Effects of hypopressive exercises on post-partum abdominal diastasis, trunk circumference, and mechanical properties of abdominopelvic tissues: a case series

Impact of postpartum exercise on pelvic floor disorders and diastasis recti abdominis: a systematic review and meta-analysis

OBJECTIVE

To examine the effect of exercise during the first year postpartum on pelvic floor disorders and diastasis recti abdominis.

DESIGN

Systematic review with random effects meta-analysis.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, SPORTDiscuss, Evidence-Based Medicine Reviews (Ovid), Scopus, Web of Science and ClinicalTrials.gov were searched until 12 January 2024.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies of all designs (except case studies) and languages were included if they contained information on the Population (individuals in the first year postpartum), Intervention (subjective or objective measures of frequency, intensity, duration, volume or type of exercise alone ('exercise-only') or in combination with other intervention (eg, biofeedback; 'exercise+co-intervention')), Comparator (no exercise or different exercise measures) and Outcome (symptom severity and risk of urinary incontinence, anal incontinence, pelvic organ prolapse, diastasis recti abdominis and sexual function).

RESULTS

65 studies (n=21 334 participants) from 24 countries were included. 'Moderate' certainty of evidence revealed that pelvic floor muscle training reduced the odds of urinary incontinence by 37% (seven randomised controlled trials (RCTs), n=1930; OR 0.63, 95% CI 0.41 to 0.97, I2 72%) and pelvic organ prolapse by 56% (one RCT, n=123; OR 0.44, 95% CI 0.21 to 0.91) compared with control groups. 'Low' certainty of evidence showed a greater reduction in inter-rectus distance measured at rest and during a head lift following abdominal muscle training compared with no exercise. Evidence on the effect of exercise on the risk of anal incontinence and diastasis recti abdominis, as well as the severity of anal incontinence, urinary incontinence, pelvic organ prolapse and sexual function, is limited.

CONCLUSION

Evidence supports the effectiveness of postpartum pelvic floor muscle training in reducing the odds of urinary incontinence and pelvic organ prolapse and postpartum abdominal exercise training in reducing inter-rectus distance.

PROSPERO REGISTRATION NUMBER

CRD42022359282.

Effect of hypopressive and conventional abdominal exercises on postpartum diastasis recti: A randomized controlled trial

BACKGROUND

Diastasis recti abdominis (DRA) is the separation of the rectus abdominis muscles along the linea alba, often occurring during pregnancy due to hormonal and mechanical changes. While DRA usually resolves post-childbirth, some women experience persistent issues. Exercise may help reduce the inter-rectus distance, though more research is needed.

OBJECTIVES

Analyze the immediate and long-term effects of hypopressive and conventional abdominal exercises on inter-rectus distance (IRD) in postpartum women, focusing on parity differences.

METHODS

Twenty-eight women who met specific inclusion criteria were randomly assigned to either the hypopressive group (n = 14) or the conventional group (n = 14). The exercise programs for both groups lasted 6 weeks. Ultrasound measurements were taken of the IRD at two locations above the umbilicus, 2 cm (AB2) and 5 cm (AB5), before and after exercise programs.

RESULTS

The IRD decreased after both exercise programs compared to baseline measurements in AB2 (mean difference: 3.06 mm, 95% CI: 1.06 to 5.05) and in AB5 (mean difference: 2.88 mm, 95% CI: 1.59 to 4.17), confirming the long-term effect of exercise. No differences were found between the application of the conventional exercise program or the hypopressive exercises, indicating that both had a similar positive effect. Regarding the immediate effect, after the performance of both programs, the IRD was greater during rest compared to abdominal contraction. This effect was more pronounced at AB5 location (mean difference: 1.00mm, 95% CI: 0.97 to 1.89). Conventional exercises result in a reduction during resting condition (mean difference: 4.52mm, 95% CI: 2.62 to 6.79), whereas with hypopressive exercises, the reduction occurs during muscle contraction (mean difference: 3.43mm, 95% CI: 1.21 to 5.65). With regard to parity, multiparous women benefit most from the application of exercise programs.

CONCLUSION

A reduction in IRD has been achieved with the implementation of both exercise programs in postpartum women, with multiparous women benefiting the most. Specifically, at 5 cm above umbilicus, conventional exercises result in a reduction during the rest condition, whereas with hypopressive exercises, the reduction occurs during muscle contraction.

TRIAL REGISTRATION

Clinical trial registration: NCT05439668.

