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Bø K, etal. Br J Sports Med 2017;0:1–10. doi:10.1136/bjsports-2017-097964
Exercise and pregnancy in recreational and elite
athletes: 2016/17 evidence summary from the IOC
Expert Group Meeting, Lausanne. Part 3—exercise in
the postpartumperiod
Kari Bø,1 Raul Artal,2 Ruben Barakat,3 Wendy J Brown,4 Gregory A L Davies,5
Michael Dooley,6,7 Kelly R Evenson,8 Lene A H Haakstad,1 Bengt Kayser,9
Tarja I Kinnunen,10 Karin Larsén,11 Michelle F Mottola,12 Ingrid Nygaard,13
Mireille van Poppel,14 Britt Stuge,15 Karim M Khan,16 IOC Medical Commission17
Consensus statement
To cite: BøK, ArtalR,
BarakatR, etal.
Br J Sports Med Published
Online First: [please include
Day Month Year]. doi:10.1136/
bjsports-2017-097964
For numbered affiliations see
end of article.
Correspondence to
Professor Kari Bø, Department
of Sport Medicine, Norwegian
School of Sport Sciences, Oslo
0806, Norway; kari. bo@ nih. no
Accepted 23 April 2017
BACKGROUND
This is Part 3 in the series of reviews from the
IOC expert committee on exercise and pregnancy
in recreational and elite athletes. Part 1 focused
on the effects of training during pregnancy and
on the management of common pregnancy-re-
lated complaints experienced by athletes1; Part 2
addressed maternal and fetal perinatal outcomes.2
In this part, we review the implications of preg-
nancy and childbirth on return to exercise and on
common illnesses and complaints in the postpartum
period.
The postpartum period can be divided into
hospital-based (during hospital stay), imme-
diate postpartum (hospital discharge to 6 weeks
postpartum) and later postpartum (6 weeks to
1 year, corresponding sometimes to cessation of
breast feeding).3 In the literature, the postpartum
period is usually defined as the first 6 weeks after
pregnancy, during which time women have not
typically been encouraged to exercise, except
for strength training of the pelvic floor muscles.
However, 6 weeks is an arbitrary time point and,
anecdotally, many elite athletes report starting
exercise inside that period. For the purpose of the
present review, we consider the postpartum period
to be up to 12 months following birth.
AIMS
The aims of this paper are to present (1) the
findings from a systematic review of the scien-
tific literature on factors related to returning to
exercise after childbirth in recreational and elite
athletes, and (2) the prevalence, risk factors and
evidence for prevention and treatment of common
postpartum conditions that may affect sport perfor-
mance and overall quality of life.
METHODS
For each section of the document, a search strategy
was performed using search terms such as ‘preg-
nancy’ OR ‘pregnant’ OR ‘postpartum’ AND
‘exercise’ OR ‘physical activity’ OR ‘leisure activity’
OR ‘leisure’ OR ‘recreation’ OR ‘recreational
activity’ OR ‘physical fitness’ OR occupational
activity’ AND terms related to the condition under
study (eg, ‘pelvic girdle pain’, ‘urinary inconti-
nence’, ‘weight retention’). All available databases
were searched, with an emphasis on PubMed,
Embase, Cochrane, PEDro, Web of Science and
SPORTDiscus. In addition, existing postpartum
physical activity guidelines with reference lists
were scanned. The review of each topic followed
the general order: prevalence of the condition in
the general postpartum population, prevalence in
high-level exercisers or elite athletes, risk factors
in the general population and in relation to exer-
cise and sport, and effect of preventive and
treatment interventions for common conditions
and complaints following pregnancy and childbirth.
Level of evidence and grade of recommendations
are reported for the common conditions and
complaints only, and are according to the Cochrane
Handbook (table 1), for prevention and treatment
interventions.
Each member of the working group was assigned
to be the lead author of one or more topics, and
one to three others were assigned to review each
topic. A first full consensus draft was reviewed
before and during the 3-day IOC meeting (27–29
September 2015), and a new version of each topic
was submitted to the meeting chairs (KB and KMK)
shortly after the meeting. Each topic leader made
amendments before sending a new version for
comments to the working group.
FACTORS RELATED TO RETURNING TO EXERCISE
AFTER CHILDBIRTH IN ELITE ATHLETES
Pelvic floor injury and recovery after childbirth
To date, scant research has been conducted regarding
the regenerative capacity of the pelvic floor muscles
following first-time vaginal delivery.4–6 However,
early histological and proteomic markers of regen-
eration have been observed in the largest muscle of
the pelvic floor, the levator ani muscle.4 5
Nerve injuries to the pelvic floor muscles during
delivery have not been widely studied. In a longi-
tudinal study of 96 first-time pregnant women,
concentric needle electromyography tests showed
partial denervation of the pelvic floor with conse-
quent reinnervation in 80%.7 In another study
of primiparous women, 30% demonstrated
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Consensus statement
denervation of the levator ani muscle at 6 weeks postpartum.
Only 35% recovered by 6 months.8
Changes in preparation for childbirth begin long before the
onset of labour. The levator hiatus area begins to widen during
pregnancy, increases significantly after vaginal birth, and in most
women returns to an area similar to that seen after caesarean
birth by 12 months postpartum.9 Recovery of the levator hiatus
area, a reflection of recovery of the levator ani muscle and asso-
ciated connective tissue and nerves, is generally maximised by
4–6 months postpartum.9 10 Bladder neck mobility increases
after vaginal birth and, while the support to the bladder neck
improves postpartum, mobility remains higher than when
measured at 37 weeks’ gestation.9 11
Postpartum MRI or ultrasound has shown that levator ani
muscle defects resolve in some women between 6 weeks and
1 year.9 12–15 It is unclear whether this represents actual repair,
anatomic variation in muscle insertions or the technical limita-
tions of the procedures.16
There are scant data about whether or not future pelvic floor
health is impacted by resuming strenuous physical activity in
the early postpartum period, during which muscles, nerves and
connective tissue are actively recovering from vaginal birth.
Early return to heavy physical work after childbirth increased the
risks of urinary incontinence and pelvic organ prolapse in small
populations of women in India17 and Nepal,18 respectively. We
identified no studies on how the timing of return to strenuous
exercise or competitive sport postpartum affects pelvic floor
function in elite athletes. Theoretically, the pelvic floor muscles
may be overloaded if they have not recovered completely before
resuming strenuous exercise. It may be prudent for athletes
whose delivery was complicated by a risk factor for levator ani
muscle injury (anal sphincter tear, forceps delivery, long second
stage, large baby) to minimise activities that generate large
increases in intra-abdominal pressure and/or repetitive high
impact for several months postpartum. However, we emphasise
that there is no evidence to support this recommendation. There
is an urgent need for more research on the effect of exercise
postpartum on the pelvic floor.
Returning to sport after operative delivery
Women who undergo operative vaginal delivery (vacuum and
forceps procedures) or caesarean section will have different
recovery timelines than those who have had an uncomplicated
vaginal birth. This may impact their desire and functional ability
to return to exercise. The prevalence of levator avulsion is
substantially higher after forceps compared with vacuum deliv-
ery.19–21Compared with spontaneous vaginal delivery, forceps
delivery, but not vacuum delivery, is associated with greater odds
of pelvic organ prolapse and surgery for prolapse.20 There is
conflicting information about the long-term impact of forceps
versus vacuum delivery on urinary and faecal incontinence.22–25
Women who have undergone caesarean birth will experi-
ence more abdominal pain postpartum than those who have
had vaginal birth. The Pfannenstiel incision, typically used for
caesarean birth, is a horizontal incision about 3 cm above the
symphysis pubis and typically 12–15 cm in length. The Pfannen-
stiel incision is not a muscle-cutting incision but rather splits the
rectus abdominis muscles in the midline. The transversalis fascia
is incised horizontally and during closure is usually closed with
a running suture with a knot at either end of the incision. After
caesarean birth, most women experience pain along the incision
site requiring analgesia for 5–10 days. This pain is commonly
worse in the corners of the incision where the body has begun
reacting to the stitch material in the knots. Most, but not all,
women will be physically recovered to begin training 4–6 weeks
after surgery.
A multicentre follow-up study of 1507 primiparous women
in Australia identified those who experienced caesarean section
were more likely to report extreme tiredness at 6 (adjusted OR:
1.39; 95% CI 1.07 to 1.82) and 12 months postpartum (adjusted
OR: 1.40; 95% CI 1.05 to 1.85), and were more likely to report
back pain at 6 (adjusted OR: 1.37; 95% CI 1.06 to 1.77) and 12
months postpartum (adjusted OR: 1.41; 95% CI 1.06 to 1.87).
