Category: Publications

Beriman Rahmansyah¹, Lucky Anggiat²

Corresponding Author:

Physiotherapy Program, Fakultas Vokasi, Universitas Kristen Indonesia

Email : beriman.rahmansyah@uki.ac.id

Author:

Physiotherapy Program, Fakultas Vokasi, Universitas Kristen Indonesia

ABSTRACT

Background: In applying the physiotherapy interventions, physiotherapists frequently use electro physical agent (EPA) which is therapeutic modalities that have indeed become one of the popular therapies besides exercise therapy and manual therapy. This study aimed to identify the availability and usage of EPA by physiotherapists in East Jakarta, Indonesia.

Methods: This study used online survey research method. The target population was physiotherapists in East Jakarta who joined in the WhatsApp group of the Indonesian Physiotherapy Association, East Jakarta Branch. From 189 target respondents, only 73 respondents were willing to fill out the questionnaires given by the researchers.

Results:In the view from the availability of EPA modalities, most respondents or 91.8% answered the availability of electrical stimulation. It is followed by ultrasound therapy (84.9%). The least EPA modalities found in the respondent’s workplace were paraffin bath (23.3%). From the results, the use of EPA modalities in the form of ultrasound therapy and electrical stimulation was the most widely used. Subsequently, as many as 49.3% of respondents used the ultrasound therapy modality every day. A total of 45.2% of respondents used electrical stimulation modality.

Conclusion. The EPA modalities are quite widely available among physiotherapists in East Jakarta, Indonesia. The most widely available modalities are electrical stimulation, ultrasound therapy, and infrared radiation and in addition to the diathermy modality, which is also quite widely available. The availability of EPA tools is also in line with the frequency of use dominated by ultrasound therapy, electrical stimulation, and Microwave Diathermy.

Keywords: Electro Physical Agents; Modality, Intervention; Physiotherapy

Received on 4thFebruary 2022, Revised on 19thFebruary 2022, Accepted on 26thFebruary 2022, DOI:10.36678/IJMAES.2022.V08I01.008

INTRODUCTION

In clinical practice, physiotherapists carried out all physiotherapy processes from examination, planning, physiotherapy interventions and evaluations, to developing, maintaining, and restoring body movement and function¹. Physiotherapists can provide interventions to patients with various options, such as manual therapy, therapeutic exercise, and interventions with physical equipment as well as electrophysical and mechanical modalities². In applying the physiotherapy interventions, physiotherapists frequently use electro physical agent (EPA) which is therapeutic modalities that have indeed become one of the popular therapies besides exercise therapy and manual therapy³.

Electrophysical agent is defined as the use of physiotherapy modalities for evaluation, treatment, prevention of activity disturbances, and participation restrictions. With EPA, physiotherapist can help establish a physiotherapy diagnostic and evaluate treatment outcomes⁴. Furthermore, EPAis an important component of physiotherapy and consists of the application of various forms of EPA for therapeutic purposes³. Electro physical agents modalities are generally categorized as thermal (hot and cold), electromagnetic (diathermy, ultraviolet, and infrared light), or mechanical (traction and compression)^5,6. Electro physical agents is very widely used in physiotherapy interventions because it has become a standard in hospitals, such as Micro Wave Diathermy (MWD), Short Wave Diathermy (SWD), Infra-Red Radiation, and Laser Therapy and Ultrasound therapy (US)⁷. There are also electrical stimulations such as Transcutaneous Electrical Nerve Stimulation (TENS), Interferential Therapy (IFT), and Neuromuscular Electrical Stimulation (NMES). However, there are also types of non-thermal applications, namely variations in the use of Pulsed MWD, Pulsed SWD, Pulsed Laser Therapy, and Pulsed Ultrasound therapy. However, scientific results related to the frequency of using EPA device are still rare^8,9.

There are not many studies on the use of EPA in Indonesia. Therefore, the development of EPA in Indonesia is not known^4,8. From that background, this study is needed to be able to identify the use of EPA by physiotherapists. However, this study is a preliminary study in the East Jakarta area because it is close to the researchers’ university (Universitas Kristen Indonesia) and there are quite a number of representative hospitals. In addition, it is suggested that future studies are conducted more comprehensively. This study also aims to see the availability of EPA modalities used by physiotherapists so that they can be used as a reference in teaching and learning EPA at universities.

