DRAM abdominal muscle separation
Date issued: April 2018
For review: April 2020
Ref: Ref: B-261/Physio/SA/abdominal muscle separation v2
PDF: DRAM abdominal muscle separation [pdf] 1MB
Introduction
This leaflet aims to explain what a divarication of the rectus abdominis muscles (DRAM) postpartum means, and how physiotherapy can assist in your recovery.
What is DRAM?
Pregnancy hormones such as relaxin can cause increased elasticity (stretchiness) of the connective tissue that joins the abdominal muscles together.
DRAM is a condition where the rectus abdominis (‘six-pack’) muscle spread apart at the stomach midline (linea alba) to allow room for the growth of your baby.
Risk factors
- Large baby (8lb plus).
- Multiple births, especially close together.
- Small frame/petite woman (e.g. small pelvis).
- Well defined abdominal muscles.
- Skin tone.
- Position of the baby.
Why is it important to treat?
- To decrease the risk of developing a hernia if the divarication remains.
- To improve control of your spinal and pelvic joints to decrease risk of injury.
- To support the pelvic floor muscle to prevent incontinence or bowel problems.
- To help improve the appearance and body image.
Recovery Timeframes
A small divarication usually resolves in 4-8 weeks after delivery. However, it is important not to overwork the rectus abdominis (‘six-pack’) muscle initially. Instead focus on the deeper ‘core’ type muscles around your trunk. A larger DRAM will take longer and you may need physio input.
Things you can do to help yourself
|
Don’ts |
Do’s |
|---|---|
|
Sit-up exercise
|
Try the basic exercises in this booklet |
|
Holding your baby on one hip |
When lifting your baby, draw in and hold your tummy muscle and squeeze your pelvic floor muscles.Keep the baby close to your chest
|
|
Lifting or carrying heavy objects |
Build up your strength before lifting heavy objects and make sure you bend your knees and use your legs muscles |
|
Intense coughing whilst muscles are unsupported
|
Cross your arms over your tummy and squeeze your pelvic floor muscle when coughing |
|
Sitting straight up when getting out of the bed or the bath |
Roll over onto one side (log roll) |
|
Placing stress on your stomach or over stretching the abdominals whilst you are recovering |
Listen to your body but keep exercising and moving gently |
How to get out of bed correctly
Try rolling on to your side with your knees bent
Push with your elbow and arm whilst your legs drop over the edge of the bed the edge
How to self-check
Most pregnant women will have a small gap in the centre of their tummy of one to two fingers width and this is not a problem. If at eight weeks you feel the gap in your midline is more than two fingers width and you can see a visible bulge you may have a DRAM and need physiotherapy input.
The picture below shows a gap running down the length of their tummy, bulging and doming of the abdomen. If you notice this during the following tests you may have a DRAM.
The following tests are helpful to diagnose and you can perform them yourself.
- Curl up test: Lie on your back with your knees bent. Slowly lift your head and shoulders up off the floor keeping your chin tucked in.
- Leg lift test: Lie on your back with your legs straight. Lift one leg up off the floor about six inches.
Basic exercises
- These exercises should not be painful so if you experience pain please speak to your physiotherapist.
- With the following exercises it is important to achieve control and go for quality over quantity.
- Initially try and do the following exercises three times per day.
Transverse Abdominis (Deep tummy muscle exercises)
These muscles span from side-to-side and form the front part of your deep trunk muscles.
- Lie on your back with your knees bent.
- Gently draw your lower tummy muscles (below your belly button) in towards your spine, maintaining a relaxed normal breathing pattern.
- Hold the contraction 10-30 seconds and repeat up to 10 times.
- You can try this exercise in 4-point kneeling, sitting and then standing to increase the difficulty.
Pelvic Floor Muscle (PFM) exercises
It is important to train this muscle too as it works together with the transverse abdominis muscle. The pelvic floor muscle is like a sling/hammock that runs from inside the front of your pelvis to the coccyx. Like all muscles there are deep and superficial layers and fast and slow twitch muscle fibres that need to be worked differently.
Try these two ways of working the PFM, firstly trying in lying or sitting and then working towards standing.
- Tighten the back passage, close around the vaginal exit and lift the muscles at the front, as if you are stopping the flow of urine or squeezing tight inside your vagina.
- Try to hold for as long as you can and then relax and repeat, aiming for 10 seconds and 10 repetitions.
- Now try squeezing quickly then relax, repeat 10 fast repetitions.
Further exercises
- Make sure you have the correct technique on the previous exercises before moving on to these further exercises.
- With all these exercises it is much more important to achieve good control than to do lots of them.
- Think quality over quantity.
- The exercises should not be painful; therefore if you experience pain you must stop, check your technique and if the pain persists tell your physiotherapist.
- It is very important to build up your strength through your trunk muscles and glute (bottom) muscles before returning to other exercises such as running.
Bent knee drop out, be careful if you have any pubis pain with this exercise, if you do experience pain you must stop.
Breathe in, breathe out, engage abdominals and pelvic floor and allow one knee to gently move away from the midline. As soon as you feel any movement in the pelvis hold that range, breathe in to hold, breathe out and return to neutral, releasing abdominals and pelvic floor.
4-point kneeling
On your hands and knees with wrists positioned below shoulders, knees below hips and back in neutral position. Allow tummy to relax, breathe in to prepare, breathe out and gently lift belly button to spine and squeeze pelvic floor muscles. Breathe in to hold, breath out and slowly release.
You can make this exercise harder by following the pictures and lifting alternate arms, then alternate legs and finally trying opposite arm and leg lifts.
Pelvic tilts/Shoulder Bridge
Breathe in, breathe out and engage deep abdominals and pelvic floor. Gently from the tailbone roll the pelvis off the bed. If you want to make this harder, continue to peel the spine off the bed lifting your hips to the ceiling.
Breathe in, breathe out and gently roll back to the start position. To make this harder you can hold the position at the top.
Leg lift
Breathe in, breathe out and engage deep abdominals and pelvic floor. Lift one leg so the hip and knee rest at 90 degrees. Breathe in, breathe out and gently lower leg to start position.
Keep the pelvis perfectly level and stable throughout the movement. Release the pelvic floor and abdominals before repeating the exercise.
Heel slides
Breathe in, breathe out and engage deep abdominals and pelvic floor. Gently slide one heel away from you, keeping the heel in contact with the floor.
Breathe in and on your next out breath gently draw heel back to the starting position. Keep the pelvis perfectly level and stable throughout the movement.
Final word
The importance of this treatment and exercise programme is to enable you to regain your control with all movements.
Once you can confidently control all the exercises with no doming of the abdominals, you may like to consider gently returning to your chosen activities.
