Physiotherapy - Diastasis of the Rectus Abdominas Muscle (DRAM)

Separation of the abdominal muscles (Diastasis of the Rectus Abdominis Muscles also known as DRAM) can happen during pregnancy, most often during the second or third trimester.

Often this will get better naturally within a few weeks, after the birth of your baby. If the separation does not improve you will need an assessment from a specialist Physiotherapist.

This leaflet will give you some basic information and advice on how to manage your condition.

During pregnancy, the tummy (abdominal) muscles stretch to make room for the growing baby. This causes them to lengthen and weaken.

The top layer of the abdominal muscles is known as the rectus abdominis. These muscles are connected in the middle by a seam- like structure known as the Linea Alba, which softens due to the hormonal changes during pregnancy. When excessive stretching occurs, the left and right rectus abdominis muscles may separate above and below the tummy button (umbilicus) as shown in the diagram below.

What causes DRAM?

• Most commonly pregnancy with an increased risk with twins or large bump size
• Many years of heavy lifting with poor technique
• Chronic straining (constipation)
• Obesity
• Hypermobility
• Multiple pregnancies

How will I know if I have a DRAM?

You may notice a bulge or doming of your abdominal muscles when you sit up from lying down or when trying to get out of the bath.

How to check for a DRAM

In lying with your knees bent and feet flat, tuck your chin in towards your chest and gently lift your head and shoulders up from the floor.

If you have DRAM, you will see doming down the middle of your tummy (see picture below).

Antenatal advice

• Avoid straining on the toilet
• Try to avoid heavy lifting, if this is unavoidable hold whatever the item is as close to you as possible.
• When lifting engage your abdominal muscles and pelvic floor
• When getting out of bed, roll on to your side first before pushing up, avoiding the sit up motion as illustrated below and reverse for getting in to bed

Post natal advice

• Exercise your pelvic floor muscles
• Start exercises to strengthen your deep core muscles
• Tubigrip or stomach supports can be useful to help activate your tummy muscles and support your posture initially but should be avoided after 6 weeks
• When getting out of bed, roll on to your side first before pushing up, avoiding the sit up motion
• Avoid straining on the toilet
• Avoid holding baby on one hip
• Avoid aggressive abdominal exercises that would put strain on the midline of the abdominals such as sit ups or crunches or rising from a lying position by pulling up and twisting at the same time

Deep core muscles (transversus abdominis)

These muscles form a corset around your tummy and help support your back and pelvis and when used correctly will help to prevent postural back pain and help manage your DRAM.

Do this exercise in the most comfortable position for you; for example, lying on your back or side with your knees bent, or sitting with your back well supported.

Gently pull in your lower tummy below your umbilicus ensuring that your upper tummy and chest remain relaxed.

Hold for as long as you can, aim to gradually increase the length of hold up to 10 seconds and repeat 10 times.

Do not pull in your tummy too hard - you should be able to breathe normally when performing this exercise.

This muscle works with the pelvic floor and it is therefore important to exercise these muscles together.

The pelvic floor

These muscles form a sling across the bottom of the pelvis (see diagram page 6). They support the pelvic organs (womb, bladder and bowel) and work with the deep abdominal muscles which is important in the management of DRAM.

Pelvic floor exercises

Sitting in a comfortable position, imagine you are trying to stop the flow of urine and stop passing wind at the same time. It should feel like a lift and squeeze in your vagina and back passage. This is known as a pelvic floor ‘contraction’.

Now you can use this exercise to build up the strength and endurance of the pelvic floor muscles so they can work harder and longer. It is important to exercise the muscles both slowly and quickly.

A good strong pelvic floor should be able to contract for a 10 second hold 10 times, followed by 10 fast contraction 3 times a day.

If your pelvic floor is weak, you may only manage a 2 or 3 second hold, do not worry this will improve with practice but may take a few months.

The Squeezy NHS APP is available to help you consistently exercise your pelvic floor. It costs £2.99 and is available for Androids and iPhone.

It is important not to:

• Clench your buttocks
• Hold your breath
• Bear down or push through your bottom

Warning - Do not try stopping your urine midstream as this may interfere with the normal function of the bladder.

Abdominal Prep

Breathe in, breathe out, and engage your abdominal muscles and pelvic floor. Gently lift your head and look through your knees; stretch fingertips towards heels. Be careful not to strain around the neck or bear down on the pelvic floor, then lower.

Repeat the image below 10 times

Hip twist

Breathe in, breathe out, engage your abdominal muscles and pelvic floor, and allow one knee to gently move away from your midline. As soon as you feel any movement in the pelvis, hold that position as you breathe in, breathe out and return to neutral, releasing your abdominals and pelvic floor.

Repeat the image below 10 times

Heel slide

Breathe in, breathe out, and engage your abdominal muscles and pelvic floor. Gently slide one heel away from you, keeping the heel in contact with the floor and return to the start position.  Keep your pelvis perfectly level and stable throughout the movement.

Repeat the image below 10 times

Scissors

Breathe in, breathe out, and engage your abdominal muscles and pelvic floor. Lift one leg so the hip and knee rest at 90 degrees, gently lower your leg to the start position. Keep your pelvis perfectly level and stable throughout the movement.

Repeat the image below 10 times

Shoulder Bridge (not until 6 weeks post-natal)

Breathe in, breathe out, and engage your abdominal muscles and pelvic floor. Gently roll your lower back into the floor, scoop your tailbone upwards and continue to peel your spine up, bone by bone until you are resting on your shoulder blades and then slowly lower.

Repeat the image below 10 times

Caution

• Avoid holding your breath with any of the exercises
• If you notice any bulging of your abdominal muscles while doing any of the above exercises, stop the exercise and return to deep core exercise (Transversus Abdominis). Contact your specialist physiotherapist for further advice

What will the physiotherapist do?

If you require physiotherapy an assessment will be carried out to find out the extent of the DRAM.

The physiotherapist will assess the tummy muscles in lying while they are relaxed and contracted and assess the gap along the whole length of the tummy. Following the assessment, you will be a given a tailored exercise program which will be reviewed as required.

Useful contacts

Salford Royal Hospital
Tel: 0161 206 1063
Email: pelvic.health@nca.nhs.uk

Fairfield General Hospital
Tel: 0161 778 3882
Email: FGHphysio@nca.nhs.uk

Rochdale Infirmary
Tel: 01706 517 316
Email: physiori.op@nca.nhs.uk

Royal Oldham Hospital
Tel: 0161 627 8517
Email: physio.therapy@nca.nhs.uk

Useful Websites

POGP - https://pogp.csp.org.uk/information-patients

APPI - https://appihealthgroup.com

Michelle Kenway - 

https://www.youtube.com/watch?v=gmqjLD_hJ-c rg.uk/ information-patients