Re-thinking abdominal training in pregnant and postnatal women
Abdominal separation is one of the most common conditions that physiotherapists see in pregnant and postnatal 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 transversus 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.
As a result, DRAM can have a number of implications for pre and postnatal women. It can affect the stability of the trunk and may contribute to pelvic floor dysfunction (66% of patients with DRAM have reported to have pelvic floor dysfunction), back and pelvic girdle pain, and hernias. This may be a factor in persistent postnatal lumbar, pubic symphysis and sacroiliac 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 correctly. 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, 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 assist in determining abdominal-wall functioning and to give instant feedback on the quality of deep abdominal and pelvic floor activation. Exercises should focus on improving core stability, strengthening pelvic floor muscles and improving abdominal-wall function.
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.
Avoiding any activities that work the outer abdominals from the early stages of pregnancy is important. That means no sit-ups, planks or high impact activities such as running and jumping. Also, avoid heaving up from a lying position to sitting or standing, instead rolling onto your side first. That’s a good idea for all pre and postnatal women whether they have a separation or not. Also, avoid excessive coughing and constipation. Getting started on some deep abdominal and pelvic floor muscle exercises will optimise the function of your torso during pregnancy and as a new mum.
Training considerations for clients with DRAM
After ascertaining whether a client is experiencing DRAM, it is also prudent to consider the following:
- Prescreening: by conducting a pre-exercise analysis with your pre and postnatal 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 (e.g. abdominal curls, oblique curls, double leg lifts) increase the stress on both abdominals and pelvic floor and can further increase muscle separation.
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.
In addition to the training you deliver your pre and postnatal 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 such as lifting her baby or lifting a pram in and out of the car.
Written by Shira Kramer, women's health physiotherapist and Pelvic Floor First ambassador.