What Is Known from the Existing Literature about Hypopressive Exercise? A PAGER-Compliant Scoping Review

Introduction: Hypopressive exercise (HE) can be viewed as a mind-body activity, characterized by the integration of breath control and stretching postures. Proponents of HE claim that this type of training can offer potential therapeutic or health benefits. To date, there is no existing comprehensive published overview on HE. This scoping review aims to map and summarize the current literature reporting data on HE and identify key knowledge gaps and future research directions. Methods: This review considered studies that report on the immediate, short-, or long-term practice of HE regardless of condition, sex, age, and/or level of practice or physical condition. Any context or setting was considered for inclusion. This review was performed in accordance with the methodological framework proposed by the Joanna Briggs Institute and by Arksey and O'Malley. MEDLINE, CINAHL, SPORTDiscus, Scopus, and Web of Science were searched from inception up to July 2023. Literature was mapped following the Patterns-Advances-Gaps-Evidence for Practice Recommendations framework to identify patterns and inform practice. Results: In total, 87 studies were identified that reported on the following themes: (1) therapeutic application of a short- or long-term HE programs (n = 56); (2) physiologic and physical responsiveness to a short- or long-term HE programs (n = 22); (3) psychologic and behavioral response to a short-term HE program (n = 14); and (4) acute or immediate physiological responses (n = 21). Literature gaps included poor methodological design, incomplete reporting of intervention, lack of male participants, and exploration of muscle groups distinct from the pelvic floor and abdominal muscles. Discussion: There is a need for high-quality randomized controlled trials, adherence to reporting guidelines on exercise, and the use of active control groups to verify clinical significance, the dose response, and health applications of HE.

Muscle mechanical properties of pelvic floor and paravertebral muscles in women with and without urge urinary incontinence: a case-control study

BACKGROUND

Muscle mechanical properties (MMPs) are relevant in the pathophysiology of lumbopelvic disorders. However, they have not been described in the pelvic floor muscles (PFM) and lumbar paravertebral muscles (LPM) of women with urge urinary incontinence (UUI).

OBJECTIVE

To identify differences between MMPs of PFM and LPM in patients with UUI and healthy controls. Secondarily also aimed to observe the relationship between sociodemographic and clinical variables with the PFM and LPM MMPs.

METHODS

The participants of this case-control study comprised 34 women with UUI (UUI group) and 34 continent women (control group). Sociodemographic variables were obtained together with data on the clinical status of the pelvic floor. The MMPs, i.e., frequency (tone), stiffness, decrement (inverse of elasticity), and viscoelastic properties (VP), such as relaxation time and creep, of PFM and LPM were assessed with a hand-held tonometer. Between-group differences and intra-group correlations were identified.

RESULTS

The UUI group presented higher frequency and stiffness, as well as lower relaxation time in PFM, whereas the LPM had lower tone and stiffness, and higher VP, compared to the control group (p < 0.05). The UUI group showed a pattern of moderate correlations (|0.403|

CONCLUSION

The presence of UUI may influence MMPs at PFM and LPM levels, increasing the tone and stiffness of PFM, whereas these properties are reduced in LPM. These findings emphasize the clinical interest of the lumbopelvic determination of MMPs, obtained through externally applied hand-held instruments, in the pathophysiology of UUI.

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Key Words

• Pelvic floor disorders
• Regional interdependence
• Tonometry

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MESH Headings

• Humans
• Case-Control Studies
• Pelvic Floor/physiopathology
• Female
• Urinary Incontinence, Urge/physiopathology

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Affiliation(s)

María Teresa Garzón-Alfaro Department of Nursing, Pharmacology and Physical Therapy, Faculty of Medicine and Nursing, University of Córdoba, Córdoba, Spain
Inés Cruz-Medel Department of Nursing, Pharmacology and Physical Therapy, Faculty of Medicine and Nursing, University of Córdoba, Córdoba, Spain
Sandra Alcaraz-Clariana Department of Nursing, Pharmacology and Physical Therapy, Faculty of Medicine and Nursing, University of Córdoba, Córdoba, Spain
Lourdes García-Luque Department of Nursing, Pharmacology and Physical Therapy, Faculty of Medicine and Nursing, University of Córdoba, Córdoba, Spain
Cristina Carmona-Pérez Department of Nursing, Pharmacology and Physical Therapy, Faculty of Medicine and Nursing, University of Córdoba, Córdoba, Spain
Juan Luis Garrido-Castro Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Córdoba, Spain; Department of Computer Science and Numerical Analysis, Rabanales Campus, University of Córdoba, Córdoba, Spain
Francisco Alburquerque-Sendín Department of Nursing, Pharmacology and Physical Therapy, Faculty of Medicine and Nursing, University of Córdoba, Córdoba, Spain; Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Córdoba, Spain.
Daiana Priscila Rodrigues-de-Souza Department of Nursing, Pharmacology and Physical Therapy, Faculty of Medicine and Nursing, University of Córdoba, Córdoba, Spain; Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Córdoba, Spain