METHODOLOGY

This study used online survey research method. The target population were physiotherapists in East Jakarta who joined in the WhatsApp group of the Indonesian Physiotherapy Association, East Jakarta Branch with 189 respondents. The questionnaires were distributed to all respondents. However, only 73 physiotherapists were willing to fill them out. The data were collected using survey questionnaires to obtain responses from the respondents. The questionnaire consisted of 14 questions. The questions in the questionnaire were divided into several parts, firstly profile part which includes the identity of the physiotherapist and their education level. However, the respondent’s detailed identity was not displayed to maintain the respondent’s privacy. Subsequently, the second part was related to the physiotherapist’s work experience, namely the length of years of work, the number of patients treated in one day, and the condition of the patients often encountered. After that is the last part related to the availability and frequency of using EPA modalities. Before distributing the questionnaires, the questionnaires were tested by physiotherapists and made improvements if needed. The questionnaires were distributed within 3 months, namely December 2021 to February 2022. After the distribution was the processing of the survey results from the questionnaires. At the end, the results were reported and discussed.

RESULTS AND DISCUSSION

From 189 target respondents, only 73 respondents were willing to fill out the questionnaires given by the researchers. The physiotherapist’s identity is in the following table of respondent profiles.

It can be seen that of 73 physiotherapists as respondents in this survey, 35 people or around 47.9% worked in hospitals and only 4 people or around 4.1% worked in community health centers. The previous study also stated that in a hospital, there were more than 10 physiotherapists⁸. The workplace of physiotherapists in some countries is also dominated by hospitals and clinics^10,11. In terms of education level of the respondents, as many as 40 respondents or around 54.8% had a diploma which is three-year study in university level.

There were 7 people or around 9.6% who had a master’s degree. In Indonesia, those who are given the authority to practice physiotherapy are physiotherapists starting at the diploma level to the professional level². This is already in line with the provisions of the World Physiotherapy Organization, although there is still a national government that gives authority to physiotherapists at the diploma level¹. Thus, physiotherapists in East Jakarta are considered to meet the minimum qualifications to practice physiotherapy. Likewise, in some countries, it is found that the qualifications for physiotherapy education are quite varied and still follow the national regulations of each country^10,11.

The following result of the questionnaire is about the physiotherapists’ work experience which describes the range of work of physiotherapists, the average number of patients treated in one day, and the condition of patients treated by the physiotherapists. The data are presented in the following Table 2.

The following result of the questionnaire is about the physiotherapists’ work experience which describes the range of work of physiotherapists, the average number of patients treated in one day, and the condition of patients treated by the physiotherapists. The data are presented in the following Table 2.

In the table, it can be seen that the majority of respondents who have worked for more than five years are 41.1%, which indicates that the physiotherapists have experienced in working and using EPAmodalities. Physiotherapists with more than five years of experience will indeed provide better patient satisfaction¹².

As many as 35.6% physiotherapists treated more than ten patients daily and around 16.4% treat one to two patients every day. From these data, it can be seen that some physiotherapists still treat too many patients in one day, that is, more than ten patients daily. If there are more than 10 patients treated daily by the physiotherapist, assuming one patient is an hour, it indicated that the physiotherapist in providing services is not optimal, because in general, the number of daily working hours is only about 8 hours^11–13. However, there are not many studies that support this. It can also cause harm to the physiotherapist who is likely to experience fatigue. Thus, the number of physiotherapists must be increased in order to provide optimal services¹⁴.

Most respondents or 84.9% treated patients with musculoskeletal condition and the least treated were patients with respiratory condition. Several studies also support this. As in a study by Jahan et al., (2021) who found that physiotherapists mostly treated musculoskeletal patients. Likewise, in a study in a hospital, physiotherapists generally dealt with various types of patients with musculoskeletal disorders⁸. In addition, a study in a certain region also stated that musculoskeletal cases were very dominant in the physiotherapy practice¹⁵.

The following result is related to the availability of EPA modalities as well as the frequency of use. Table 3 shows the available modalities in each physiotherapist’s workplace.

In the view from the availability of EPA modalities found in each respondent’s workplace, most respondents or 91.8% answered the availability of electrical stimulation. It is followed by EPA modalities in the form of ultrasound therapy (84.9%). The least EPA modalities found in the respondent’s workplace were paraffin bath (23.3%). The availability of diathermy modalities in the form of Micro Wave Diathermy at the respondents’ workplace had a considerablevalue of around 61.1%, including Short Wave Diathermy which had a considerable percentage (37%).

