What is a DRAM?
DRAM/DRA is the acronym for diastisis of the rectus abdominus muscle, which is a separation between the left and right halves of the rectus abdominus through widening for the central ligament known as the linea alba (LA). This increase in inter-rectus distance (IRD) has been shown to be present in 27%-100% of women during the second and third trimester of pregnancy and up to 68% of women in the post-partum period (Hilde, Tennfjord, Sperstad & Engh., 2017). Currently, there are only a small amount of research trials investigating this condition. There is no evidence that confirms that there are any risk factors for developing a DRAM (Gluppe, et al., 2018). “Natural resolution and greatest recovery of DRAM occurs between 1 day and 8 weeks after delivery, after which time recovery plateaus” (Benjamin, van de Water & Peiris., 2014, p.1).
It is suggested that increasing the distance between the rectus abdominus muscle through a DRAM may lead to reduced lower back and pelvic stability and be related to the development of urinary incontinence, pelvic organ prolapse and pelvic floor muscle (PFM) weakness. For this reason, research trials have aimed to explore the impact of pelvic floor and abdominal muscle training on the recovery of DRAM, but conclusive evidence is yet to be found showing a direct correlation between DRAM severity and back pain and/or PFM dysfunction. Despite this, physiotherapists continue to offer pelvic floor muscle training and abdominal muscle strengthening exercises as a treatment for patients. I, am one of those. After reading the available research, it appears that while there is no reported risk in providing patients with these exercises, it cannot be conclusively know that performing them will lead to a faster recovery. There is also no evidence suggesting that one exercise program is superior to another.
- What is the ideal assessment?
- What is the ideal exercise program?
- What is the ideal frequency for completing the exercise program?
What is the ideal assessment of a DRAM?
>2.7cm at the level of the umbilicus is considered pathological (Benjamin, et al., 2014). Smaller levels of widening are considered physiological.
- “Assessment with finger breadth has been found to have an intra- and inter-observer ICC value of 0.7 and 0.5, respectively.” (Hilde, Tennfjord, Sperstad & Engh., 2017, p. 717)
- Cut off of ≥ 2 fingers width 4.5cm above, at the level of, and 4.5cm below the umbilicus (Benjamin, van de Water & Peiris., 2014; Gluppe, et al., 2018).
- The position is in supine with knees bent and feet flat. Some authors have arms across chest. (I learnt with hands below lower back.)
- The movement performed by the patient during assessment is a small sit up only until the level of the shoulder blades.
Categorising DRAM (Gluppe et al., 2018)
- Normal < 2 fingers
- Mild DRAM 2-3 fingers
- Moderate DRAM 3-4 fingers
- Severe DRAM >4 fingers
- Test-retest reliability ICC of 0.83-0.95 above the umbilicus and 0.5-0.85 below the umbilicus. (Benjamin et al., 2014).
- The reliability is highly dependent on the operator.
Benjamin et al (2014) pose a valid question that all clinicians should consider: are we using assessment to diagnose the presence of a DRAM or to monitor change in DRAM width over time?
- As a diagnostic tool, palpation and ultrasound can be used. i.e is a DRAM present or not?
- As a monitoring tool, palpation is not recommended as an accurate tool and instead U/S, MRI and callipers are preferred.
Clinicians need to be clear about their goals for assessment. Most Physical Therapists continue to use finger palpation in assessment and this is suitable to detect the presence/absence of a DRAM. For monitoring change over time, U/S, MRI or callipers are more suitable assessment tools.
Are there exercises that help?
Benjamin et al (2014) completed a systematic review to determine the effectiveness of non-surgical interventions for DRAM. Their aims were to understand if exercises could reduce/prevent a DRAM in the ante-natal period? And, if they could reduce DRAM and health-related negative effects of a DRAM in the post-natal period.
The systematic review located 8 studies of various design and ranging levels of study quality. The interventions included abdominal muscle strengthening and provision of an abdominal corset/tubigrip.
It has previously been suggested that exercise during pregnancy can reduce the presence of DRAM development by 35% as well as DRAM width (Chiarello et al., 2005), however after further evaluation, the quality of this trial was low. The conclusion of this SR was that non-specific exercise may or may not help to prevent DRAM or reduce DRAM in the post-natal period.
Since this systematic review in 2014, four additional RCTs have been published looking into this topic. A recent RCT published in the Physical Therapy Journal in April 2018 (Gluppe et al., 2018) looked at the impact of a 16 week training program in addition to daily HEP on the recovery of DRAM. The program involved one supervised class each week and daily PFM as a HEP.
In this particular study, at the 6 week post-partum period, ~55% of each group were diagnosed with a DRAM. The exercises included in this trial were: draw in on all fours (quadruped), draw in while lying prone, forearm kneeling plank, kneeling side plank, oblique sit up and straight sit up. In each of these six position there were three sets of 8-12 contractions of abdominal muscle activations.
Pelvic floor muscles were trained in 5 different positions. In each position there were 8-12 attempts of a maximum contraction for 6-8 second holds. For the last 4-5 contractions in each position 4-5 fast contractions were added on to the end of each long hold. This can be referred to as long holds and quick flicks. The pelvic floor muscle HEP consisted of 3 sets of 8-12 contractions of maximum holds each day. Further detail of the training program protocol can be found in a separate paper by Bø et al (2017).
Do exercises have an effect on DRAM recovery?