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The Impact of Exercising on Pelvic Symptom Severity, Pelvic Floor Muscle Strength, and Diastasis Recti Abdominis After Pregnancy: A Longitudinal Prospective Cohort Study

OBJECTIVE

The objective of this study was to evaluate whether early postpartum exercise is associated with changes in pelvic symptom severity, pelvic floor muscle strength, and diastasis recti abdominis (DRA) from 3 to 12 months postpartum.

METHODS

In this prospective cohort study, 504 participants with and without pelvic symptoms (pelvic girdle pain, stress urinary incontinence, vaginal heaviness) were followed. At 3, 6, 9, and 12 months postpartum, we assessed pelvic symptoms, exercise behavior (by questionnaires), pelvic floor muscle strength (by vaginal palpation), and DRA (by caliper measurement). Based on the 3-months questionnaire, participants were categorized as nonexercisers (n = 105), minimal low-impact exercisers (n = 249), regular low-impact exercisers (n = 117), and high-impact exercisers (n = 32). Between-group differences and within-group changes from 3 to 12 months were calculated using Chi-square tests, Kruskal-Wallis tests, and Friedman analysis of variance.

RESULTS

At 3 months, no differences in symptom prevalence were seen between the groups. Nonexercisers reported higher pelvic girdle pain severity and had weaker pelvic floor muscles. The within-group analysis showed that pelvic girdle pain severity did not change in nonexercisers or high-impact exercisers, but decreased in minimal and regular low-impact exercisers. Stress urinary incontinence increased in nonexercisers from 3 to 12 months, while it remained unchanged in regular low-impact and high-impact exercisers, and decreased in minimal low-impact exercisers. Across all groups, vaginal heaviness and DRA decreased, and pelvic floor strength increased from 3 to 12 months.

CONCLUSION

The study indicates that early low-impact exercising is associated with reduced pelvic girdle pain severity during the first postpartum year. Minimal low-impact exercisers also showed a slight reduction in stress urinary incontinence. Conversely, nonexercisers reported an increase in stress urinary incontinence between 3 and 12 months postpartum.

IMPACT

Physical therapists should encourage women to start with low-impact exercise early after pregnancy.

LAY SUMMARY

This study highlights the positive effects of starting gentle, low-impact exercise early after childbirth to reduce pelvic girdle pain and urinary incontinence.

Diastasis Recti Abdominis Rehabilitation in the Postpartum Period: A Scoping Review of Current Clinical Practice

INTRODUCTION AND HYPOTHESIS

Despite exercise being the standard approach to diastasis recti abdominis (DRA) rehabilitation, there is no consensus on the most effective exercise routine and adjunct modalities for reducing DRA and improving functional parameters. The present study is aimed at investigating evidence for DRA rehabilitation in postpartum women, as well as knowledge gaps and areas for future research.

METHODS

For this scoping review a systematic search was conducted in MEDLINE, AMED, CINAHL, Embase, ScienceDirect, Scopus, and PEDro up to November 2022. Selection criteria included studies investigating exercise therapy interventions both with and without adjunct modalities for postpartum DRA. Sample characteristics, diagnostic criteria, program design, and outcome measures were recorded. Critical appraisal of clinical trials was performed using PEDro classification.

RESULTS

Twenty-eight studies were included: 14 clinical trials, 3 case series, and 11 observational studies. DRA exercises that focused on deep and superficial muscles, pelvic floor muscles, respiratory maneuvers, functional exercises, or alternative interventions (yoga, suspension training, hypopressive exercise) and adjunct modalities showed promising results in reducing the inter-recti distance and related dysfunction. However, there was great variability in diagnostic criteria and methods, DRA severity, time post-birth, and exercise program design.

CONCLUSIONS

Reviewed studies provide valuable insights into exercise therapy, but it is important to recognize their limitations, as variability in diagnostic criteria, sample characteristics, and exercise program design hinder the generalizability of the findings. Further high-quality research is needed to strengthen the evidence in this area and provide reliable recommendations for clinical practice.