There are also heat therapy modalities that are quite popular among physiotherapists, namely Infrared Radiation device which was answered by 50% of the total respondents. A study in Australia also shows that ultrasound therapy is a modality that has considerable availability¹⁶. Furthermore, the use of EPA interventions is still a trend among physiotherapists in Asia^4,17.

However, apart from Asia, in America there is also a trend in the use of EPA¹⁸. The most widely available modality tools are cold and hot agents, with electrical stimulation therapy and ultrasound therapy. It was also found that in America, there are very few diathermy modalities available.

From the results of this study, it can be seen that physiotherapists in East Jakarta have the availability of adequate EPA modalities in accordance with the needs of the patients. Nevertheless, the needs for EPA must really be acknowledged and the latest research developments should keep up with the effectiveness of existing EPA modalities(Belanger, 2015; Bellew et al., 2016;

Goh &Abe, 2015). There are also some EPA modalities in the table 3 that tend to be new and have very little availability.In addition, the existing modalities data can also be a reference for lecturers to continue to provide updates on the science of EPA modalities. By understanding the availability, the lecturer needs to provide understanding to physiotherapy students at the university in order to be more critical in the use of electrophysical instruments in clinical practice. Previous studies also used the survey results in the availability of physiotherapy modalities for teaching purposes at universities¹⁸.

The last results of this study were related to the frequency of the use of EPA. In this study, we only prepare the types of modalities that are popularly used by physiotherapists, which are SWD, MWD, US, IRR, Mechanical Traction, Electrical Stimulation, LASER, and paraffin bath. It is also based on the availability of such modalities at the physiotherapists’ place of practice. Moreover, we conducted a survey related to how many combinations of EPA modalities were used by physiotherapist for each patient with certain condition.

 The time frame we chose was one week to make it easier for the physiotherapists to remember the modalities they used on average. Frequency classification was also made using the range: always (everyday), often (four to five times a week), rarely (one to three times a week), and none (not using the modality or the modality is not available). All usage and frequency data are shown in Table 4.

From the results above, it can be seen that the use of EPA modalities in the form of ultrasound therapy and electrical stimulation was the most widely used. Subsequently, as many as 49.3% of respondents used the ultrasound therapy modality every day and only 12.3% never used the ultrasound therapy modality. A total of 45.2% of respondents used electrical stimulation modality and only 5.5% never used it. The modalities of paraffin bath and mechanical traction were the least used EPA modalities. As many as 83.5% of respondents never used paraffin bath and 61.6% of respondents never used mechanical traction.

The use of electrical stimulation is believed to reduce neuromusculoskeletal disorders. As in the results of a previous study by Manik  & Rahmansyah (2021), it mentioned that EPA modalities in the form of electrical stimulation can reduce pain in neuromuscular and musculoskeletal conditions²⁰. In line with this, a study by Abe et.al (2016),  which surveyed 1099 respondents from 170 hospitals/clinics showed that the use of electrical stimulation in the form of low frequency currents and ultrasound therapy ranked second and third below the modality in the form of hot pack⁴. Furthermore, a study by Greco et al. (2018) also found that the use of electrical stimulation was quite dominant, along with ultrasound therapy and thermal modality (cold or hot). In addition, we should take attention to the results of the existing research is that despite the availability of diathermy physiotherapy tools, it does not guarantee that they are often used. The trend that is developing in the world is that diathermy modality should be abandoned and replaced with more effective modality ^9,18,19.

In this study, it was also found that physiotherapists used more than two modalities in one patient with one condition. This shows that physiotherapists very often used EPA modalities. The use of more than two modalities is possible if the patient’s condition requires intensive intervention and there are more than two symptoms in one condition^19,21. Knowledge of the use of appropriate and effective interventions needs to be carried out in the future to be able to provide optimal services to the patients^22,23.

This study is a very simple survey as a preliminary study. More complex analysis in the existing data can be done as a development of future research. Likewise, the survey in this study was only conducted in one city, so more detailed research using a larger population is needed as a development in the future. This study also has many limitations, one of which is the willingness of the physiotherapist to fill out the questionnaire. Therefore, it is possible to conduct more interesting research that can attract the attention of the physiotherapist to fill out the questionnaires in the future. The reasons for selecting interventions related to the condition of the patients have not been captured in this study, so further research development is needed.