The results of this study found that no significant difference in DRAM measurement was found in the test group at 6 months and 12 months post-partum. However, after looking more closely at the study design 2 elements stood out to me.
- The first, is that these participants only included vaginal deliveries. With caesarian section being an exclusion criteria (and this is common for all articles I read) there is little know about the recovery of a DRAM in this population.
- The second, was that they measures DRAM severity in 4 categories (normal, mild, moderate, severe) and then grouped all DRAMS ≥ 2 fingers into the same group. This means that little is known about the effectiveness of an exercise program on DRAM recovery based on the initial severity.
The presence of a DRAM has not been shown with convincing evidence to result in an increased prevalence of pelvic floor muscle weakness in post-partum women. “No significant differences in PFM function were found between women with or without diastasis at 6 weeks, 6 months, and 12 months postpartum.” (Hilde, Tennfjord, Sperstad & Engh., 2017, p. 718) Therefore, if it is not clearly linked to pelvic organ prolapse, urinary incontinence or pelvic floor muscle dysfunction, should we routinely assess for this problem? Personally I believe that women benefit from an assessment and education of what a DRAM is and provision of safe modification of daily movements. For example, how to get out of deep chairs or out of bed while pregnant so that they do not strain their stomach or lower back.
Are sit ups safe?
This is a common question pertaining to the presence of a DRAM during pregnancy and after, because the way in which an abdominal contraction impacts the linea alba is of debate. In 2016, Lee & Hodges conducted a study to explore the impact that contracting the rectus abdominus muscles during a sit up with/without pre-activation of the transversus abdominus muscle (TrA) has on the inter-rectus distance and therefore tensioning through the linea alba.
Although prescription of exercises to narrow the IRD would seem a logical objective of rehabilitation for cosmetic purposes, this may not be the best way to support the abdominal contents. What this study found is that:
- People diagnosed with a DRAM with have a wider IRD at rest than those without (makes sense) and that this IRD will be widest at the level of the umbilicus (Lee & Hodges., 2016, p. 583).
- During an automatic sit-up (without pre-activation of the TrA), the IRD will narrow and the linea alba will slacken. This may result in bulging of the abdominal contents.
- During a sit-up with pre-activation of the TrA, the IRD will not reduce as much but the LA will tighten. This is due to the horizontal orientation of TrA muscle fibers. This pattern was observed in both DRAM and control group participants.
Although pre-activation of the TrA does not reduce the IRD as much, it provides more support to the abdominal contents and this would be visualised by reduced bulging during the sit up movement. So should we be telling women to avoid sit ups post-partum? Perhaps not? I believe that is very important however to educate and teach them about safe technique for performing a sit-up with pre-activation of the TrA to support their abdomen.
Other helpful tools
External supports may mimic muscle function and therefore feel supportive. We can use simple supports like tubigrip to more structured abdominal support bands and recovery shorts. Anecdotally, my patients have always loved the support from SRC recovery shorts but I am sure there are many other similar products available. None of them have been evaluated in high quality research trials but again, there is little to no harm that can occur from trying them to improve comfort levels in the post-partum period.
Take away messages:
- Be careful with promising results that exercise can speed up recovery beyond the natural healing time frames.
- Be realistic with patients that exercises may or may not help. In saying that, exercises have minimal risk and there is no harm in trying.
- If a DRAM is present, educate patients about safe biomechanics and movement patterns to prevent unnecessary stress on the abdomen.
*** side note: I was very fortunate to study under Deenika at the Angliss Hospital and everything I know and practice comes from my training during my Women’s health rotations there. This hospital provides excellent pre/post natal exercise and education classes and have a strong focus on the identification of those at risk for developing PND and offering support and treatment for them.
Benjamin, D. R., Van de Water, A. T. M., & Peiris, C. L. (2014). Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy, 100(1), 1-8.
Bø, K., Hilde, G., Tennfjord, M. K., Sperstad, J. B., & Engh, M. E. (2017). Pelvic floor muscle function, pelvic floor dysfunction and diastasis recti abdominis: prospective cohort study. Neurourology and urodynamics, 36(3), 716-721.
Chiarello, C. M., Falzone, L. A., McCaslin, K. E., Patel, M. N., & Ulery, K. R. (2005). The effects of an exercise program on diastasis recti abdominis in pregnant women. Journal of Women’s Health Physical Therapy, 29(1), 11-16.
Gluppe, S. L., Hilde, G., Tennfjord, M. K., Engh, M. E., & Bø, K. (2018). Effect of a Postpartum Training Program on the Prevalence of Diastasis Recti Abdominis in Postpartum Primiparous Women: A Randomized Controlled Trial. Physical therapy, 98(4), 260-268.
Keeler, J., Albrecht, M., Eberhardt, L., Horn, L., Donnelly, C., & Lowe, D. (2012). Diastasis recti abdominis: a survey of women's health specialists for current physical therapy clinical practice for postpartum women. Journal of women’s health physical therapy, 36(3), 131-142.
Lee, D., & Hodges, P. W. (2016). Behavior of the linea alba during a curl-up task in diastasis rectus abdominis: an observational study. Journal of orthopaedic & sports physical therapy, 46(7), 580-589.
van de Water, A. T., & Benjamin, D. R. (2014). Measure DRAM with a purpose: diagnose or evaluate. Archives of gynecology and obstetrics, 289(1), 3-4.