Systematic reviewEffects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review☆
Introduction
During and after pregnancy, many women experience an increase in the inter-recti abdominal muscle distance due to stretching and thinning of the linea alba [1]. A widening of >2.7 cm at the level of the umbilicus is considered a pathological diastasis of the rectus abdominis muscle (DRAM) [2]. Other studies have defined DRAM as an inter-recti distance of >2 cm at one or more assessment points (at the level of the umbilicus or 4.5 cm above or below the umbilicus) [3], [4]. DRAM occurs due to hormonal elastic changes of the connective tissue, mechanical stresses placed on the abdominal wall by the growing fetus, and displacement of the abdominal organs [4], [5], [6], [7]. DRAM usually appears in the second trimester of pregnancy and is found most frequently in the third trimester [6]. Studies have demonstrated that the inter-recti distance increases at approximately 14 weeks of gestation and continues to increase until delivery [7]. Natural resolution and greatest recovery of DRAM occurs between 1 day and 8 weeks after delivery, after which time recovery plateaus [8].
DRAM is relatively common and can have negative health consequences for women during and after pregnancy (ante- and postnatal periods). Varying estimates of incidence of DRAM have been reported ranging from 66% to 100% during the third trimester of pregnancy [6], [9], and up to 53% immediately after delivery [10]. The abdominal wall has important functions in posture, trunk and pelvic stability, respiration, trunk movement and support of the abdominal viscera. An increase in the inter-recti distance puts these functions in jeopardy [11], [12], [13], and can weaken abdominal muscles and influence their functions [14], [15]. This may result in altered trunk mechanics, impaired pelvic stability and changed posture, which leave the lumbar spine and pelvis more vulnerable to injury [4], [7], [13].
Despite DRAM being a common and significant clinical problem, little is known about its prevention or management. Risk factors such as multiparity, maternal age and childcare responsibilities have been associated with DRAM. There is conflicting evidence linking DRAM with weight gain and higher body mass index [4], [10], [16]. Surgical correction of DRAM has been demonstrated to reduce some of the effects of a wide diastasis such as back pain [17]. Anecdotally, regular exercise prior to pregnancy and during the antenatal period seems to reduce the risk of developing DRAM and reduce the size of DRAM, respectively [6]. Abdominal exercises are also frequently prescribed to postnatal women who have DRAM. Other regularly used non-surgical interventions in women with DRAM include postural and back care education, external support (e.g. tubigrip or corset) and aerobic exercises [18], [19], [20], [21]. However, it is unclear what types of non-surgical interventions, including exercise, are effective to prevent and/or reduce DRAM.
Therefore, the aims of this review were to determine whether non-surgical interventions can prevent or reduce DRAM in the antenatal period, and reduce DRAM and health-related negative effects of DRAM in the postnatal period.
Section snippets
Methods
This systematic review was registered in the PROSPERO database (CRD42012002944).
Flow of studies through the review
The search strategy yielded 1382 potentially relevant studies. Selection on title and abstract excluded 1362 studies, and the full text of 20 articles was reviewed (Fig. 1). A further 12 potential studies were excluded based on the full-text evaluation due to no intervention being investigated (n = 7), no DRAM outcomes reported (n = 4), and the type of publication (n = 1). A manual search of the reference lists of included studies did not result in more eligible studies. Consensus was reached to
Discussion
This systematic review analysed eight studies of varying designs evaluating interventions to prevent and/or reduce DRAM. All studies presented some form of exercise as an intervention alone or in combination with education and/or external support garments. Due to the low number and quality of included articles, there is insufficient evidence to recommend that exercise may help to prevent or reduce DRAM.
Although all studies showed that exercise was protective for the development and/or reduction
Conclusion
Due to the poor quality of the current literature, current evidence suggests that non-specific exercise may or may not help to prevent or reduce DRAM during the ante- and postnatal periods.
Acknowledgements
The authors would like to thank Professor Nick Taylor for his guidance around the development of the review protocol and suggestions on a draft manuscript.
Conflict of interest: None declared.
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Systematic review registration no: PROSPERO CRD42012002944.