Women who had a caesarean section were less likely to report
urinary incontinence at 3, 6 and 12 months postpartum, respec-
tively (adjusted OR: 0.26; 95% CI 0.19 to 0.36; adjusted OR:
0.36; 95% CI 0.25 to 0.52; adjusted OR: 0.48; 95% CI 0.33
to 0.68). For all other physical health problems, the pattern of
morbidity did not differ between caesarean section and sponta-
neous vaginal birth.26 After caesarean delivery, the uterine scar
is initially about fivefold thicker on ultrasound but decreases
gradually over 6 weeks. At 6 weeks, the scar thickness is still
increased, suggesting that the process of uterine scar remodel-
ling extends beyond this traditional postpartum period.27 We are
not aware of any literature suggesting an association between
physical activity and uterine scar dehiscence in non-pregnant
women, regardless of whether the incision on the uterus is made
horizontally or vertically.
The decision when to recommence exercise after caesarean
section will be dependent on issues such as blood pressure,
anaemia, fatigue, pain management and wound healing.
Elite athletes who plan to regain their prepregnancy fitness
levels should do this in collaboration with their obstetric care
provider to ensure they are medically fit for exercise. Once
medically cleared, women may participate in both aerobic and
strength training starting gradually and increasing exercise time,
frequency and intensity as tolerated by their body. Women
need to be conscious of the fact that even a 15-day to 30-day
detraining period can lead to significant muscle atrophy, which
will require reconditioning over time to replace.28 Given the
recent abdominal surgery, women postcaesarean section must
also be conscious of the time required for complete repair of
the abdominal fascia, which regains 51%–59% of its original
tensile strength 6 weeks postsurgery and by 6–7 months has
only 73%–93% of its original tensile strength.29 Elite athletes
returning to exercise postcaesarean section should reduce their
level of exercise if they experience pain or other negative symp-
toms related to their surgery site.
Physiological adaptations postpartum
The substantial cardiovascular and respiratory adaptations of
pregnancy were discussed in the first part of this series.1 After
Table 1 Levels of quality of a body of evidence in the GRADE
statement
Underlying methodology Quality rating
Randomised trials, or double-upgraded
observational studies
High
Downgraded randomised trials, or upgraded
observational studies
Moderate
Double-downgraded randomised trials, or
observational studies
Low
Triple-downgraded randomised trials, or
downgraded observational studies or case series/
case reports
Very low
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Bø K, etal. Br J Sports Med 2017;0:1–10. doi:10.1136/bjsports-2017-097964
Consensus statement
giving birth, in a non-athlete female population, one study
suggested that it takes at least 2 months postpartum for the
augmented cardiac response to exercise during pregnancy to
subside.30 Another study found that, relative to prepregnancy
values, fitness (VO2=MAX) and strength (1-RM) levels were
decreased at 6 weeks postpartum, presumably as a consequence
of reduced physical activity levels during pregnancy.31 Some of
the loss was restored at 27 weeks postpartum. In one study of 13
healthy women, systemic vascular resistance remained decreased
at 12 weeks postpartum compared with before conception.32
Longitudinal data from 15 nulliparous and 15 parous women,
collected every 8 weeks during pregnancy, showed that resting
heart rate peaked at term 15+/−1 beat/min above prepregnancy
levels (57+/−1 beat/min), while resting mean arterial pressure
reached its low (−6+/−1 mm Hg) at 16 weeks, returning to
baseline at term.33 The increases in left ventricular volumes
peaked and the decrease in peripheral resistance troughed at 24
weeks of gestation, and cardiac output peaked (2.2+/−0.2 L/
min) at 38 weeks. The magnitude was significantly greater
during the second pregnancy than during the first.33 Postpartum
measures at 12, 24 and 52 weeks showed that all cardiovas-
cular measures (heart rate, arterial pressure, cardiac output, etc)
gradually returned towards baseline, but remained significantly
different from prepregnancy values at 1 year after both the first
and second pregnancy. All respiratory parameters returned to
prepregnancy values within 6–12 weeks postpartum.
One pregnancy training study was found on trained women
among whom several were elite athletes.34 The general conclu-
sion was that high fitness levels could be maintained or even
increased during pregnancy with appropriate strenuous training
regimens. No formal studies were found on elite athletes
reporting the timing of return to prepregnancy training regimens
and competition.
Exercise and breastfeeding
The WHO advises women to breast feed for at least 6 months.35
In a study of long distance runners, many modified their running
behaviour during breast feeding, but of those who ran competi-
tively prior to pregnancy and breast fed, 84.1% reported running
during breast feeding.36 Most felt that running had no effect on
their ability to breast feed.
Pivarnik et al reviewed breast feeding in athletes, and
found that the increased caloric expenditure associated with
breast feeding impacts an athlete’s postpartum weight loss and
return to competition.37 The concern that intense exercise may
impair milk production in quantity and nutritional qualities has
not been confirmed.38 39 Instead, high-volume aerobic exercise
during breast feeding resulted in slightly greater quality and
quantity of milk.40 Moderate weight reduction while nursing
is safe and does not compromise neonatal weight gain.41 Lactic
acid concentration in breast milk increases after intense exer-
cise.42 Further, as energy expenditure increases during physical
activity, there is an increase in proinflammatory cytokines, but
no change in immunoglobulin A.43
During pregnancy, if intestinal calcium is insufficient to meet
the combined needs of the mother and the baby, there may be
some bone resorption, which may be exacerbated by breast
feeding. There is no evidence that this causes osteoporosis or
fractures, as the maternal skeleton is restored to its prepregnancy
mineral content and strength after weaning. To our knowledge
there are no reports of pregnancy or lactation-related fractures
in athletes, although ‘excess exercise’ is thought to be a risk
factor for these rare conditions.44
At this time, data do not support a recommendation
concerning exercise intensity and breast feeding. The Society
of Obstetricians and Gynaecologists of Canada (SOGC) Clin-
ical Practice Obstetrics Committee, the Executive and Council
of SOGC, and the Board of Directors of the Canadian Society
for Exercise Physiology guidelines state that women should be
advised that moderate exercise during lactation does not affect
the quantity or composition of breast milk or impact infant
growth.45 In reviewing guidelines from different countries,
Evenson et al3 found that breast feeding was mentioned in the
Australian, Norwegian and Canadian guidelines.3 In particular,
the Australian guideline indicated that physical activity would
not impact breast milk volume or composition or infant growth
as long as the woman had appropriate food and fluid intake. The
American College of Obstetricians and Gynecologists recom-
mends that nursing women ensure adequate hydration before
commencing exercise and that they consider feeding their infants
before exercising to avoid the discomfort of engorged breasts
during exercise.46
Athletes may benefit from wearing a personally fitted sports
bra that offers support rather than compression,47 48 as this
provides significantly increased breast and bra comfort compared
with a standard encapsulation sport bra during exercise.49 Using
a breast pump before exercise may allow the postpartum athlete
greater flexibility in the workout and feeding schedule and
should result in a more comfortable exercise experience if the
breasts are not full.42
Return to competitive sport
There is scant knowledge on athletes returning to exercise
and competition after childbirth. Beilock et al50 suggested that
athletes may be able to alter their training patterns during preg-
nancy without a significant impact on their postpartum training
programme. In a retrospective study of 40 Norwegian elite
athletes, 77% continued to compete at the same level after child-
birth.51 Within the first 6 weeks postpartum, 12 (38%) of the
elite athletes started jogging compared with 2 (4.3%) in non-ath-
letes. In a case study of a marathon runner, Potteiger et al52 found
that while the individual did not qualify for the Olympic mara-
thon, she was able to resume an intense training regimen within
4 weeks after delivery with no apparent medical complications.
In another study, female Olympic and masters athletes reported
feeling more physically fit and having improved technical skill
after childbirth and often improved the records they achieved
before pregnancy.53
Since research concerning the exercise patterns of physically
fit athletes during the postpartum period is limited, studies on
physically fit soldiers can serve as a guide. The amount of time
needed for postpartum soldiers to return to prepregnancy fitness
condition, as evidenced by Army Physical Fitness Test scores,
ranged from 2 to 24 months, with a mean of 11 months.54 Post-
partum test scores were significantly affected by complications
(postpartum thyroiditis, hypertension, haemorrhoids, mastitis
and postpartum surgery), weight gain and breast feeding. Only
17% of the soldiers believed that 6 months is enough time to
return to prepregnancy physical condition, while only 19% of
the women performed at levels equal to or better on the 6-month
test, compared with their prepregnancy test.
Postpartum resumption of physical activity is an individual-
ised process. Given the scant data, there are no studies indicating
that rapid resumption of activities is associated with adverse
outcomes. However, because postpartum women have a degree
of deconditioning, accepted wisdom is for gradual resumption of
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Consensus statement
exercise. This phase clearly requires additional research. (Part 4
of this series will address research gaps.)
