Diastasis of the Rectus Abdominis Muscles + Pregnancy

Diastasis of the Rectus Abdominal Muscles (DRAM) and Pregnancy

“In liu of our pregnancy talk this upcoming February 24, 2016, I decided to write a bit about diastasis recti for our February newsletter. This topic doesn’t seem to come up very often during regular “pregnancy talk” but can have an impact on a mother’s self esteem and physical function, therefore showing the importance on proper education around the subject!”

- Dr. Brianna Busch, DC

Introduction

Many changes occur to a mother’s (or mother to be’s) body during pregnancy, sometimes too fast for the body to effectively adapt. Diastasis of the rectus abdominal muscles (DRAM for short) usually occurs during the later stages of pregnancy, as the uterus expands, leading to a separation of the rectus abdominis (the most superficial of the 4 main abdominal muscles).

Is it just me?

Incidence of DRAM has ranged “…from 66% to 100% during the third trimester of pregnancy… and up to 53% immediately after delivery…” (Benjamin, van de Water & Peiris, 2014). It has been suggested that pregnancy does not cause DRAM, rather, DRAM is a symptom related to intra-abdominal pressure.

What causes DRAM?

Separation of the rectus abdominis from increased width of the linea alba (connective tissue that runs vertically down your midline separating the 2 sides of the rectus abdominis muscle). Maternal hormones, organ displacement, mechanical stress from the growing baby and weak abdominal musculature have been mentioned as causes of DRAM. Pregnancy causes an increase of hormones that affect the elasticity of your connective tissue, which can play a part in DRAM.

When is DRAM most noticeable?

The most common time to notice DRAM is usually just after delivery. Some describe it as a “pooch” or “dome” of the stomach. Sometimes DRAM can last up to a year after pregnancy, or even more, but the widening of the muscles usually dissipates in the initial months post pregnancy. The separation of the abdominal musculature may be noticeable at all times, or potentially only during certain movements such as coughing, sneezing, sitting up from a lying down position, or other movements that tense the abdominal muscles.

Is it dangerous?

Mothers who have never heard of DRAM may be shocked and worried at this new bodily change, as feeling a gap in their abdomen can understandably be a bit disconcerting, however I would not call it “dangerous.” It is important to put a focus on function (as opposed to just physical appearance) when dealing with DRAM.

“The abdominal wall has important functions in posture, trunk and pelvic stability, respiration, trunk movement and support of the abdominal viscera. An increase in the inter-recti distance puts these functions in jeopardy… and can weaken abdominal muscles and influence their functions…This may result in altered trunk mechanics, impaired pelvic stability and changed posture, which leave the lumbar spine and pelvis more vulnerable to injury…” (Benjamin, van de Water & Peiris, 2014)

Who may be at a higher risk for DRAM?

*Age over 35

*High birth weight delivery

*Childcare responsibilities

*Multiple pregnancies

*A pregnancy with twins, triplets, and beyond!

*Potentially weight gain and a higher body mass index

DRAM Test:

“Lie on your back with your knees bent and your feet flat on the floor. Relax your head and shoulders and place your fingers (palm facing you) just above your belly button.

Lift your head and neck very slightly off the floor and press down with your fingertips. If you feel a gap, that’s the diastasis. You will feel the muscles close in around your fingers as you lift your head and neck. Don’t lift your shoulders. Repeat the test in two other place: directly over the belly button, and a couple of inches below.

A diastasis recti gap is measured in finger width’s. You are aiming for a 1-2 finger gap or less, but don’t panic if it’s much bigger at first.

Even more important than the width of the gap though, is the tension (or lack of tension) in the midline – the linea alba. Contracting the muscles should create tension and resistance to your application of gentle pressure with your fingers to the midline. If it doesn’t – you have some re-connecting to do…”- Wendy Powell, 2009

Do this test or have a health provider test this for you before starting any abdominal exercises while you are pregnant. Make sure you test at the belly button, but also approximately 4.5 cm above and below it.

What should I avoid during pregnancy?