CONCLUSION

The EPA modalities are quite widely available among physiotherapists in East Jakarta, Indonesia, both in health facilities and independent clinical practices. The most widely available modalities are electrical stimulation, ultrasound therapy, and infrared radiation and in addition to the diathermy modality, which is also quite widely available. The availability of EPAtools is also in line with the frequency of use dominated by ultrasound therapy, electrical stimulation, and Microwave Diathermy. Physiotherapists also quite often use EPA because in one patient with one condition, physiotherapists frequently use more than one modalities.

Recommendation: Physiotherapists in East Jakarta should pursue their education to a higher level to find out the latest developments in electrophysical interventions. The use of diathermy should also be reduced by its decreasing use abroad. The number of patients handled by one physiotherapist in one day is too many, so it is necessary to add the number of physiotherapists who work in a hospital. Based on the result, it also suggested that at universities, it is still necessary to provide scientific development in EPA, especially the frequent modalities like ultrasound therapytherapy, electrical stimulation, and diathermy so that when the students graduate, they can practice well.

Acknowledgement: The researcher would like to thank every physiotherapist who is willing to participate in this research. Furthermore, we also thank the of the Indonesian Physiotherapy Association, East Jakarta Branch, for allowing us to collect data from the organization members.

Conflict of interest: The author has no conflict of interest to declare.

Funding of study: This study was funded by Universitas Kristen Indonesia.

Compliance with Ethics: This research does not provide anything that is harmful to the respondents so that it does not use ethical research. However, this research was conducted with the permission of the university and the permissionfrom chairman of the Indonesian physiotherapy association, East Jakarta branch, with reference number 03/IFI-JAKTIM/XI/2021.

REFERENCES

1.    World Confederation for Physical Therapy. Guideline for standards of physical therapy practice. Published online 2011:1-19. https://world.physio/sites/default/files/2020-07/G-2011-Standards-practice.pdf

2.    Kementerian Kesehatan Republik Indonesia. Peraturan Menteri Kesehatan No.80 Tahun 2013.; 2013.

3.    Watson T. The role of electrotherapy in contemporary physiotherapy practice. Man Ther. 2000;5(3):132-141.

4.    Abe Y, Goh AC, Miyoshi K. Availability, usage, and factors affecting usage of electrophysical agents by physical therapists: A regional cross-sectional survey. J Phys Ther Sci. 2016;28(11):3088-3094. doi:10.1589/jpts.28.3088

5.    Starkey C. Therapeutic Modalities. Fourth Edi. (McDonald Q, ed.). F. A. Davis Company; 2013. www.fadavis.com

6.    Belanger A-Y. Therapeutic Electrophysical Agents. Lippincott Williams & Wilkins; 2015.

7.    Kementerian Kesehatan Republik Indonesia. Peraturan Menteri Kesehatan Republik Indonesia Nomor 65 Tahun 2015 Tentang Standar Pelayanan Fisioterapi. Vol 16.; 2015.

8.    Panjaitan LA. Penggunaan Terapi Elektrofisis Pada Satu Rumah Sakit Umum Swasta di Jakarta. J Fisioter. 2020;20(2):40-45.

9.    Goh A-C, Abe Y. New directions in electrophysical agents : where do we go from here? Japanese J Electrophysical Agents VO – 22. 2015;(April):4.

10. Khairy WA, Bekhet AH, Sayed B, Elmetwally SE, Elsayed AM, Jahan AM. Prevalence, profile, and response to work-related musculoskeletal disorders among egyptian physiotherapists. Open Access Maced J Med Sci. 2019;7(10):1692-1699.

11. Nkhata L a, Zyaambo C, Nzala SH, Siziya S. Work-related Musculoskeletal Disorders : prevalence , contributing factors and coping strategies among Physiotherapy personnel in Lusaka , Kitwe and Ndola districts , Zambia. Physiotherapy. 2010; 37(4):262-267.

12. Jahan AM, Rwaiha AE, Gusaibat SR, Al-Ahwal NA, Al-Jafairi ZM, Al-Rashidi MA. Patient Satisfaction With Physiotherapy Services in Libya: A Cross-Sectional Study. J Patient Exp. 2021;8:1-7.

13. Hima Bindu P, Thiruppathi A. Work Related Musculoskeletal Discomfort (WRMSD) among Physiotherapists. Int J Physiother. 2014;1(4):200.

14. Manurung NSA, Sunaryo T, Gunawan I, Anggiat L. Analysis of the need for Physiotherapists in a private hospital in Indonesia using the workload indicator of staffing need referring to the implementation of the physiotherapy process as risk mitigation of services. Int J Med Exerc Sci. 2020;06(01):697-705.