Elite athletes are likely to encounter the same physiological
limitations during pregnancy as those faced by recreational
athletes during pregnancy.37 Elite athletes tend to maintain a
more strenuous training schedule throughout pregnancy and
resume high-intensity postpartum training sooner. Based on the
available data, prepregnancy exercise routines may be resumed
gradually, as soon as it is physically and medically safe. This
will vary from one individual to another and some women may
resume an exercise routine within a few weeks of delivery.55
Women should discuss plans to resume exercise during the
postpartum period with their physician to obtain individualised
advice.
COMMON POSTPARTUM COMPLAINTS AND DISEASES: RISK
FACTORS, PREVENTION AND TREATMENT OPTIONS
Postnatal depression
The most common mental health problem in the postpartum
period is postpartum or postnatal depression.56 This is defined
as depression occurring within the 12 months after giving birth,
and is experienced by approximately 20% of women. However,
up to 50% of women experience high levels of depressive symp-
toms in this period.56 57 Depressive symptoms typically include
feelings of helplessness and hopelessness, sleep problems,
decreased energy, decision-making difficulties, sad mood, loss of
interest in activities, irritability, changes in eating patterns, rest-
lessness and suicidal ideations or attempts.57 There is no specific
information about the prevalence of postnatal depression in
female athletes.
Postnatal depression is associated with lower quality of life
in mothers and their babies, negative parenting behaviours,
poorer mother–infant bonding, and physical and emotional
problems.58–60 Women who experience postnatal depression also
have twice the risk of suffering episodes of depression later in
life.61
Prevention of postnatal depression
In a review of associations between physical activity (either
prepregnancy, during pregnancy or postpartum) and postnatal
depressive symptoms, there was an inverse association in 7/7
intervention studies and 6/10 observational studies.62 While
noting the limited quality of many of these studies, the authors
concluded that leisure time physical activity prior to, during and
after pregnancy may be important for reducing the risk of post-
natal depressive symptoms.62
The results of a large Norwegian randomised controlled
trial (RCT) (n=855) published after the above 2013 review
concluded that a 12-week programme of aerobic and strength
training during weeks 20–36 of pregnancy did not result in
differences in the prevalence of high depressive symptoms in
the intervention and control groups.63 Surprisingly, a subsample
of the intervention group who had not exercised prior to preg-
nancy had reduced risk of postnatal depression at follow-up.63
Level of evidence: Low, no studies of athletes.
Treatment of postnatal depression
Treatment options for postnatal depression are the same as in
other periods, and include the use of antidepressants and cogni-
tive therapy.64 Although there are plausible mechanisms by which
exercise may improve the symptoms of postnatal depression, a
2004 review of 21 non-biological or behavioural interventions
for the treatment of postnatal depression found insufficient
data from which to draw conclusions relating to exercise.65 In
contrast, a 2007 review found two small RCTs that supported
exercise as a useful treatment for women with postnatal depres-
sion.66 A further review and meta-analysis in 2009 included five
RCTs or quasi-RCTs that compared any type of exercise interven-
tion with other treatments in women with diagnosed postnatal
depression.67 Three trials showed a significant difference and
two did not. The effect of exercise (compared with no exercise)
was small, there was considerable heterogeneity, and the overall
difference was reduced and not significant when one study that
included social support and exercise was excluded. The authors
concluded that it was uncertain whether or not exercise reduces
symptoms of postnatal depression, or whether or not the effects
of exercise were confounded by the beneficial effects of social
support.67 Further RCTs are required.
Level of evidence: Low, insufficient studies, none in athletes.
Postpartum weight retention/loss
Background
Average weight retention 1 year after pregnancy in the general
population ranges from 0.5 to 4 kg.68–70 Gaining more weight
during pregnancy is consistently identified as the strongest
predictor of excess postpartum weight retention.71 72 Excess
weight retention postpartum is associated with increased long-
term risk of obesity, cardiovascular disease and type 2 diabetes
during midlife.69 73 Both energy intake and energy expenditure
(including energy expended through breast feeding) are associ-
ated with the rate of weight loss postpartum.
There are sparse data on postpartum weight loss in athletes.
One small retrospective observational study of elite Norwe-
gian athletes has shown that self-reported body mass index was
lower at prepregnancy, at 6 weeks postpartum and at the time
of completing the survey than in age-matched controls.51 At
the time of completing the questionnaire, 81% of the athletes
(mean: 6.5 years after birth) and 48% of the controls (mean:
8.5 years after birth) had returned to their prepregnancy weight.
Role of physical activity in postpartum weight loss
Most of the systematic reviews in this area included studies that
evaluated the role of physical activity, either alone or in combina-
tion with a dietary intervention, on postpartum weight retention
or weight loss. All of the included studies were with population
samples (ie, non-athletes), and most physical activity interven-
tions aimed to encourage the women to achieve recommended
levels of physical activity for health benefits (ie, ≥150 min per
week of at least moderate-intensity activity). This is much less
than that typically reported by elite athletes and results differed
between studies.69 71 74–77 We identified only one small inter-
vention study with athletes. Kardel compared the effects of two
training interventions on gestational weight gain and postpartum
weight.34 Both groups had the same intensity of muscle strength
training, aerobic interval training and aerobic endurance training
in their programmes, but the high-volume exercise group (n=20)
had more of each type of training than the medium-volume exer-
cise group (n=21). There was no non-exercising control group,
and the athletes selected their preferred programme. There were
no differences in body weight between the groups at 6 or 12
weeks postpartum. The mean weight was 72.2 kg in both groups
at 38 weeks’ gestation. At 6 weeks postpartum the high-volume
exercise group weighed slightly less than the medium exercise
group, but the mean weight at 12 weeks postpartum was very
similar (63.2 and 63.0 kg, respectively).
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Consensus statement
Level of evidence: Low, insufficient studies in the general
exercising population and in elite athletes.
MUSCULOSKELETAL COMPLAINTS
Low back and pelvic girdle pain
Although the majority of women with low back pain and
pelvic girdle pain recover spontaneously soon after delivery,
about 20% report persistent pain for years.78 A large longitu-
dinal population-based study found that 22% of women with
pelvic girdle pain in pregnancy reported persistent pelvic girdle
pain 6 months after delivery.79 Of these, 16% reported severe
complaints. The recovery rates were high, but decreased with
increasing levels of pain severity in pregnancy.80 Caesarean
delivery increased the risk for persistent severe pelvic girdle pain
6 months postpartum.80 In the only study among elite athletes,
12.6% reported retrospectively that they experienced pelvic
girdle pain 6 weeks postpartum and 9.7% experienced low back
pain.51 The prevalence increased to 19.4% for pelvic girdle pain
and 29.0% for low back pain from 6 weeks postpartum to the
time of completing the questionnaire 0–17 years after delivery.
Prevention and treatment
Four RCTs of high methodological quality have investigated
the effectiveness of different exercise programmes of low back
pain and pelvic girdle pain in the general postpartum popula-
tion.81–84 Only one of these RCTs demonstrated statistically and
clinically significant positive and long-lasting effects of specific
exercises in combination with individual physiotherapy on func-
tional status, pain and physical health (SF-36).84 85 Disability was
reduced by more than 50% for the exercise group compared
with negligible changes in the control group. The main focus
of the exercises (which was on the dynamic control of a neutral
position of the lumbopelvis, ergonomic advice and development
of strength and endurance to manage the physical demands
facing each individual) was to improve coordination of the local
and overall muscle system. The women were asked to perform
their 30–60 min exercise programme 3 days per week and they
adhered closely to this individually designed programme for
20 weeks. Compared with the other three studies, the study by
Stuge et al differed in many aspects, such as individual guidance
of a specialised women’s health physiotherapist, dosage, and
type and duration of exercises.86 No studies examining a treat-
ment programme for low back pain or pelvic girdle pain in elite
athletes were found. In the last decade, core stabilisation exer-
cises have grown in popularity.87 However, a recent systematic
review showed strong evidence that stabilisation exercises gener-
ally are not more effective than any other form of active exercise
in the long term.88 A condition-specific outcome measure, the
Pelvic Girdle Questionnaire, is reliable, valid and developed for
pregnant and non-pregnant women with pelvic girdle pain for
use in research and in clinical practice.89 90
Level of evidence: Moderate in the general postpartum popu-
lation. No studies in elite athletes.
Diastasis recti abdominis
Postpartum prevalence rates of diastasis recti abdominis in the
general population vary between 30% and 68%.91 92 In a longi-
tudinal study of 300 first-time pregnant women, prevalence rates
were 33% at gestational week 21, 60% at 6 weeks postdelivery,
45.4% at 6 months and 32.6% at 12 months postpartum.93
Diastasis recti abdominis is also common in middle-aged women
with a prevalence of 52% among all questioned and 35% in
nulliparous women,94 and may also be present in men.95 No
studies were found on elite athletes postpartum.
