Diastasis

DRAM: what is it?

DRAM = Diastasis of your rectus abdominis muscle. Sounds like a mouthful! It really just means that there is a widening between your six pack muscles. The linea alba is a piece of connective tissue that runs in a line between the six pack muscles.  Prior to pregnancy this can be quite stiff so you wouldn’t have noticed it . During pregnancy your body gets more stretchy and this part of the body becomes more floppy so that your uterus can expand and grow. That stretchy tissue becomes more noticeable when you sit up as you take it off its stretch when the two muscles contract closer together. This creates the visible doming in your abdomen that is associated with pregnancy.

Most people associate it with pregnancy and postpartum. It can happen to men and women outside of these times. For the purpose of this blog we are going to stick with the pregnancy and postpartum period.

DRAM in pregnancy:

As I mentioned DRAM can be a normal adaptation in pregnancy. As your uterus expands it creates a widening or some people call a ‘gap’. Doming is considered a sign that you have diastasis. This is where there is a bulge in the midline of your abdomen. You might notice this as you start to sit up when your bump gets  bigger.

As physios we were worried that if this was happening you might somehow make this worse. This is based on a theory of managing pressure. We thought that the pressure you created would stretch the linea alba further. We don’t have any solid evidence that this is happening. The truth is that we need more research to understand if this is actually creating problems. At present we will assess and modify exercise if needed. We are moving away from blanket do’s and don’t with certain exercises. It is more about modification as needed. Specific to the individual not in terms of the stage of pregnancy.

DRAM postpartum:

Firstly the look: Let’s be a bit more kind to our bodies in that early postpartum period. It has taken 9 months for your body to adapt to the changes that happen. We need to be realistic about the changes we will see in that early postpartum period. Your uterus will begin to shrink after birth but that stretch to your abdomen will take time to recover from that. In standing, some will notice that there abdomen is still that bit more rounded. As the connective tissue starts to stiffen and the abdominal wall gets stronger, this can improve.  

There is some promising research that early postpartum supporting the abdomen might help with overall strength rather than narrowing the IRD (Keswani et al 2019). We don’t have enough to say whether you need a binder vs some gentle compression wear. Some people will probably not even need it! This is a case of stay tuned until we have more solid evidence to give better recommendations.

How do I know I have it:

You can assess your own gap at home. Unfortunately finger gaps aren’t the most accurate. Ideally we would measure via ultrasound but most physios don’t have access to a ultrasound machine. There is debate about what is ‘normal’ in terms of the width of the gap. It might be different also if you’ve only had one pregnancy versus multiple.

Another way to look at it is the depth. There is a bit of debate on how relevant it is. Like most of what we know on DRAM it’s based on a theory of the importance of being able to develop tension in the abdominal wall.

My favourite way? Looking at how you move! I use a few different exercises to assess how your abdominal wall responds to loading. This may vary depending on if you have particular goals e.g. getting back to Pilates vs getting back to CrossFit.

Am I at risk?

The truth is we need much more research to see who is at risk of developing DRAM. Some will notice that with increased number of pregnancies, they have worsening DRAM. We need much more research on this to actually make this claim. Is it actually the effect of the pregnancies? Is it the difficulty with getting back to exercise or fitting it in with childcare? Have we actually made women fearful of moving their bodies which has lead them to not exercise or do exercise that is too easy for them and won’t lead to the adaptations that we need to change the tissues.

There is a theory that it might be a link with your genetics. We are starting to look at peoples collagen make up to see if this is why some people recover easier than others. We definitely need more research on this. If this happens, the good news is that we can take the blame off ourselves. Rather than thinking we have done something to cause it or make it worse.

Fortunately women are more aware of Diastasis. Unfortunately this has created some fear.  This itself could be a risk factor for not progressing postpartum. Did you avoid core movements in pregnancy. Are you scared to include them postpartum with the fear of causing more harm than good? All of this might link to a weaker core. You’ll be tired of me saying it but again we need more research to test whether core exercise in pregnancy and early postpartum is actually protective.

How can I make it better:

There is no one size fits all. Previously we would have been told to avoid certain exercises. There is emerging evidence that sit ups can actually help to narrow the gap to allow the linea alba to reduce or at least do not worsen it. We only have a few small studies with this so we probably need a bit more research in terms of when to introduce this. There may be individual factors to consider. (El-Mackawy et al 2013, Gluppe et al 2023)

Can I make it worse?

At about 3 years postpartum the prevalence of Diastasis is approximately 12.5% (Lin et al 2024). Some risk factors that have been associated with increased prevalence is BMI and increased number of pregnancies. Note that this does not necessarily mean they cause diastasis but their does appear to be some link.

There is no evidence that a particular exercise does harm. We might need to assess the impact of exercise on how you engage the abdominal wall and the pressure you create as you do it.

What would happen at a physiotherapy appointment for Diastasis?

A Diastasis check is included in your postpartum check. Or if you just want a check on your diastasis and core advice at any time in life, an initial assessment is appropriate to book.

I know you are going to want to know about the gap. So we will measure this. It is the way at the moment that we determine if you have a Diastasis. So we will look at rest and when you actively contract by doing a head lift. We will look at the change that occurs.

We will then move through a variety of core exercises that allows us to get a gauge of what the strength is like with the various movements that your core can complete.

We will get an idea of what your goals are for the appointment. This is really important to make sure that you get the most out of it. Are you just worried you have a diastasis and want to get checked? Do you have back pain and think this might be related? Are you feeling weak in your core and are not sure how to get stronger? Whatever your concern physiotherapy can help improve strength and function.

The information here has been taken from a 2024 research update on DRAM, so hat-tip to WHTA for helping to interpret the research and keep me up to date. I have learned a lot from other physiotherapists so I hope that I have helped inform you too. Good physiotherapists to follow on social media are:

Grainne Donnelly

Christina Previtt

And a person who has gone on a long journey of rehab and surgery of DRAM is

Claire Black

Want to talk more? Feel free to message me or book online.

References:

1. Keshwani N, Mathur S, McLean L. The impact of exercise therapy and abdominal binding in the management of diastasis recti abdominis in the early post-partum period: a pilot randomized controlled trial. Physiotherapy Theory and Practice. 2019 Oct 25:1-6.

2. Lin, S., Lu, J., Wang, L., Zhang, Y., Zhu, C., Qian, S., Xu, H. and Gu, Y., 2024. Prevalence and risk factors of diastasis recti abdominis in the long-term postpartum: a cross-sectional study. Scientific Reports, 14(1), p.25640.

3. El-Mekawy H, Eldeeb A, Lythy M and El-Begawy A 2013, Effect of abdominal exercises vs abdominal supporting belt on post- partum abdominal efficiency and rectus separation, Int J of Medical Health Science, vol 7 (1), pp. 75 - 79

4. Gluppe SB, Ellström Engh M, Bø K. Curl-up exercises improve abdominal muscle strength without worsening inter-recti distance in women with diastasis recti abdominis postpartum: a randomised controlled trial. J Physiother. 2023 Jul;69(3):160-167. doi: 10.1016/j.jphys.2023.05.017.