15. Odumodu IJ, Olufunlayo TF, Ogunnowo BE, Kalu ME. Satisfaction With Services Among Attendees of Physiotherapy Outpatient Clinics in Tertiary Hospitals in Lagos State. J Patient Exp. 2020;7(4):468-478.

16. Chipchase LS, Williams MT, Robertson VJ. A national study of the availability and use of electrophysical agents by Australian physiotherapists. Physiother Theory Pract. 2009;25(4):279-296.

17. Shah SGS, Farrow A. Trends in the availability and usage of electrophysical agents in physiotherapy practices from 1990 to 2010: a review. Phys Ther Rev. 2012;17(4):207-226.

18. Greco JL, Lamberg EM, McKenna RF, Muratori LM. Trends in availability and usage of biophysical agents among physical therapists in the United States. Phys Ther Rev. 2018;23(2):116-123.

19. Bellew JW, Michlovitz SL, Nolan TP. MODALITIES For Therapeutic Intervention. F. A. Davis Company; 2016.

20. Manik JWH, Rahmansyah B. The effect of nerve mobilization on the median nerve in pain perception of electrical stimulation. Int J Med Exerc Sci |2021;7(3). 2021; 7 (August):1104-1112.

21. Kim MK, Ji SG, Cha HK, Chang JS. Effects of electromagnetic diathermy in conjunction with nerve mobilization in the management of lower back pain. J Phys Ther Sci. 2012;24(12):1337-1339.

22. Beales D, Mitchell T, Holthouse D. Stepped care for musculoskeletal pain is ineffective: A model for utilisation of specialist physiotherapists in primary healthcare management. Aust J Prim Health. 2021;27(6):431-436.

23. Tiktinsky R, Chen L, Narayan P. Electrotherapy: Yesterday, today and tomorrow. Haemophilia. 2010;16(SUPPL. 5):126-131.

Citation: Beriman Rahmansyah, Lucky Anggiat. Availability and usage of electro physical agentmodality by Physiotherapist in East Jakarta, International Journal of Medical and Exercise Science, March 2022; 8(1); 1228-1237.

Lisnaini

Corresponding Author:

Physiotherapy Program, Faculty of Vocational Studies, Universitas Kristen Indonesia, Jakarta

Mail id: lisnaini@uki.ac.id

ABSTRACT

Background: Diastasis Recti Abdominis (DRA) is a stretching and widening of the linea-alba which is a connective tissue that stretches in the middle of the abdomen that occurs in the second trimester to the third trimester and will continue until after delivery. Usually it cause complaints such as abdominal muscle weakness, lower back pain and posture disorders. Efforts that can be made to reduce the dilation of the postnatal linea-alba are by therapeutic exercise or physical exercise on the abdominal muscles. This study will focus on plank exercise was conducted to determine its effect on reducing the distance of the DRA below umbilicus.

Method: This research is a quantitative analysis with a quasi-experimental design that uses a two-group approach where the treatment was only given to one group and the other group only as a control.

Result: There was a reduction in the width of the diastasis rectus abdominis below the umbilicus by (67.7%) or as many as 42 people who did plank exercise while in the control group only (75.8%) or as many as 47 people who experienced a reduction in the width of the DRA lower umbilicus.

Conclusion: There is an effect of plank exercise on changes in the distance of the DRA below umbilicus and there is a relationship between plank exercise and a reduction in the width of the DRA below umbilicus in postpartum women.

Keywords: Diastasis Recti Abdominis; Postpartum; Plank exercise; Physiotherapy

Received on 4thFebruary 2022, Revised on 19thFebruary 2022, Accepted on 26thFebruary 2022, DOI:10.36678/IJMAES.2022.V08I01.007

INTRODUCTION

Diastasis Recti Abdominis (DRA) is stretching and widening of the linea alba, which is the connective tissue that runs down the middle of the abdomen and connects major abdominal muscles such as external obliques, internal obliques, transversus abdominis, and rectus abdominis¹. Some researcher also stated that this condition usually happens when entering the second trimester and will become clearer in the third trimester and will continue after childbirth (postpartum)^2,3.

Diastasis Recti Abdominis will widen due to frequent pregnancies. It also occurs because during pregnancy there is an increase in body weight and an increase in the hormonal levels of relaxin, progesterone, and estrogen from the connective tissue which causes mechanical pressure on the abdominal wall by the growing fetus so that the connective tissue becomes soft and the linea alba becomes tenuous⁴.