Influence ofdiastasis recti abdominison abdominal strength
In six women from gestational week 14 to 8 weeks postpartum,
Gilleard and Brown found that women with inter-rectus
distance >3.5 cm measured with palpation had reduced curl-up
capacity.96 This was supported by a study following 40 women
postpartum, which found that postpartum women had weaker
abdominal muscles than a control group.97 However, at 6
months postpartum there was no correlation between inter-
rectus distance and reduced abdominal muscle strength.
Diastasis and low back and pelvic girdle pain
Parker et al98 found that women with diastasis recti abdominis
had more abdominal and pelvic pain at 3 months postpartum
than women without diastasis recti abdominis.98 However, two
other studies found no differences in prevalence rates of low
back pain or pelvic girdle pain in primiparous women 6 and 12
months postpartum with or without diastasis recti abdominis.93
99 No studies were found on elite athletes postpartum.
Prevention and treatment
While several web pages recommend different types of abdom-
inal exercises to treat diastasis, there are no data to support these
recommendations. A case–control study by Lo et al showed a
protective effect of antepartum physical activity level.100 This
was also the case in the study by Chiarello et al.101 In a system-
atic review by Benjamin et al,102 eight studies reported treating
diastasis recti abdominis using abdominal exercises: four case
studies, two retrospective observational studies, one quasi-ex-
perimental post-test study and one small RCT of a brief training
intervention.103 This review concluded that non-specific exercise
may or may not help to prevent or reduce diastasis recti abdom-
inis during the antenatal or postnatal periods. An additional
small RCT of only nine women, 3 months to 3 years post-
partum, found a decline in diastasis recti abdominis in women
doing a traditional abdominal exercise programme and women
performing a core stability plank exercise, but no difference
between the two groups.104
Given the limited research from very small studies of low
methodological quality, there is no consensus on which abdom-
inal exercises to recommend to correct diastasis recti abdominis
postdelivery.99 105 Recent research has questioned the use of the
recommended in-drawing exercises (lifting the naval towards the
spine, activating mainly the transversus abdominis and internal
obliques) as these appear to widen, rather than narrow, the gap
on ultrasound.105–107
There is little evidence for surgery to restore diastasis. Akram
and Matzen identified 15 studies on surgical repair and found
only one RCT, which compared the results of using two different
sutures.108 The authors concluded that both groups had adequate
correction of diastasis recti abdominis 6 months after surgery.
This was supported by a recent RCT also comparing different
sutures.109 No studies have been found on the prevention or
treatment of diastasis recti abdominis in elite athletes.
Level of evidence: Insufficient evidence for the effect of either
surgery or different exercise regimens on diastasis recti abdom-
inis in the postpartum period. No studies on elite athletes.
Pelvic floor disorders
The main pelvic floor disorders postpartum are urinary incon-
tinence, anal incontinence and pelvic organ prolapse. The
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Consensus statement
prevalence of any type of urinary incontinence in primiparous
women during the first year postpartum, regardless of delivery
mode, is between 15% and 30%.110 Johannessen et al found that
one in five primiparous women suffered from anal incontinence
1 year after delivery.111 The main predictor for anal incontinence
1 year postpartum was anal incontinence in late pregnancy.
Obstetric anal sphincter injury increased the risk of incontinence
of stool and flatus (OR: 4.1; 95% CI 1.7 to 9.6). Urgency of
bowel evacuation was associated with older age and operative
delivery. It is estimated that >50% of women lose some pelvic
support after vaginal delivery.112 At 3–6 months postpartum,
prevalence rates of pelvic organ prolapse (stage II or higher in
a scale of 0–4) are between 18% and 56%.113–115 Moreover,
15%–40% of primiparous women have a major defect of the
levator ani muscle, and these women are twice as likely to have
pelvic organ prolapse stage II or higher than those with an intact
levator ani muscle.116
In a small retrospective questionnaire study on 40 elite
athletes who had given birth (selected from Norwegian Olympic
Committee and Confederation of Sport), the prevalence rate of
stress urinary incontinence was 29% at 6 weeks postpartum and
35% at the time of completing the questionnaire.51 There were
no differences in stress urinary incontinence prevalence between
elite athletes and a matched control group of 80 women, with a
measured mean of 7.5 years after delivery (range: 0–17 years).
Prevention and treatment
A Cochrane review concluded that postnatal women with
persistent urinary incontinence 3 months after delivery and who
received pelvic floor muscle training were about 40% less likely
than women who did not receive treatment, or who received
usual postnatal care, to report urinary incontinence 12 months
after delivery (RR: 0.60, 95% CI 0.35 to 1.03, combined result
of three trials).117 The more intensive the programme, the greater
the treatment effect.117 However, the Cochrane review also
concluded that ‘the extent to which mixed prevention and treat-
ment approaches to pelvic floor muscle training in the postnatal
period are effective is less clear’ (ie, offering advice on pelvic
floor muscle training to all pregnant or postpartum women
whether or not they have incontinence symptoms). Further, ‘it is
possible that mixed prevention and treatment approaches might
be effective when the intervention is intensive enough’.
There is lack of evidence from RCTs on the effect of pelvic
floor muscle training on anal incontinence postpartum.117
Several RCTs have found that pelvic floor muscle training can
reduce pelvic organ prolapse stage and symptoms in middle-aged
women, and it is recommended as first-line treatment (Durnea
et al 2013).118 However, one RCT did not find any effect of
pelvic floor muscle training starting 6 weeks postpartum on
pelvic organ prolapse in primiparous women.119 Postpartum, the
pelvic floor is weak and injured in most women, and women
who did not train these muscles before birth may need instruc-
tion and supervision to be able to perform a correct pelvic floor
muscle contraction. Women should start with contractions of
short duration, with progression to holding periods of 6–8 s and
continue to contract as close to maximum as possible with three
sets of 8–12 contractions per day.117 120
A pessary, or a vaginal device placed into the vagina to support
the pelvic organs, is also used to treat symptoms of pelvic
floor disorders. Scant data suggest that in women with urinary
incontinence, a pessary might be better than no treatment in
reducing leakage.121 In women with pelvic organ prolapse, one
randomised trial that compared two types of pessaries found
reduction in symptoms in about 60% of women who completed
the study.122 Whether a pessary might prevent pelvic floor symp-
toms, postpartum or at any other time has not been studied.
Level of evidence: Low for pelvic floor muscle training
as prevention, but strong for pelvic floor muscle training as
treatment of urinary incontinence in the general postpartum
population. No studies on elite athletes. Low for pessary treat-
ment of urinary incontinence or pelvic organ prolapse in the
general population. No studies with postpartum women or elite
athletes. Elite athletes with urinary incontinence or pelvic organ
prolapse should be referred for pelvic floor muscle training and
pessary use if necessary.
Pelvic floor pain
Pelvic floor pain is a specific subset of pelvic pain that consists of
pain due specifically to the pelvic floor muscles, connective tissue
or ligaments. Given this musculoskeletal aetiology, it is conceiv-
able that highly active women might report different rates of
pelvic floor pain than less physically active women. However,
studying pelvic floor pain is difficult, as many different terms
are used to express the finding of pelvic floor muscle pain and
increased tension, including ‘pelvic floor muscle pain syndrome’,
‘overactive pelvic floor’, ‘myofascial pelvic pain’, ‘levator
tension myalgia’ or ‘hypertonic pelvic floor muscles’. Further
compounding this difficulty is the fact that pain thought to be
related to the pelvic floor is often due to other aetiologies. For
example, in a prospective study of 114 female athletes with a
suspected musculoskeletal aetiology for pelvic pain, who were
referred to a surgical practice, 64.9% turned out to have injuries
of the hip and/or soft tissue surrounding the hip.123 We identified
no observational studies about pelvic floor pain in athletes.
Prevention and treatment
In a systematic review of 10 RCTs of pelvic floor muscle training
for pelvic floor pain, Frawley concluded that to date there is
scant evidence from high-quality RCTs to guide clinical practice
in prevention and treatment of pelvic floor pain.124 Scant data
suggest that, compared with saline injection, injection of botu-
linum toxin A into the pelvic floor muscles may decrease pain
scores in non-athletes with chronic pelvic pain and ‘evidence
of pelvic floor muscle spasm’.125 We identified no RCTs about
treatment of such pain in athletes.
Level of evidence: Low. No studies in elite athletes.
Sexual dysfunction
Sexual function is divided into four categories: pain, desire,
arousal and orgasmic disorders. Disorders in each category are
common,126 and diagnosing these disorders relies on self-report.