After the 1st trimester be careful about the intensity of your abdominal exercises, as this may contribute to the formation of DRAM. Some recommend that if there are more than 2 finger widths of separation not to do abdominal exercises during pregnancy. If you do not have DRAM, kegel exercises and the act of pulling the belly button towards the spine have been recommended as preventive measures.

What should I do during pregnancy?

There is still not enough known about managing or preventing DRAM but it has been suggested that DRAM often coincides with pelvic floor dysfunction, and as such it is important to train pelvic floor muscles prior to, during, and post pregnancy (not only for DRAM prevention and treatment, but to combat what I like to call the “sneeze and pee!” and other unwanted postpartum symptoms. Research has mentioned that “…regular exercise prior to pregnancy and during the antenatal… [pregnancy] …period seems to reduce the risk of developing DRAM and reduce the size of DRAM respectively.” (Benjamin, van de Water & Peiris, 2014)

Abdominal and aerobic exercise, forms of bracing, and posture and spinal education have also been mentioned; however “…it is unclear what types of non-surgical interventions, including exercise, are effective to prevent and/or reduce DRAM.” (Benjamin, van de Water & Peiris, 2014)

More of the research by Benjamin, van de Water & Peiris, 2014

A Systematic review by Benjamin, van de Water & Peiris, 2014 looked at “…interventions to prevent DRAM during the antenatal period and for interventions to treat DRAM during the postnatal period.” Although the overall quality of the studies looked at by the authors was labelled as “fair” results were still intriguing.

In the groups that did exercise during pregnancy a 35% reduction in DRAM was seen. The authors quoted, “…for every three pregnant women treated with exercise, one woman would be prevented from developing DRAM.” (Benjamin, van de Water & Peiris, 2014) Research showed that those who exercised during pregnancy (some studies of which also included education and/or bracing type measures + exercise) had reduced DRAM width during pregnancy or postpartum, while those that did not exercise had either less improvement in their width, or even a wider width after they delivered their baby. Though not found to be significant in the research, exercise may help a mother recover faster from DRAM if they exercise during pregnancy.

Note: 5/8 of the studies looked at in the review were related to strengthening of the transversus abdominis (the deepest of the 4 main core muscles). Though it is the deepest, and DRAM occurs mainly to rectus abdominis (the most shallow), utilizing the transversus abdominis helps draw the 2 sides of rectus abdominis closer together, among other things.

One study showed that utilization of core strength, neuromuscular education and aerobic exercise improved a mother’s quality of life (she still had DRAM after giving birth 8 years prior).

Out of the 8 studies that qualified for review none reported on any adverse events. Overall, however, authors quote, “[d]ue to the low number and quality of included articles, there is insufficient evidence to recommend that exercise may help to prevent or reduce DRAM.” (Benjamin, van de Water & Peiris, 2014) Authors concluded, “[d]ue to the poor quality of the current literature, current evidence suggests that non-specific exercise may or may not help to prevent or reduce DRAM during the ante- and postnatal periods.” (Benjamin, van de Water & Peiris, 2014). It can’t hurt to strengthen your abdominal muscles prior to pregnancy, as the more conditioning you have going into a pregnancy, means you will probably have more conditioning during and post pregnancy.

PLEASE JOIN US FOR OUR PREGNANCY HEALTH TALK ON FEBRUARY 24, 2016 WHERE DR. BUSCH WILL BE TEACHING MORE ON THE BIOMECHANICAL CHANGES THAT OCCUR DURING PREGNANCY, WITH A FOCUS OF GETTING YOU UP AND MOVING DURING HER PORTION OF THE TALK, WITH EXERCISE AND REHABILITATION RELATED TO THESE BIOMECHANICAL CHANGES.

References

Text references:

Websites:

http://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/expert-answers/diastasis-recti/faq-20057825

https://mutusystem.com/diastasis-recti-test-what-works-and-what-to-avoid

https://en.wikipedia.org/wiki/Linea_alba_(abdomen)

Lectures:

Dr. Kelly A. Pennell BSc, DC, MSc

Dr. Ayla Azad DC

Dr. Carol Ann Weis MSc, DC

Articles:

Benjamin D.R., van de Water ATM, Peiris CL. Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy. 2014.100: 1-8