Almost 100% of pregnant women experience DRA^5,6. Approximately 50% of nulliparous women experienced DRA and in women who undergo abdominal surgery and in postmenopausal patients⁷.Factors causing DRA are found in women who do excessive abdominal exercises especially in the first trimester, women who like to use hormone therapy, women who perform repeated operations on their abdomen, women with multiple pregnancies, large babies, and caesarean sections⁸. Ambarwati and Candido also stated that age and multiparity can be risk factors for rectus abdominis diastasis in women^9,10.

Several studies have stated that the general impacts of DRA are the weakness of the abdominal muscles, urinary incontinence, decreased elasticity of the abdominal wall, functional and cosmetic disorders, low back pain^5,6,9. Furthermore, about 52% of patients with urogynecological disorders stated that they had DRA and about 66% had complaints of pelvic floor muscle weakness such as stress urinary incontinence, stool incontinence and/or pelvic organ prolapse⁷.

Efforts that can be made to reduce the dilation of the postnatal linea alba are by therapeutic exercise or physical exercise on the abdominal muscles⁴. Previous research by Gitta et al. (2016) which stated that static contraction exercises in the abdominal muscles have been shown to reduce the DRA distance¹¹. Research by Acharry & Kutty (2015) also stated that to prevent and reduce the DRA, physical therapy can be carried out after childbirth¹². Another research by Wijayanti, (2016) proved that abdominal circumference can be reduced by strengthening abdominal muscles, sit-ups, postpartum exercise, physiotherapy, and plank exercise¹³.

Plank exercise is a type of static contraction exercise that is isometric exercise, which is muscle contraction exercises against resistance without causing changes in muscle length and joint motion¹⁴. This exercise can activate neuro-adaptive and proprioceptor mechanisms through altered sensory input to muscles. Lee et al.,stated that muscle activity in plank exercise is related to posture and muscle position exercises and has been proven to strengthen core muscles (especially transverse abdominis)¹⁵.

Based on all previous evidences obtained that exercise and physical exercise of the abdominal muscles can prevent and reduce postnatal women’s problems such as reducing abdominal circumference and increasing abdominal muscle strength. This study willfocus on plank exercise was conducted to determine its effect on reducing the distance of the DRA below umbilicus.

METHODS

This research is a quantitative analysis with a quasi-experimental design that uses a two-group approach where the treatment was only given to one group and the other group only as a control¹⁶. Meanwhile, the research design used pre and post-test design and how to take samples using a purposive sampling method.This study aims to determine the effect of plank exercise on DRAin women postpartum. Before and after being given treatment, the sample was measured for the length of the uterus by palpation and using a measuring device,calipers. The number of postpartum women who participated in this study was 124 people and was divided equally into 62 people in each group.

This research was conducted in the working area of the Makassar District Health Center, East Jakarta, and was carried out from April 2019 to June 2019. Plank Exercise intervention is carried out 3 times a week for 6 weeks.

The criteria set for the research sample are as follows:

Inclusion criteria:

1. All postpartum women at the Makassar District Health Center, East Jakarta and the Kebon Pala Village Health Center, East Jakarta
2. Postpartum woman with minimum 2 hours after delivery
3. Postpartum women with DRA (>2.5 cm)
4. Postpartum women with a disease history of vaginal delivery
5. Willing to follow an exercise program regularly.
6. Willing to not do activities that are suspected of affectingDRA, such as participating in other gymnastics activities outside the given program.
7. Willing to be a sample and sign informed consent.

Exclusion Criteria:

1. Postpartum women who refused to participate in this study
2. Postpartum women who have participated in postpartum gymnastics and other physical activities
3. Postpartum women who are having heart problems, respiratory problems including excessive coughing or sneezing
4. Postpartum women with pelvic or abdominal surgery (except for cesarean section), neurological disease, bowel or bladder trauma
5. Depressed postpartum woman

Measurement of DRA:

Measurement by palpation of the fingers and calipers DRA measurements were carried out before and after plank exercise. According to Bursch, Mantle et al. and Rett et al. (2009), the palpation measurement technique meets the criteria of reliability and ease to use. The measurement can be done by placing a finger palpation between the medial border of the right and left rectus abdominis muscles, which is parallel to the linea alba^3,17,18.

The size of DRA is determined by the number of fingers that enter between the two gaps in the abdominal wall that are the muscles above and below the umbilicus when the individual performs the movement placing her chin on her chest. Clinically, this palpation technique is simple.