A three-item screening questionnaire has been shown to be as
effective as an interview with a psychologist in identifying sexual
problems.127 About 90% of women are sexually active during
pregnancy; this decreases to about 30% in the ninth month of
pregnancy.128 Sexual desire generally decreases postpartum and
improves over the course of the first postpartum year.129
About half of women who have a spontaneous vaginal delivery
resume intercourse before 8 weeks postpartum130 131 Women
with an intact perineum are more likely to resume vaginal inter-
course earlier (by 6 weeks postpartum).132 However, the effect
of perineal trauma on delaying intercourse is lost by 7–12 weeks
postpartum.129 Women who breast feed are less likely to resume
intercourse early in the postpartum period.133
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Consensus statement
Incidence of postpartum sexual dysfunction
Forty-one per cent to 83% of women report sexual dysfunction
at 2–3 months postpartum.128 134 Sexual pain is the most common
cause of sexual dysfunction in the postpartum period.129 Of
note, pain with intercourse may be present in up to one-quarter
of women before pregnancy.135 136
Risk factors for postpartum sexual dysfunction
Risk factors for postpartum sexual dysfunction include infre-
quent sexual activity or delayed initiation of sexual activity (later
than 9 weeks postpartum), being within the first 5 months after
childbirth, primiparity, postpartum depression, treatment for
depression and relationship dissatisfaction.128 134
The 2006 National Institutes of Health Consensus Confer-
ence on Maternal Demand Cesarean concluded that there was
no high-quality evidence to show that either vaginal or caesarean
birth resulted in better postpartum sexual function.137 In agree-
ment with this, 6 years after first delivery, mode of delivery was
not related to sexual function, with the exception that women
who delivered by caesarean perceived that their vaginal tone was
better.138 We identified no data on postpartum sexual dysfunction
in female athletes and also no data on whether physical activity
during or after delivery impacts sexual function in women.
Treatment of postpartum sexual dysfunction
In a systematic review that included 1341 women from eight
RCTs, pelvic floor muscle training was found to improve at least
one sexual variable in women with pelvic floor dysfunction. One
study showed an improvement in postpartum women.139 Six
years after first delivery, women who reported performing pelvic
floor muscle training scored better on numerous sexual function
questions than women who did not report this.138
Treatment is generally based on anecdotal evidence and
includes, most importantly, addressing sexual function as a
serious concern, reviewing the importance of adequate rest and
time for intimacy, and encouraging the use of vaginal lubricants.
In women who report pain with intercourse, a careful examina-
tion of the vagina and vulva to assess healing is recommended.
Level of evidence: Low, no studies on elite athletes.
SUMMARY
This review found a limited number of studies on factors relating
to return to exercise following pregnancy and childbirth in the
general exercising population, and very few in elite athletes.
There is also little information or evidence on which to base
advice for athletes on issues relating to common complaints in
the postpartum period. Both high-quality prospective cohort
studies and RCTs are required. The former would be useful from
a prevention viewpoint, in terms of understanding the determi-
nants of common problems such as postnatal depression, weight
retention and musculoskeletal complaints including pelvic floor
disorders. More RCTs would shed light on the most effective
treatment regimens for women with these problems, and would
inform the advice given to athletes in terms of the optimal time
to recommence training the cardiorespiratory and musculoskel-
etal systems.
Given the challenges of conducting studies with pregnant
athletes, it would be helpful if researchers who are working
on each of the main topics included in this chapter could agree
on the same valid and reliable outcome measures, so that data
can be pooled and treatments compared. Similarly, consensus
is needed around how to assess physical activity to compare
across studies. We agree with the thoughtful recommendations
regarding return to sport from the First World Congress in Sports
Physical Therapy 2016 Consensus statement,140 published after
our own proceedings: Return to sport should be considered a
continuum with three distinct elements: (1) return to participa-
tion, (2) return to sport and (3) return to performance. Within
each element, the athlete, physician, physiotherapist and coach
should carefully consider the unique elements of the athlete’s
personal performance, childbirth experience, lactation and sport
demands to provide a flexible and individualised programme
during recovery.140
Author affiliations
1Department of Sport Medicine, Norwegian School of Sport Sciences, Oslo, Norway
2Department of Obstetrics, Gynecology and Women's Health, Saint Louis University,
St Louis, Missouri, USA
3Facultad de Ciencias de la Actividad Física y del Deporte – INEF, Universidad
Politécnica de Madrid, Madrid, Spain
4Centre for Research on Exercise Physical Activity and Health, School of Human
Movement and Nutrition Sciences, University of Queensland, St Lucia, Australia
5Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology,
Queen's University, Kingston, Canada
6Department of Sport Gynaecology, Poundbury Clinic, Dorchester, UK
7Poundbury Clinic, King Edward VII Hospital, London, UK
8Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill,
North Carolina, USA
9Faculty of Biology and Medicine, Institute of Sport Science, University of Lausanne,
Lausanne, Switzerland
10School of Health Sciences, University of Tampere, Tampere, Finland
11The Swedish School of Sport and Health Sciences, Stockholm, Sweden
12R Samuel McLaughlin Foundation-Exercise and Pregnancy Lab, The University of
Western Ontario, London, Canada
13Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah,
USA
14Institute of Sport Science, University of Graz, Graz, Austria
15Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
16Department of Family Practice and School of Kinesiology, Centre for Hip Health and
Mobility, University of British Columbia, Vancouver, Canada
17IOC, Medical, Commission
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
© Article author(s) (or their employer(s) unless otherwise stated in the text of the
article) 2017. All rights reserved. No commercial use is permitted unless otherwise
expressly granted.
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postpartum period exercise in the−−Lausanne. Part 3 from the IOC Expert Group Meeting, elite athletes: 2016/17 evidence summary Exercise and pregnancy in recreational and
Commission
Mireille van Poppel, Britt Stuge, Karim M Khan and IOC Medical
Tarja I Kinnunen, Karin Larsén, Michelle F Mottola, Ingrid Nygaard,
Michael Dooley, Kelly R Evenson, Lene A H Haakstad, Bengt Kayser,
Kari Bø, Raul Artal, Ruben Barakat, Wendy J Brown, Gregory A L Davies,
published online June 22, 2017Br J Sports Med
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... Elite female athletes face many challenges when considering having a baby, planning a pregnancy within an Olympic/Paralympic cycle, time away from training and competition, profound pregnancyand postpartum-related physiological and anatomical changes, and returning to previous levels of performance within a limited time frame (7). In 2016, the International Olympic Committee produced a five-part series providing expert opinion on these matters and highlights the need for more high-quality evidence investigating the impact of high-intensity exercise on pregnancy, childbirth, and the return to competitive sport in elite athletes (8)(9)(10)(11)(12). Subsequent evidence has shown that postpartum elite athletes are still unsatisfied with the training and exercise advice given to them (13), which may present practical challenges when rehabilitating in preparation for returning to sport. ...
... It is understood now that the effects of pregnancy and childbirth can extend beyond 12 months postpartum (130). The longterm health implications of returning to high-impact and intense physical activity too soon after childbirth are unknown (10). ...
... Often, women wait until after childbirth to address common complaints, meaning that they have become more established conditions and are harder to treat (148). Evidence suggests that if the intervention is intensive and early enough, pelvic floor muscle training throughout pregnancy in healthy women (with no prior pelvic floor dysfunction) may reduce the incidence of urinary incontinence and pelvic floor dysfunction in late pregnancy and the postpartum period (10,143,149). Adverse pregnancy outcomes, such as preterm birth, preeclampsia, and intrauterine growth restriction associated with physically demanding occupations, could be prevented through careful consideration of workplace guidance and strategies that reduce activities such as prolonged standing (>4 h), prolonged walking (>4 h), and heavy lifting (>100 kg·d −1 ) (134). The use of similar preventative approaches in elite athletes and women in arduous occupations may help limit pelvic floor dysfunction throughout pregnancy and after childbirth and reduce the risk of adverse pregnancy outcomes, although more research is needed to investigate preventative strategies within these cohorts. ...
Article
Best-practice guidance and management of pregnant and postpartum elite athletes and women in arduous occupations is limited by the lack of high-quality evidence available within these populations. We have summarised the adaptations and implications of pregnancy and childbirth; proposed a novel integrative concept to address these changes; and made recommendations to progress research in this area.
... 7 8 In 2016, the International Olympic Committee (IOC) convened a meeting of experts in prenatal exercise and produced five documents reviewing available literature regarding pregnant athletes. [9][10][11][12][13] At that time, there was minimal information regarding the safety and benefits of high-intensity, long-duration or extreme volumes of exercise. More recent work suggests elite sport participation during pregnancy is not associated with adverse events during pregnancy, labour or delivery. ...
