Injury & Rehab: Abdominal separation in pregnant and post-natal clients
With up to two-thirds of pregnant women experiencing abdominal separation, it is crucial that abdominal exercises in the childbearing years be carefully considered and modified says Shira Kramer.
Abdominal separation is one of the most common problems that physiotherapists see in pregnant and post-natal patients. As many as two in three pregnant women have some degree of abdominal separation. As a result, it is essential that abdominal exercises in the childbearing years be carefully considered and modified.
What is DRAM?
Diastasis of rectus abdominis muscle (DRAM) is a separation of the connective tissue (linea alba) joining the two strips of muscles (rectus abdominis) down the middle of the abdomen. It occurs when the abdominal wall muscles and their connective tissue attachments stretch. This is the result of the combination of abdominal weakness, hormonal changes, weight gain and abdominal wall stretch exerted by the growing foetus.
The abdominal wall has four layers of muscle, from superficial to deep: rectus abdominis, external oblique, internal oblique and, the deepest layer, the transverses abdominis.
Often in cases of DRAM, the rectus abdominis muscles are weak and their function is compromised. Because of the interconnectivity of the muscles (via the linea alba), this impacts the deeper muscles of the abdomen and pelvis, resulting in a destabilised support system. Stable tendinous attachments are required for the abdominal muscles to transmit forces in the desired direction, and alterations of a muscle’s angle of insertion will affect this function. Changes in rectus abdominis length, width and angle of insertion can occur after childbirth and are associated with a reduced ability to stabilise the lumbopelvic area (Gilleard & Brown, 1996).
As a result, DRAM can have a number of implications for pre- and post-natal women. It can affect the stability of the trunk and may contribute to pelvic floor dysfunction, back and pelvic pain and hernias. A separation persisting after four weeks post-natally is likely to disrupt the function of the abdominal musculature. This may be a factor in persistent post-natal lumbar, pubic symphysis and sacroiliac joint pain and even incontinence due to the interaction of the pelvic floor and abdominal musculature as a stabilising unit.
How to test for DRAM
- Have your client lie on her back with her knees bent and feet on the floor approximately hip-distance apart
- Place fingers along the linea alba (midline of stomach)
- As client relaxes her abdominal muscles while lifting head and shoulders gently off the floor, feel for a gap or bulge just above or below the belly button
- If a diastasis is present you will feel the rectus abdominis tightening on either side of your fingers. If you cannot feel this muscle contracting you may need to place more fingers in the gap between the muscles so you can measure it more accurately. In some cases this gap may be more than 10 fingers-width.
- You also need to determine the condition of the connective tissue. The deeper the fingers go towards the spine, the weaker the connective tissue.
If the gap is larger than two fingers-width then outer abdominal exercises should be avoided until the deeper core and pelvic stability muscles are strengthened.
Management of DRAM
When it comes to managing DRAM, it is best to encourage clients to seek a thorough assessment by a women’s health physiotherapist, and to create a specifically tailored exercise program. Real-time ultrasound is often used to give instant feedback on the quality of deep abdominal and pelvic floor muscle activation. Exercises should focus on improving core stability, strengthening pelvic floor muscles and improving abdominal muscle tone.
In addition to a specific exercise program, abdominal muscle support (compression garments) is essential for the management of DRAM. This combination of compression and a tailored program will achieve optimal results.
It is important that the correct type of compression garment is worn. The garments that achieve best results have gentle (medical graded) compression which promote supporting pressure to the pelvis, back and abdominal muscles. This stimulates strengthening of the abdominal muscles facilitating muscle recovery.
A garment that is tight and restrictive should not be worn for recovery after childbirth, as it places too much compression on the muscles and does not allow them to work. This ultimately causes further muscle weakness.
Training considerations for clients with DRAM
After ascertaining whether a client is experiencing DRAM, it is also prudent to consider the following:
- Pre-screening: by conducting a pre-exercise analysis with your pre- and post-natal client, you will be able to identify special considerations for her exercise programming and tailor the exercises appropriately
- Work in conjunction with a women’s health physiotherapist to devise a safe and effective program.
Many traditional exercises increase the stress on both abdominals and pelvic floor and can further increase muscle separation. Strengthening and shortening the rectus abdominis muscles may increase the chance of developing a separation in the rectus muscle. It is best to avoid these exercises from early pregnancy until well into the post-natal period. A good way to assess if an exercise is appropriate is to consider whether or not it increases intra-abdominal pressure or involves impact. If not, then the exercise is most likely to be safe for the abdominal and pelvic floor muscles. If your client notices any muscle peaking (muscles visibly protruding from the centreline of the abdomen, with pyramid-like appearance), the exercise needs to be modified.
The following exercises should be avoided when the DRAM (gap) is larger than two fingers-width:
- Abdominal curls
- Oblique curls
- Pilates 100s
- Double leg lifts
- Medicine ball rotations
- Push ups
- Valsalva manoeuvre
- High impact exercise such as jumping, running, star jumps and skipping.
While individual assessment is imperative, the above exercises may be commenced once:
- Soft tissue healing is complete post-childbirth (minimum of 6-12 weeks)
- DRAM is less than 2cm, and no muscle peaking is experienced
- Effective pelvic floor and transversus abdominus contractions are evident during the exercise
- No pelvic or back pain is present.
Safe exercise options
When working with clients with DRAM, the focus should be on strengthening from the inside to the outside. The deep abdominal and pelvic floor muscles are the priority.
The following is an example of a DRAM-safe strengthening workout.
Setting the core
Sitting upright, gently and slowly engage the pelvic floor and draw in lower (deep) abdominals (photo 1).
Trainer tip: Keep posture upright and keep upper abdominals relaxed. Breathe comfortably.
Seated knee lift
Sitting upright, with core engaged, raise alternate knees (photo 2).
Trainer tip: Keep posture upright and ball steady.
4 point kneel-arm raise
On all fours, with hands positioned beneath the shoulders, and knees directly under hips, set the core and raise one arm up (photo 3).
Trainer tip: Keep elbows soft and lower back still.
4 point kneel-leg slide
On all fours, with hands positioned beneath the shoulders and knees directly under hips, set the core and slide one leg back (photo 4).
Trainer tip: Keep elbows soft and lower back still.
Lying on one side, set the core and, keeping the heels together, raise the upper knee (photo 5).
Trainer tip: Keep hips still (no rotation) and progress by hovering feet up off the floor. Resistance can be increased with the use of a theraband.
Bridge and lat pullover
From a seated position on the Swiss ball, walk the feet forwards to a bridge position (head and shoulders supported on the ball). With trainer holding the band from behind, or with band tied to a post from behind, the client drops her hips and then pulls the band as she lifts her hips up.
Trainer tip: Ensure hips are level and weight is supported through the heels.
In addition to the training you deliver your pre- and post-natal client, it is also a good idea to encourage her to protect against further muscle stretching by activating her pelvic floor muscles while performing everyday activities like lifting her baby or lifting a pram in and out of the car.
Shira Kramer, BPhty
Shira is one of Australia’s leading women’s health and fitness professionals. An experienced physiotherapist, fitness leader, presenter and business leader, she is the founder of BeActive, a successful enterprise that has consulted to over 4,000 women at various stages of their pre- and post-natal journeys. A renowned global speaker and mentor for women’s health and wellness, Shira’s passion is to keep women active during all ages and stages in life. For more information visit www.beactivephysio.com