1.Measurement procedure by palpation is carried out as follows:

1. Make the subject lying flat on her back without a pillow under her head.
2. Place the fingertips of one hand on the midline of the abdomen with the tip of the index finger just below the umbilicus and the other finger lined longitudinally downward toward the symphysis pubis.
3. Ask the subject to raise her head to rest her chin on her chest in the area between her breasts. Make sure not to press her hands against the bed or grip the mat to help her, as this prevents the use of the abdominal muscles.
4. As the subject attempts to rest her chin between her breasts, gently press your fingertips close to her abdomen. You will feel the abdominal muscles like two rubber bandages approaching the midline from either side.
5. Measure the gap between them with calipers when the muscles are contracted.
6. Note the distance between the two slits
7. When lowering the head, the abdominal muscles move further apart and are less distinguishable when the muscles are relaxed. Your fingertips will follow the rectus muscle apart to the lateral side of each abdomen.
8. Measure the distance between the two rectus muscles when they are relaxed.
9. Note the measurement results

2. Measurement using calipers

Measurement procedure the rectal distance was measured using a caliper technique, the participant was in a lying position with a pillow under the head and feet resting on the base and arms by the side of the body. The desired measurement location is marked 4.5 cm above the midpoint of the umbilicus and 4.5 cm below the midpoint of the umbilicus. Each participant raises their head until the spine of the scapula is off the table surface.

Participants were asked to maintain this position while the examiner palpated the medial border of the right & left abdominis abdominal muscles at the marked area. Measuring the inside of the jaws of a digital nylon caliper, positioned at the location of the palpated finger, perpendicular to the direction of the muscle and adjusted for the width of the perceived intra-rectal distance. Three measurements were taken for each assessment and then recorded. Participants are allowed to rest between measurements and are also allowed to rest if they feel tired ²¹.

Intervention Group

In the treatment group, interventions were given in the form of plank exercise.Plank exercise is an isometric type of exercise, which is a type of static muscle contraction exercise against resistance without any change in muscle length or not followed by joint movement¹⁴. This exercise begins by extending the legs while supporting the upper body with the arms. Bend elbow position, hold abdominal and gluteal muscles.

This exercise is done 3 times a week for 6 weeks with 3 repetitions of each exercise. The prone plank exercise is carried out by holding it for 30 seconds for each movement then resting for 15 seconds and then repeating it ²⁰.

Control Group

In the control group, the research sample was given an education program in the form of counseling on the importance of exercise to restore the health of postpartum women with DRA conditions. Based on research, regular exercise can also improve the DRA⁴.

RESULTS AND DISCUSSION

Following is the distribution of Plank Exercisevariables and the control group

Based on table 1, each postpartum woman performs Plank Exercise that the intervention group also included 62 people (50%) and the control group with 62 people (50%).

Based on table 2, the number of postpartum women aged < 20 years or > 30 years was 59 people (47.6%), multiparous status was 59 people (47.6%), had Obesity/Overweight BMI which was 60 people (48.4%), history of singleton pregnancy namely 120 people (96.8%), and the weight of newborns was normal (not macrosomic) that was 112 people (90.3%).

Relationship between Independent and Confounding Variables on Reduction of the width of the DRA below umbilicus)

Table 3. shows that those who did plank exercise mostly reduced the width of the DRA below umbilicus was 42 people (67.7%).

 While most of the postpartum women who do not do plank exercise did not experience a reduction in the width of the DRA below umbilicus (fixed) was 47 people (75.8%). Chi Square test results stated that there is a relationship between plank exercise with a reduction in the width of the DRA below umbilicus (p value <0.05).

 Postpartum women who did Plank Exercise had a 2.3 times chance of experiencing a reduction in the width of the DRA below umbilicus compared to those who did not do it (p value =0.000; cRR=2.35;95%CI= 1.60-3.46).

Based on Table 4, the results of the cross-tabulation show that most of the postpartum women aged < 20 years or >30 years did not experience a reduction in the width of the DRA below umbilicus (fixed) was 31 people (52.5%). While those aged 20-30 years most did not experience a reduction in the width of the DRA below umbilicus (fixed) was 36 people (55.4%). Chi Square test results showed that there was no relationship between age and a reduction in the width of the DRA below umbilicus (p value> 0.05).