Article
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Objectives Athletes train and compete at the elite level during their reproductive years, yet sport policies that support pregnant athletes are lacking. The experiences of elite athletes during pregnancy are vastly under-represented, and such voices are needed to support evidence-informed policy. Thus, the purpose of this qualitative study was to describe the experiences of elite female athletes as they navigate pregnancy, and to identify sport policy considerations regarding participation during pregnancy. Methods Twenty athletes (mean age 35±5 years) who, within the last 5 years, had trained or competed at the elite level immediately prior to becoming pregnant were included. Data were generated via one-on-one semistructured interviews that were audio-recorded, transcribed verbatim and analysed through a process of content analysis. Results The findings of this study are represented by one overarching message: mother versus athlete, and five main themes: (1) pregnancy planning and fertility, (2) pregnancy disclosure and discrimination, (3) training pregnant athletic bodies, (4) safety concerns, and (5) supportive network and equitable funding. Conclusion In-depth stories shared by participants highlight the many significant decisions athletes must make as they navigate pregnancy alongside elite sport participation. The shared experiences of pregnant athletes highlight clear challenges that should be considered in the development of sport policy and practices that are inclusive and supportive of female athletes.
... Before consenting to take the survey, participants were provided with study details (S1 File). Methods and results are reported in accordance with the checklist of reporting results of internet e-surveys (CHERRIES) guidelines [14]. ...
Article
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Background In 2019, a majority of runners participating in running events were female and 49% were of childbearing age. Studies have reported that women are initiating or returning to running after childbirth with up to 35% reporting pain. There are no studies exploring running-related pain or risk factors for this pain after childbirth in runners. Postpartum runners have a variety of biomechanical, musculoskeletal, and physiologic impairments from which to recover from when returning to high impact sports like running, which could influence initiating or returning to running. Therefore, the purpose of this study was to identify risk factors associated with running-related pain in postpartum runners with and without pain. This study also aimed to understand the compounding effects of multiple associative risk factors by developing a clinical decision tool to identify postpartum runners at higher risk for pain.Methods Postpartum runners with at least one child ≤36 months who ran once a week and postpartum runners unable to run because of pain, but identified as runners, were surveyed. Running variables (mileage, time to first postpartum run), postpartum variables (delivery type, breastfeeding, incontinence, sleep, fatigue, depression), and demographic information were collected. Risk factors for running-related pain were analyzed in bivariate regression models. Variables meeting criteria (P19 (OR 2.48; 95% CI 1.44, 4.28), previous running injury (OR 1.95; 95% CI 1.31, 2.91), vaginal delivery (OR 1.63; 95% CI 1.06, 2.50), incontinence (OR 1.95; 95% CI 1.31, 2.84) and
... Obstetric factors did not adversely affect postpartum physical performance. Other smaller studies have found gestational diabetes, anemia and cesarean section may impact physical performance postpartum, however none of those factors were significant predictors in our analyses [18,23]. ...
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Introduction Pregnancy profoundly affects cardiovascular and musculoskeletal performance requiring up to 12 months for recovery in healthy individuals. Objective To assess the effects of extending postpartum convalescence from 6 to 12 weeks on the physical fitness of Active Duty (AD) soldiers as measured by the Army Physical Fitness Test (APFT) and Body Mass Index (BMI). Methods We conducted a retrospective study of AD soldiers who delivered their singleton pregnancy of ≥ 32weeks gestation at a tertiary medical center. Pre- and post-pregnancy APFT results as well as demographic, pregnancy, and postpartum data were collected. Changes in APFT raw scores, body composition measures, and failure rates across the 6-week and 12-week convalescent cohorts were assessed. Multivariable regressions were utilized to associate risk factors with failure. Results Four hundred sixty women met inclusion criteria; N = 358 in the 6 week cohort and N = 102 in the 12 week cohort. Demographic variables were similar between the cohorts. APFT failure rates across pregnancy increased more than 3-fold in both groups, but no significant differences were found between groups in the decrement of performance or weight gain. With the combined cohort, multivariable regression analysis showed failure on the postpartum APFT to be independently associated with failure on the pre-pregnancy APFT (OR = 16.92, 95% CI 4.96–57.77), failure on pre-pregnancy BMI (OR = 8.44, 95% CI 2.23–31.92), elevated BMI at 6–8 weeks postpartum (OR = 4.02, 95% CI 1.42–11.35) and not breastfeeding at 2 months (OR = 3.23, 95% CI 1.48–7.02). Within 36 months of delivery date, 75% of women had achieved pre-pregnancy levels of fitness. Conclusion An additional 6 weeks of convalescence did not adversely affect physical performance or BMI measures in AD Army women following pregnancy. Modifiable factors such as pre- and post-pregnancy conditioning and weight, weight gain in pregnancy and always breastfeeding were found to be significant in recovery of physical fitness postpartum.
Article
The impact of maternity (Mat) on subsequent athletic performance is not well known. This study aims to investigate the impact of maternity among elite marathoners on their overall performance progression. For each runner listed in the top 150 female marathoners, who had experienced a mid-career maternity, performance development was reconstituted throughout the career. Maternity data and career break time span (Ttotal) were collected from publicly available informations. Performances were modelled according to the known age-performance relationship and the impact of maternity was added into the model. Linear mixed effect model was used to study the influence of maternity on the overall career. Among this sample, thirty-seven runners had at least 1 child during her career. Among them, fourteen had two children. Eleven runners (29.72%) made their personal best performance before Mat, which occurred at an average age of 28.40 ± 4.00 years. Twenty-six runners (70.28%) establish their best performances after Mat, at an average age of 32.20 ± 4.28. The age-performance relationship model explains 92% of the performance variability during the career's progression. When age is considered, maternity does not have significant impact on performance development. World's most competitive marathoners can still perform at their best level after pregnancy. The ability to return and surpass previous performance level is influenced by the age at which pregnancy occurs, relative to the age of peak performance during career development.
Running after childbirth, specifically how or when to return, is a hot topic in the field of physical therapy and on social media; however, there are significant gaps in the literature supporting when and how to safely initiate running postpartum. During pregnancy and following childbirth (both vaginal and cesarean), the body undergoes changes that may impact strength, neuromuscular control, endurance, and the ability to withstand the high-impact forces and repetitive nature of running. Many mothers experience new or worsened symptoms of musculoskeletal or pelvic floor dysfunction following pregnancy and childbirth and require physical therapy to normalize function. After most major injuries, it is common to participate in formalized rehabilitation; however, this is not the norm for athletes returning to running postchildbirth. Because of lack of evidence, many runners and clinicians struggle to develop appropriate rehabilitation progressions for return to running after childbirth. Pelvic and sports physical therapists must understand biomechanical features of running gait and safely progress strength, endurance, and neuromuscular control of the kinetic chain when guiding a runner back to running. This clinical commentary builds on existing guidelines, research, and expert opinion to propose a 4-phase rehabilitation framework to help runners initiate and progress running after childbirth. The result is an in-depth exercise prescription (intensity, frequency, type), examples of exercises (hip, abdominal, pelvic floor, and foot), running progression, and progression goals to prepare runners for symptom-free running after childbirth (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JWHPT/A58, where authors provide more insight on this return to running framework).
Chapter
Pregnancy is a special and empowering time for women as well as an appropriate time to reassess lifestyle choices and adopt positive lifestyle changes. The female body undergoes many metabolic, biochemical, and physiologic changes during pregnancy that may affect a woman’s ability and willingness to exercise. The pelvic floor, in particular, experiences a unique combination of stressors that affect its form and function. Current research suggests that light and even moderate intensity endurance and strength training are appropriate to continue, or even commence, during healthy pregnancies without adverse outcomes for mother or child while high-intensity training and supine exercise should be avoided in second and third trimesters. Specific exercises to maintain the health and function of the pelvic floor may also be recommended during and after pregnancy. It is important to be aware that many pregnant women are not meeting exercise recommendations and/or may not have access to adequate information to maintain satisfactory physical health and function during and after pregnancy. Thus both health care and exercise professionals should be aware of the benefits and potential contraindications to exercise participation in pregnant women as well as the current evidence-based recommendations for exercise prescription in pregnant women.
