BET 1: Is exercise-related transient abdominal pain (stitch) while running preventable?

Information sourced from BMJ:

Emerg Med J 2012;29:930-931 doi:10.1136/emermed-2012-201952.2

[Link to Emerg Med J evidence report PDF | PubMed ® abstract]

Best Evidence Topic reports

BET 1: Is exercise-related transient abdominal pain (stitch) while running preventable?

Report by: Nele Pauwels, Staff member, Centre of Expertise

Search checked by: Emmy De Buck, Staff member, Centre of Expertise

[EXCERPTS]

A short cut review was carried out to establish whether drinking fluids was better than not drinking fluids at preventing exercise associated abdominal pain (stitch) in runners. 112 papers were found using the reported searches, of which 2 presented the best evidence to answer the clinical question.

Clinical scenario

A 23-year-old woman started a graduated training programme for 10 weeks since she set her goal to run 5 km non-stop. While running, she has stabbing pain under the lower edge of the ribcage, which causes her to stop. She asks you if exercise-related transient abdominal pain (or stitch) is preventable, for example, by not drinking fluids before and during the run.

Table 1 Relevant papers

Author, date and country Plunket and Hopkins, 1999, New Zealand Morton et al, 2004, Australia
Patient group 10 Healthy men (age 21 ±2 years, height 180 ±5 cm and weight 81 ±8 kg; mean ±SD). All subjects consumed 200 €“300 ml of water at 1.5 €“2 h before the testing exercise. Shortly before exercise, subjects were subjected to a body-mass-adjusted volume (14 ml/kg) of each of four fluids: water, commercially available energy drink Exceed (main energy constituent is glucose polymers), decarbonated Coca Cola (main energy constituent is sucrose) and a hypertonic solution of the sugar lactulose or no fluid. Each exercise session consisted of 5-min bouts of hard running on a treadmill, with 10 min rest between each bout. There were several days between each testing exercise. 40 Subjects (30 men and 10 women; age 21.0 ±0.5 years, height 177.1 ±1.4 cm and weight 71.9 ±1.9 kg; mean ±SEM); susceptible to ETAP). All subjects consumed 500 ml of water at 2 h before testing exercise. Shortly before and during exercise, subjects were subjected to a body-mass-adjusted volume (2 ml/kg at start and during exercise) of each of three fluids: flavoured water, sports drink and reconstituted fruit juice or no fluid. Each exercise session consisted of one trial of 23 min running on a treadmill. There was approximately 1 week between each testing exercise.
Study type (level of evidence) Crossover trial (randomised according to Latin square design) (level of evidence 2b) Crossover trial (randomised according to Latin square design) (level of evidence 2b)
Outcomes Mean intensity of stitch during first bout Mean intensity of stitch by the fourth and fifth bout Incidence of ETAP (percentage of subjects) Severity of ETAP (mean ±SEM) Duration of ETAP (min ±SEM)
Key results Significantly more with each type of fluid compared to no fluid (p<0.0001) Significantly more with each type of fluid (except for Exceed) compared to no fluid (p=0.003 €“0.02) No fluid: 40%; flavoured water: 70% (p<0.05 compared to no fluid); sports drink: 70% (p<0.05 compared to no fluid); fruit juice: 83% (p<0.05 compared to no fluid) Mean severity: no fluid: 0.4 ±0.1; flavoured water: 0.6 ±0.1 (p>0.05 compared to no fluid); sports drink: 0.8 ±0.2 (p>0.05 compared to no fluid); fruit juice: 1.3 ±0.2 (p<0.05 compared to no fluid) No fluid: 6.8 ±0.7 min; flavoured water: 9.8 ±1.2 min (p>0.05 compared to no fluid); sports drink: 13.2 ±1.4 min (p<0.05 compared to no fluid); fruit juice: 14.4 ±1.0 min (p<0.05 compared to no fluid)
Study weakness Small study population; lack of objective method of verifying the intensity of stitch; no statistical analysis was performed to compare no fluid versus fluid consumption in second and third bout; allocation concealment is not described Rate of fluid ingestion was high beyond that which occurs in a typical exercise situation and which is recommended by the American College of Sports Medicine (600 €“1000 ml/h); lack of objective method of verifying the intensity of stitch; allocation concealment is not described)

ETAP, exercise-related transient abdominal pain.

Comment

As all subjects in both studies consumed water before the testing exercise, stitch as a consequence of dehydration seems unlikely. All subjects were asked to fast for at least 5 h (Morton et al) or to abstain from eating in the morning (Plunkett and Hopkins) before the trial, but not all test persons followed the €˜eating protocol €™ (ie, 40% of the subjects of the trial of Plunkett and Hopkins preferred to consume their normal breakfasts).

Clinical bottom line

In conclusion, drinking large quantities immediately before exercise is associated with exercise-related stitch.

[Link to free Emerg Med J evidence report PDF for full text, tables, and references]

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