability, exerting a potentially negative impact on quality of life (1). These issues can be particularly exacerbated after a caesarean section, which is one of the most common surgeries performed on women (2). After a caesarean section, abdominal muscle strength is decreased and the risk of diastasis recti abdominis (DRA) is increased, especially following a second caesarean procedure (3).

Although the mechanism of effect for Kinesio Tape (KT) has not been fully explained, one theory is that the tape application on the skin stimulates mechanoreceptors, causing local depolarization and transmission of nerve impulses, via afferent fibres, to the central nervous system (4). It is also possible that taping may affect muscle function by modulating tension in the fascia (5).

The role of exercise in abdominal recovery post-caesarean section has been well established. The purpose of this study was to evaluate the effectiveness of Kinesio taping combined with exercise on abdominal recovery in women post-caesarean section compared with exercise alone.

Pertinent Results:

45 subjects completed the study: 22 in the exercise alone group and 23 in the exercise plus KT group. The groups showed no significant differences in characteristics or outcome measures at baseline and showed no significant differences in exercise adherence throughout the study.

KT plus exercise was shown to be more effective for abdominal “recovery”, with statistically significant differences seen in rectus abdominus muscles (RAM) and oblique abdominal muscles (OAM) strength, performance of the sit-up and static endurance tests, VAS scores, measurements at the waist and umbilicus, and Turkish version of the Roland Morris Disability Questionnaire (RMDQ) scores post-treatment. The exercise only group showed statistically significant differences in the static endurance test and VAS groups only, and the changes were smaller. The authors concluded that this indicates that KT can increase the effect of exercise by stimulating muscle facilitation (NOTE: This conclusion is supposition. The study does not show how the KT might cause these changes, so we should be hesitant in drawing any conclusions about causality from this study.)

Changes in VAS scores were seen immediately post-intervention in both groups, with a greater decrease seen in the KT plus exercise group. Differences of 2.3% in waist circumference and 2.5% in umbilicus circumference were noted in the KT plus exercise group compared to 0.4% and 1% respectively in the exercise group.

Clinical Application & Conclusions:

The addition of KT to exercise was effective in increasing abdominal muscle strength and endurance, decreasing pain severity, improving waist and umbilicus circumference, and decreasing disability levels in women after caesarean section.

REVIEWER’S NOTE: Although we cannot be sure how KT might promote these differences, we would be foolish to discount the positive effects seen in this study. No matter the mechanism(s) involved, the positive results for the patient make the use of KT worth considering in women who have undergone a caesarean section. It certainly represents a very low risk intervention that might be helpful!

Study Methods:

This study was a prospective, assessor-blinded, pilot randomized controlled trial (RCT). 48 Participants between four and six months post-natal, who had given birth via caesarean section, and had not been given a regular abdominal exercise program in the past six months were recruited. Women with abdominal hernias, diastasis recti abdominis larger than 2cm, a history of abdominal surgery (except caesarean section), or any condition preventing them from performing exercises were excluded. Patients were randomly assigned to the exercise or KT plus exercise groups.

Participants in both groups were taught posterior pelvic tilt, core stabilization and abdominal correction exercises, and respiration techniques. They were asked to perform them 5 days a week, 3 times a day, with 15 repetitions of each exercise. They were also all educated in biomechanical corrections of the lumbar, thoracic, and cervical spine. No further descriptions of the exercise protocol or biomechanical corrections were provided.

The participants in the exercise plus KT group also received a KT application to the rectus abdominus muscles (RAM), oblique abdominal muscles (OAM), and caesarean incision twice a week over a period of four weeks. All taping was performed by the same two experienced and skilled physical therapists. Taping included application of the scar technique (an I band applied at 50%) over the caesarean incision with the patient lying supine. Next, tape was applied on the RAM from origin to insertion by applying the tape at the symphysis pubis (with no tension), having the patient take a deep abdominal breath to stretch the abdominal region, applying the tape at 15-25%, and ending at the xyphoid process with no stretch. The right and left internal oblique muscles were taped starting with no tension at the bottom edge of the 6-12th ribs. The patient’s hip was then placed in flexion and rotation in the opposite direction and the tape applied at 15-25% ending on the pubic bone.