Women are running as soon as 8 weeks postpartum and there is currently little understanding of the effects of pregnancy and childbirth on the postpartum runner (PPR). Pregnancy-related musculoskeletal and physiological changes could impact running gait postpartum. The purpose of the current study was to investigate differences in overground running kinetics, strength and flexibility in PPRs, and age-matched nulliparous controls. Vertical and anteroposterior ground reaction force (APGRF) data were collected during overground running and normalized to body weight (NBW). Hip and knee strength, and hamstring flexibility measures were collected using a handheld dynamometer and inclinometer, respectively. Data were averaged for both legs. Independent-samples t tests and effect size (ES) estimations were conducted using α = .05. Nine PPRs (33.10 ± 5.60 years; ≤2 years postpartum) and 9 age-matched nulliparous women (31.67 ± 4.55 years) participated. PPRs had 24.3% greater braking loading rate for APGRF than controls (mean difference [MD] 3.41 NBW/s, 95% confidence interval [CI] 0.08, 6.74; P = .046; ES 1.08). PPRs had 14% less hamstring flexibility (MD 10.98°, 95% CI 0.97, 20.99; P = .034; ES 1.14), 25.9% less hip abduction strength (MD 0.04 NBW, 95% CI 0.00, 0.08; P = .045; ES 1.07) and 51.6% less hip adduction strength (MD 0.06 NBW, 95% CI 0.02, 0.10; P = .003; ES 1.68). These preliminary findings suggest that PPRs demonstrate altered running braking strategies and decreased hamstring flexibility and hip strength compared with nulliparous controls. As running guidelines for PPRs have been derived mostly from expert opinion, this exploratory cohort study suggests that PPRs should be evaluated for musculoskeletal impairments before initiating or returning to running. (See the Video, Supplemental Digital Content A, available at: http://links.lww.com/JWHPT/A67, which discusses the significance, innovation, and clinical applicability of this study.)
Chapter
The notion of physical activity during pregnancy has gained substantial momentum over the recent years. This is likely due to the increasing number of studies that have shown what the benefits exercise can have during this unique time in a woman's life. Pregnancy no longer needs to be thought of as a time to cease all activity, and it is important to counsel patients that there can be increased complications by not exercising. The goal of this chapter is to discuss the specific considerations and recommendations of exercise during pregnancy.
Article
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This is Part 2 of 5 in the series of evidence statements from the IOC expert committee on exercise and pregnancy in recreational and elite athletes. Part 1 focused on the effects of training during pregnancy and on the management of common pregnancy-related symptoms experienced by athletes. In Part 2, we focus on maternal and fetal perinatal outcomes.
Article
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Background/aim Diastasis recti abdominis (DRA) is defined as a separation of the 2 muscle bellies of rectus abdominis. To date there is scant knowledge on prevalence, risk factors, and consequences of the condition. The present study aimed to investigate the prevalence of DRA during pregnancy and post partum, presence of possible risk factors, and the occurrence of lumbopelvic pain among women with and without DRA. Methods This prospective cohort study followed 300 first-time pregnant women from pregnancy till 12 months post partum. Data were collected by electronic questionnaire and clinical examinations. DRA was defined as a palpated separation of ≥2 fingerbreadths either 4.5 cm above, at or 4.5 cm below the umbilicus. Women with and without DRA were compared with independent samples Student's t-test and χ2/Fisher exact test, and OR with significance level >0.05. Results Prevalence of DRA was 33.1%, 60.0%, 45.4%, and 32.6% at gestation week 21, 6 weeks, 6 months and 12 months post partum, respectively. No difference in risk factors was found when comparing women with and without DRA. OR showed a greater likelihood for DRA among women reporting heavy lifting ≥20 times weekly (OR 2.18 95% CI 1.05 to 4.52). There was no difference in reported lumbopelvic pain (p=0.10) in women with and without DRA. Conclusions Prevalence of mild DRA was high both during pregnancy and after childbirth. Women with and without DRA reported the same amount of lumbopelvic pain 12 months post partum.
Article
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Deciding when to return to sport after injury is complex and multifactorial-an exercise in risk management. Return to sport decisions are made every day by clinicians, athletes and coaches, ideally in a collaborative way. The purpose of this consensus statement was to present and synthesise current evidence to make recommendations for return to sport decision-making, clinical practice and future research directions related to returning athletes to sport. A half day meeting was held in Bern, Switzerland, after the First World Congress in Sports Physical Therapy. 17 expert clinicians participated. 4 main sections were initially agreed upon, then participants elected to join 1 of the 4 groups-each group focused on 1 section of the consensus statement. Participants in each group discussed and summarised the key issues for their section before the 17-member group met again for discussion to reach consensus on the content of the 4 sections. Return to sport is not a decision taken in isolation at the end of the recovery and rehabilitation process. Instead, return to sport should be viewed as a continuum, paralleled with recovery and rehabilitation. Biopsychosocial models may help the clinician make sense of individual factors that may influence the athlete's return to sport, and the Strategic Assessment of Risk and Risk Tolerance framework may help decision-makers synthesise information to make an optimal return to sport decision. Research evidence to support return to sport decisions in clinical practice is scarce. Future research should focus on a standardised approach to defining, measuring and reporting return to sport outcomes, and identifying valuable prognostic factors for returning to sport.
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Guidelines on physical activity or exercise and pregnancy encourage pregnant women to continue or adopt an active lifestyle during and following pregnancy.1–3 Two systematic reviews of pregnancy-related guidelines on physical activity found similarities between recommendations from different countries, but noted that the guidelines differed in focus.4 ,5 The guidelines provided variable guidance on prenatal exercise, or on how pregnant women might approach continuing or adopting sport activities.6 However, most guidelines did not include important topics such as prevalence and known risk factors for common pregnancy-related diseases and complaints, and the role of exercise in preventing and treating them. Importantly, the focus of most previous guidelines has been on healthy pregnant women in the general population, in whom there is almost always a decline in physical activity during pregnancy.7 ,8 Indeed, a high proportion of pregnant women follow neither physical activity nor exercise guidelines,9 putting them at increased risk of obesity, gestational diabetes mellitus (GDM), and other pregnancy-related diseases and complaints.1 On the other hand, there are enthusiastic exercisers and elite athletes who often meet and exceed general exercise recommendations for pregnant women, but there are no exercise guidelines specifically for these women. Important questions for such women are unanswered in current guidelines: Which activities, exercises and sports can they perform, for how long and at what intensity, without risking their own health and the health of the fetus? How soon can they return to high-intensity training and competition after childbirth? The IOC and most National Sports Federations encourage women to participate in all Olympic sport disciplines. The IOC promotes high-level performance, and it is also strongly committed to promoting lifelong health among athletes10—not just during their competitive sporting careers. With an increasing number of elite female athletes competing well into …
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Purpose/Hypothesis: The purpose of this randomized controlled study was to determine if there was a significant difference between a six week traditional treatment program compared to an experimental treatment program consisting of core stabilization plank exercise routine in the closure of diastasis recti abdominis (DRA) and to determine the relationship between DRA measurements, pain, Oswestry Disability Index (ODI), and Pelvic Floor Disability Index scores (PFDI). Study design: Subjects were recruited in the local community utilizing a purposive sampling technique that considered women (postpartum 3 months to 3 years) between the ages of 18-45. Nine subjects volunteered to be in the study, signed an informed consent, and were randomly selected to be in either in a traditional or experimental group. Each participant completed both pre and post test diagnostic ultrasound and caliper measurements for DRA, health questionnaire, PFDI, and ODI scores. Materials and methods: A pilot study (n=5) was performed prior to the full study and indicated significant and strong inter-rater and intra-rater reliability for the diagnostic ultrasound DRA measurement at (r=0.945-0.989, p<0.0005). All participants were measured prior to being randomly placed into either the traditional or experimental group. Co-researchers who were in charge of DRA measurement were blinded from the group designation. The traditionalgroup received a supine strengthening program and the experimental group received a dynamic core stabilization program including the addition of plank exercise to approximate the DRA. Results: Overall, in both groups there was a measured, significant decline in the DRA measurement at the umbilicus (F=7.28, p=0.036), but the traditional group showed a slightly greater decline from pre to posttest (M(pre)=10.97+/-1.96; M(post)=6.63+/-1.65) compared to the experimental group (M(pre)=8.75+/-0.87) (M(post)=7.58+/-2.01). Disability scores also revealed a significant decline with respect to the ODI for both the traditional group (Z=-1.95, p=0.50) (M(pre)=5.50+/-5.51) (M(post)=3.50+/-3.00) and the experimental group (M(pre)=14.40+/-15.39) (M(post)=4.40+/-3.58). A significant difference was not found within groups, from pre to post-test, for the overall PFDI scores and its components (UDI and POPDI). However, a significant difference was found, within group, with respect to CRADI scores (Z=-2.032, p=0.042). In addition, a significant difference was not found between women who reported participation in pre-natal exercises compared with those who did not participate in pre-natal exercises with respect to baseline DRA measurements (above umbilicus: Z=-0.980, p=0.327), (at umbilicus: Z=-0.735, p=0.462), and (below umbilicus: Z=-0.980, p=0.327). Finally, a negative but non-significant correlation was found between PFDI scores and DRA closure measurements (r=0.605, r2=0.366, p=0.084). Conclusions: Both the traditional and experimental group showed significant reduction in DRA measurement from pre to posttest, with the traditional program exhibiting a slightly greater decline from pre to post DRA measurement than the experimental group. These findings suggest that either strengthening program, traditional or experimental, could be effective at reducing DRA measurement in postpartum women. However, this study was limited by a small sample size and would benefit from future research focused on specific exercise prescription progression.
