An evidence-based comparison of rehabilitation strategies for diastasis recti abdominis in postpartum women: a systematic review and network meta-analysis

This study aimed to compare the effectiveness of various physical therapy interventions, including exercise and non-exercise-based approaches, for improving intera recti distance (IRD) in women with postpartum diastasis recti abdominis (DRA). A systematic review and network meta-analysis (NMA) of randomized controlled trials (RCTs) was conducted following PRISMA-NMA guidelines. Databases searched included PubMed, Scopus, ISI Web of Science, Cochrane Library Databases, and manual searches were systematically searched from their inception until October 2024. A total of 27 RCTs involving 1340 postpartum women with DRA and 39 interventions were included. IRD was assessed via ultrasonography or calipers. Treatment effects on IRD were analysed using mean differences (MDs), 95% confidence intervals (CIs), and minimal clinically important differences (MCID) thresholds to determine clinical relevance. All networks revealed low heterogeneity and non-significant inconsistency (I2 = 26.80%). Combined deep and superficial abdominal muscle training versus no-treatment group was associated with a greater reduction in IRD compared to single-muscle approaches and non-exercise modalities, like TCMEB + KT(MD = -26.25, 95% CI = -29.41; -23.09, SUCRA = 0.96), TCME + BPFM + NMES (MD = -25.94, 95% CI = -32.33; -19.54, SUCRA = 0.95), NMES + TCME + MMT (MD = -24.62, 95% CI = -29.78; -19.47, SUCRA = 0.92) and NMES + TCME ( MD = -22.62, 95% CI = -26.58; -18.67, SUCRA = 0.88). The kinesio-taping (MD = -3.93, 95% CI = -6.20; -1.65, SUCRA = 0.18) and abdominal binders (MD = -10.32, 95% CI = -13.81; -6.83, SUCRA = 0.52) demonstrated moderate to low effectiveness. The overall quality of the evidence varied from low to High according to the GRADE approach. No serious publication bias was identified. Based on the findings of this study, comprehensive exercise programs that engage both superficial and deep abdominal muscles, especially when combined with neuromuscular electrical stimulation and breathing techniques, appear more effective than passive or isolated approaches in reducing inter-recti distance in postpartum women. Nevertheless, given the limited direct comparisons and low certainty in some evidence, clinical interpretation should remain cautious. Further well-designed studies with robust controls and direct comparison are needed to confirm and strengthen these findings. Registration: PROSPERO CRD42024593155.