Image below, left to right: Scar technique, RAM technique, OAM technique
kinesiotape protocols
All participants were evaluated at baseline and the end of the 4-week treatment by a third experienced physiotherapist who remained blinded to group allocation. Abdominal muscle strength was tested using the following tests from Dr. Lovett, graded from 0-5 points (6).
  • RAM – patients began in the supine position with their legs in flexion and their arms straight and were asked to lift themselves into a curl up position with the scapulae just off the ground. From here, they were asked to move up into a sit up position with their arms crossed over their chests and then up farther with their hands behind their heads.
  • OAM – The same procedures as above were used with the patients lying diagonally.
  • Lower Abdominal Muscles (LAM) – Patients began in the supine position with their legs at 90 degrees of hip flexion and knee flexion. The physiotherapist kept one hand on the lumbar area while having them lower their legs as slowly as possible. The physiotherapist recorded the angle between the patients’ legs and the ground using a goniometer at the point where lumbar lordosis was observed.
In addition, muscular strength and endurance were evaluated using the half sit-up test. In this test, patients began supine with their knees flexed to 90 degrees and their feet flat on the ground. The number of correctly performed sit-ups in 30 seconds was recorded (7). Next, the abdominal static endurance test was performed. The patient began sitting with the trunk and legs in flexion and the trunk supported by a 70-degree wood support. The hands were crossed on the chest and, at a “start” command, the support was removed. The patient was asked to hold this position as long as possible and the duration of the hold was recorded (8). All tests were performed by the same physiotherapist, in the same order, with a 5-minute rest between tests.

Diastasis recti abdominis (DRA) was assessed with the patient in the hook-lying position. The patient was asked to raise their head and shoulders with their arms extended until the lower angle of the scapulae left the ground. This was done during exhalation. The examiner palpated for DRA at the umbilicus, 4.5 cm above, and 4.5 cm below. A separation of 2 or more fingers (≥ 2cm) indicated the presence of DRA (9). The Visual Analog Scale (VAS) was used to assess both waist pain, with 0 being no pain and 10 being very severe pain, and exercise adherence, with 0 being “did not perform any exercises” and 10 being “performed all exercises”. Measurements of waist, umbilicus, and hip circumference were taken to evaluate recovery of the abdominal region. These measurements were taken with the patient standing, at the end of expiration, and without compressing the skin. Measurements were repeated twice and the average was recorded. Finally, the Turkish version of the Roland Morris Disability Questionnaire (RMDQ) was used to evaluate physical disability due to low back pain, with total scores ranging from 0 (no disability) to 24 (maximum disability) (10).

Study Strengths / Weaknesses:

Strengths:
  • Consistency in treatment and assessment was achieved by having the same physiotherapists perform all the treatments and a third physiotherapist perform all of the assessments.
Weaknesses:
  • The authors used the muscle testing positions proposed by Dr. Lovett. These were updated by Kendall in 1993. It would have been more appropriate to use the updated testing protocols as they are more commonly used in modern practice.
  • No rationale was provided for the use of waist, umbilicus, and hip circumference measurements as a proxy measure of abdominal “recovery”.
  • The descriptions of the exercises and “biomechanical corrections” could have been more robust to assist in the potential application of these techniques in clinical practice.
  • The use of more objective measures such as electromyography or isokinetic dynamometry to measure the activation of abdominal muscles, strength and endurance could have enhanced their results. However, these are not commonly used in a clinical setting, which could have limited the external validity of this study.
  • This pilot study involved a small sample size and should be repeated with a larger sample.
  • The absence of a sham taping intervention does not allow us to assess the possibility that the improvements seen in the KT group were due to a placebo effect (this is a common criticism of KT!).

Additional References:

  1. Gutke A, Lundberg M, Ostgaard HC et al. Impact of postpartum lumbopelvic pain on disability, pain intensity, health-related quality of life , activity level, kinesiophobia, and depressive symptoms. Eur Spine J 2011; 20: 440-448.
  2. Mathai M, Hofmeyr GJ. Abdominal surgical incisions for caesarean section. Cochrane Database Syst Rev 2007; 24:CD004453.
  3. Turan V, Colluoglu C, Turkyilmaz E, et al. Prevalence of diastasis recti abdominus in the population of young multiparous adults in Turkey. Ginekol Pol 2011;82:817-821.
  4. Ptak A, Konieczny G, Stefanska M. The influence of short-term kinesiology taping on force-velocity parameters of rectus abdominus muscle. J Back Musculoskelet Rehabil 2013; 26: 291-297.
  5. Vithoulka I, Beneka A, Malliou P, et al. The effects of Kinesio taping on quadriceps strength during isokinetic exercises in healthy non athlete women. Isokinet Exerc Sci 2010; 18: 1-6.
  6. Cuthbert SC, Goodheart GJ Jr. On the reliability and validity of manual muscle testing: a literature review. Chiropract Osteopat 2007;15:4.
  7. Larson LA. Fitness, health, and work capacity. International standards for assessment 1974; Macmillan.
  8. Moreland J, Finch E, Stratford P, et al. Interrater reliability of six tests of trunk muscle function and endurance. J Orthop Sports Phys Ther 1997; 26: 200-208.
  9. Boissonnault JS, Blaschak MJ. Incidence of diastasis recti abdominus during the childbearing year. Phys Ther 1988; 68: 1082-1086.
  10. Roland M, Fairbank J. The Roland-Morris disability questionnaire and the Oswestry disability questionnaire. Spine 2000; 25: 3115-1124.