The prevalence of obesity has reached alarming proportions globally, and continues to rise in both developed and developing countries. Maternal obesity has become one of the most commonly occurring risk factors in obstetric practice. For the mother, obesity increases the risk of obstetric complications during the antenatal, intrapartum and postnatal period, as well as contributing to technical difficulties with fetal assessment. The offspring of obese mothers also have a higher rate of perinatal morbidity and an increased risk of long-term health problems.
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Background: About one-third of women have urinary incontinence and up to one-tenth have faecal incontinence after childbirth. Pelvic floor muscle training (PFMT) is commonly recommended during pregnancy and after birth for both prevention and treatment of incontinence.This is an update of a review previously published in 2012. Objectives: To determine the effectiveness of pelvic floor muscle training (PFMT) in the prevention or treatment of urinary and faecal incontinence in pregnant or postnatal women. Search methods: We searched the Cochrane Incontinence Specialised Register (16 February 2017) and reference lists of retrieved studies. Selection criteria: Randomised or quasi-randomised trials in pregnant or postnatal women. One arm of the trial included PFMT. Another arm was no PFMT, usual antenatal or postnatal care, another control condition, or an alternative PFMT intervention. Data collection and analysis: Review authors independently assessed trials for inclusion and risk of bias. We extracted data and checked them for accuracy. Populations included: women who were continent (PFMT for prevention), women who were incontinent (PFMT for treatment) at randomisation and a mixed population of women who were one or the other (PFMT for prevention or treatment). We assessed quality of evidence using the GRADE approach. Main results: The review included 38 trials (17 of which were new for this update) involving 9892 women from 20 countries. Overall, trials were small to moderate sized, and the PFMT programmes and control conditions varied considerably and were often poorly described. Many trials were at moderate to high risk of bias. Other than two reports of pelvic floor pain, trials reported no harmful effects of PFMT.Prevention of urinary incontinence: compared with usual care, continent pregnant women performing antenatal PFMT may have had a lower risk of reporting urinary incontinence in late pregnancy (62% less; risk ratio (RR) for incontinence 0.38, 95% confidence interval (CI) 0.20 to 0.72; 6 trials, 624 women; low-quality evidence). Similarly, antenatal PFMT decreased the risk of urinary incontinence in the mid-postnatal period (more than three to six months' postpartum) (29% less; RR 0.71, 95% CI 0.54 to 0.95; 5 trials, 673 women; moderate-quality evidence). There was insufficient information available for the late (more than six to 12 months') postnatal period to determine effects at this time point.Treatment of urinary incontinence: it is uncertain whether antenatal PFMT in incontinent women decreases incontinence in late pregnancy compared to usual care (RR 0.70, 95% CI 0.44 to 1.13; 3 trials, 345 women; very low-quality evidence). This uncertainty extends into the mid- (RR 0.94, 95% CI 0.70 to 1.24; 1 trial, 187 women; very low-quality evidence) and late (RR 0.50, 95% CI 0.13 to 1.93; 2 trials, 869 women; very low-quality evidence) postnatal periods. In postnatal women with persistent urinary incontinence, it was unclear whether PFMT reduced urinary incontinence at more than six to 12 months' postpartum (RR 0.55, 95% CI 0.29 to 1.07; 3 trials; 696 women; very low-quality evidence).Mixed prevention and treatment approach to urinary incontinence: antenatal PFMT in women with or without urinary incontinence (mixed population) may decrease urinary incontinence risk in late pregnancy (26% less; RR 0.74, 95% CI 0.61 to 0.90; 9 trials, 3164 women; low-quality evidence) and the mid-postnatal period (RR 0.73, 95% CI 0.55 to 0.97; 5 trials, 1921 women; very low-quality evidence). It is uncertain if antenatal PFMT reduces urinary incontinence risk late postpartum (RR 0.85, 95% CI 0.63 to 1.14; 2 trials, 244 women; low-quality evidence). For PFMT begun after delivery, there was considerable uncertainty about the effect on urinary incontinence risk in the late postnatal period (RR 0.88, 95% CI 0.71 to 1.09; 3 trials, 826 women; very low-quality evidence).Faecal incontinence: six trials reported faecal incontinence outcomes. In postnatal women with persistent faecal incontinence, it was uncertain whether PFMT reduced incontinence in the late postnatal period compared to usual care (RR 0.68, 95% CI 0.24 to 1.94; 2 trials; 620 women; very low-quality evidence). In women with or without faecal incontinence (mixed population), antenatal PFMT led to little or no difference in the prevalence of faecal incontinence in late pregnancy (RR 0.61, 95% CI 0.30 to 1.25; 2 trials, 867 women; moderate-quality evidence). For postnatal PFMT in a mixed population, there was considerable uncertainty about the effect on faecal incontinence in the late postnatal period (RR 0.73, 95% CI 0.13 to 4.21; 1 trial, 107 women, very low-quality evidence).There was little evidence about effects on urinary or faecal incontinence beyond 12 months' postpartum. There were few incontinence-specific quality of life data and little consensus on how to measure it. We found no data on health economics outcomes. Authors' conclusions: Targeting continent antenatal women early in pregnancy and offering a structured PFMT programme may prevent the onset of urinary incontinence in late pregnancy and postpartum. However, the cost-effectiveness of this is unknown. Population approaches (recruiting antenatal women regardless of continence status) may have a smaller effect on urinary incontinence, although the reasons for this are unclear. It is uncertain whether a population-based approach for delivering postnatal PFMT is effective in reducing urinary incontinence. Uncertainty surrounds the effects of PFMT as a treatment for urinary incontinence in antenatal and postnatal women, which contrasts with the more established effectiveness in mid-life women.It is possible that the effects of PFMT might be greater with targeted rather than mixed prevention and treatment approaches and in certain groups of women. Hypothetically, for instance, women with a high body mass index are at risk factor for urinary incontinence. Such uncertainties require further testing and data on duration of effect are also needed. The physiological and behavioural aspects of exercise programmes must be described for both PFMT and control groups and how much PFMT women in both groups do, to increase understanding of what works and for whom.Few data exist on faecal incontinence or costs and it is important that both are included in any future trials. It is essential that future trials use valid measures of incontinence-specific quality of life for both urinary and faecal incontinence.
Article
This 5-year follow-up study contrasted the effects on maternal and child health of two forms of assisted delivery: forceps and vacuum extraction. Of 313 women randomized into the study, 306 were sent follow-up questionnaires and 228 of them (nearly 75 percent) responded. The group included 115 women having forceps-assisted deliveries and 113 undergoing vacuum extraction. Either a third-degree perineal tear or an extended upper vaginal tear occurred in 5 percent of the ventouse group and 10 percent of the forceps group. Just over 40 percent of women in each group had had another child when followed up 5 years after the index delivery. Urinary incontinence was described by 47 percent of all women, and bowel urgency by 44 percent. One in five women reported losing bowel control sometimes or frequently. None of these symptoms correlated significantly with one or the other form of assisted delivery. Visual problems were reported for 12 to 13 percent of children in each group; all but one of 18 of these children had a family history of vision problems. Development did not differ significantly in the two groups of children; the overall incidence of developmental problems was low. This study, the first long-term follow-up of mothers and their children after assisted delivery, revealed no substantial differences in morbidity between the vacuum extraction and forceps techniques. Br J Obstet Gynaecol 1999;106:544–549
Article
b>Context : Postnatal depression is highly prevalent in mothers. Although physical activity has been found to reduce the risk of depression in the general population, little is known regarding its link with postnatal depression. This review examined original research investigating the relationship between physical activity and sedentary behavior dose (frequency, intensity, and duration) and domain, and postnatal depressive symptoms. Evidence acquisition : A systematic search for original research investigating the relationship between physical activity and sedentary behavior dose and domain, and postnatal depressive symptoms, was performed using several electronic databases in early 2012. A total of ten observational and seven intervention studies were included. Evidence synthesis : Most studies (one cross-sectional, two longitudinal, and six intervention studies) found an inverse association between postpartum leisure-time physical activity (LTPA) and postnatal depressive symptoms. One longitudinal study found that occupational physical activity was positively associated with postnatal depressive symptoms. There was inconclusive evidence to suggest an optimal dose of postpartum physical activity for reducing postnatal depressive symptoms. Two longitudinal studies found an inverse association between antenatal LTPA and presence of postnatal depressive symptoms. One of two studies that investigated sedentary behavior found a positive cross-sectional association between sedentary behavior and presence of postnatal depressive symptoms. Conclusions : Although studies are limited, on balance, LTPA prior to, during, and after pregnancy may be important for reducing the risk of postnatal depression. Further research is required to determine the optimal dose and domain of physical activity for reducing postnatal depressive symptoms as well as to examine the link between sedentary behavior and postnatal depressive symptoms.