The results of cross tabulation showed that most of the postpartum women with multiparous status did not experience a reduction in the width of the DRA below umbilicus (fixed) was 47 people (79.7%). While most of the primipara experienced a reduction in the width of the DRA below umbilicus was 45 people (69.2%). Chi Square test results stated that there is a relationship between plank exercise with a reduction in the width of the DRA below umbilicus (p value <0.05). Primipara postpartum women were 2.6 times more likely to experience a reduction in the width of the DRA below umbilicus than multiparous women (p value =0.000; cRR=2.59;95%CI= 1.76-3.81).

The results of the cross tabulation showed that the postpartum women who were obese/overweight mostly did not experience a reduction in the width of the DRA below umbilicus (fixed) was 43 people (71.7%). Meanwhile, postpartum women with normal/ideal BMI experienced a reduction in the width of the DRA below umbilicus was 40 people (62.5%). Chi Square test results showed that there was a relationship between excess BMI and a reduction in the width of the DRA below umbilicus (p value <0.05). Postpartum women with normal/ideal BMI were 1.9 times more likely to experience a reduction in the width of the DRA below umbilicus compared to obesity/overweight (p value=0.000; cRR=1.91;95%CI=1.34-2.72).

The results of cross tabulation showed that postpartum women with multiple pregnancies 50% experienced a reduction in the width of the DRA below the umbilicus. While postpartum women with singleton pregnancies mostly did not experience a reduction in the width of the DRA below the umbilicus (fixed) was 65 people (54.2%). Fisher Exact test results showed that there was no relationship between multiple pregnancies with a reduction in the width of the DRA below umbilicus (p value> 0.05).

The results of cross tabulation showed that postpartum women who gave birth to babies weighing 4000 grams mostly experienced a reduction in the width of the DRA below the umbilicus was 11 people (91.7%). Meanwhile, postpartum women with babies weighing <4000 grams mostly did not experience a reduction in the width of the DRA below umbilicus (fixed) was 66 people (58.9%). Chi Square test results showed that there was a relationship between large baby weight and a reduction in the width of the DRA below umbilicus (p value <0.05). Postpartum women with not macrosomic babies were 0.1 times more likely to experience a reduction in the width of the DRA below umbilicus compared to women with macrosomic babies (p value=0.002; CRR=0.14;95%CI=0.02-0.93).

The results of this study are in line with research by Fitriahadi ²¹. With a quasi-experimental research model and similar types of interventions. The results of the study stated that most of the decrease in DRA occurred quickly in the treatment group (plank exercise) by 10 (66.65), while a slower decline in DRA occurred in the untreated group (control group) by 9 (60%), supported by bivariate analysis with p value = 0.003, this proves that there was an effect on strengthening the rectus abdominis muscle to reduce the DRA distance in postpartum women.

The results of the study are in line with previous research that there was an effect of sit-up exercise with prone plank exercise on decreasing abdominal circumference in adolescent girls¹³. Other research also stated that exercise will have an effect after being done for 6 weeks, for example, weight training can increase muscle strength by 20.1% within those weeks²². In general, previous research by Khandale & Hande also stated that abdominal muscle training can reduce DRA in early postpartum women and can prevent complications due to DRA²³.

This research still has some limitations. This research method is still very simple and needs to be improved for the better in future research. The examination is also carried out in a simple manner, the use of other, more sophisticated examination tools is needed in future research. Likewise, this study only evaluates short-term effects, then, long-term research to determine long-term effects also needs to be done. The use of the results of this study must be responsible to avoid misunderstanding.

CONCLUSION

Based on data analysis, it was found that there was a reduction in the width of the DRA below umbilicus in postpartum women with treatment of 42 people (67.7%) while in the control group only 15 people (24.2%). Thus, it can be concluded thatthere is an effect of plank exercise on changes in the distance of the DRA below umbilicus and there is a relationship between plank exercise and a reduction in the width of the DRA below umbilicus in postpartum women.

Recommendations: As a recommendation from this study, physiotherapists would be able to advise postpartum women to do plank exercise in reducing various postnatal complaints and increasing quality of life both in the community and at home.

Ethical Clearance: This research was approved by the East Jakarta Health Service Center with reference number 1950/1.772.2.

Acknowledgements: We would like to thank the postpartum women in Makassar Health Center, East Jakarta who are willing to participate in this research.

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Citation: Lisnaini. Effect of plank exercise on diastasis recti abdominis lower umbilicus in postpartum women, International Journal of Medical and Exercise Science, March 2022; 8(1): 1219-1227.