Between-sexes differences in lumbopelvic muscle mechanical properties of non-climacteric adults: a cross-sectional design

The lumbopelvic muscle mechanical properties (MMPs) are clinically relevant, but their dependence on sex remains unknown. Therefore, this study aimed to identify if lumbopelvic MMPs depend on the sex in a young adult population. Thirty-five healthy nulliparous women and 35 healthy men were analyzed (age range: 18-50). Lumbopelvic MMPs, that is, tone, stiffness, elasticity, relaxation and creep, assessed with MyotonPRO®, and pelvic floor (PF) health questionnaires were compared between-sexes. Intra-group correlations between sociodemographic and clinical data, and MMPs were also determined. The MMPs of PF were different between healthy non-climacteric adults of both sexes, with women showing higher values of tone and stiffness and lower values of elasticity and viscoelastic properties than men (in all cases, p < 0.03). At lumbar level, tone and stiffness were higher for men at both sides (in all cases, p < 0.04), and relaxation was lower at left side (p = 0.02). The MMPs showed few correlations with sociodemographic data within women. However, within males, there were positive correlations for PF stiffness and viscoelastic parameters with age, BMI and function (0.334 < r < 0.591) and, at lumbar level, negative correlations for tone and stiffness ( - 0.385 < r < -0.590) and positive correlations for viscoelastic properties (0.564 < r < 0.719), with BMI. This indicated that between-sexes differences of lumbopelvic MMPs depend on the specific location of assessment in healthy non-obese young individuals. Women show higher tone and stiffness and lower elasticity and viscoelasticity than men, at PF level.

Rehabilitations for maternal diastasis recti abdominis: An update on therapeutic directions

Diastasis recti abdominis (DRA) affects a significant number of postpartum women, while its treatments are still under debate. This study aimed to systematically evaluate the effectiveness of rehabilitation training programs for postpartum DRA treatment. Four databases were systematically searched to identify eligible studies published up to February 1, 2023. We followed the PRISMA for scoping reviews guideline in this study. The characteristics and the main findings of the included studies were extracted. Sixteen studies enrolling 1129 women during the ante- and/or postnatal period were included. The common rehabilitation training for DRA included physical exercise, non-exercise physical therapy, acupuncture, and electrotherapy. The presence of DRA could be diagnosed by ultrasound, caliper, or palpation, of which ultrasound had the best reliability. Besides, these assessments could also be used for evaluating the therapeutic efficacy after the rehabilitation training programs. Several studies concluded that patients with DRA could be effectively improved by specific interventions. But a few included studies revealed rehabilitation training might be not more effective than no interventions when treating DRA. For example, some investigators did not recommend physical exercise for DRA patients due to this intervention during pregnancy kept the linea alba less stressed by maintaining abdominal tone, strength, and control, and therefore might aggravate DRA. However, it should be noted that this evidence was derived from limited studies (16/60, 27 % papers) with small samples. To some extent, women with postpartum DRA can benefit from the specific rehabilitation regimen by alleviating postpartum inter-rectus distance. Further research is still warranted to propose strategies for improving postpartum DRA.

Asymmetries of the Muscle Mechanical Properties of the Pelvic Floor in Nulliparous and Multiparous Women, and Men: A Cross-Sectional Study

This study aimed to identify if the muscle mechanical properties (MMPs) of both sides of pelvic floor muscles (PFMs) are symmetrical in different populations of both sexes. Between-sides comparisons of MMPs of PFMs, assessed with manual myotonometry, were performed in three groups, with 31 subjects each, composed of healthy nulliparous women (without any type of delivery or pregnancy), multiparous women (with at least two vaginal deliveries), and healthy adult men. Intra-group correlations between MMPs and age, body mass index (BMI), or clinical state of pelvic floor were also obtained. The nulliparous women and the men showed no between-sides differences in any MMP of PFMs. However, the multiparous women showed that the right side displayed less frequency (−0.65 Hz, 95% CI = −1.01, −0.20) and decrement (0.5, 95% CI = 0.11, 0.01), and more relaxation (1.00 ms, 95% CI = 0.47, 1.54) and creep (0.07 De, 95% CI = 0.03, 0.11), than the left side. Further, MMPs were related to age, sex, and BMI, also depending on the population, with the multiparous women being the only group with some between-sides asymmetries, which in this case were positive and of fair intensity for the left side of the PFMs, between BMI, and frequency and stiffness (rho Spearman coefficient: 0.365 and 0.366, respectively). The symmetry of MMPs of the PFMs could depend on the subject’s condition. Multiparous women show a higher tendency to asymmetries than nulliparous women and men, which should be considered in research and clinical settings.