Diastasis of the Rectus Abdominus Muscles (DRAM)

facts-educate-when-tasmania

WHAT IS IT?

Diastasis of the rectus abdominus muscles (DRAM) is the separation of the ‘six-pack muscles’ (rectus abdominus). It is particularly prevalent during and after pregnancy and can also occur after abdominal surgery. Some men and postmenopausal women can also develop DRAM for reasons outside of pregnancy.[1]

The deep gap running down the centre of a ‘toned’ stomach may or may not indicate a toned, healthy tummy, and instead may be various forms of diastasis. Intra-abdominal pressure applied to this midline muscle – called the linea alba – causes the widening space between the rectus muscles, or the abs, as the linea alba itself thins and widens.[2],[3] This also causes a protrusion of this muscle.  

Hormonal changes by relaxin, progesterone and estrogen, combined with uterine growth may cause the stretching of abdominal muscles. Postural changes and loss of the force vector in these muscles may also contribute to the manifestation of DRAM.[4] Lack of abdominal exercise further increases the likelihood of developing DRAM before and during pregnancy. As the woman gives birth, the act of pushing naturally increases the pressure on the intra-abdominal area.[5]

Its reported prevalence is 35-100% following pregnancy.[6] There is a possibility of 66-100% in the third trimester and persisting in up to 53% of women after delivery.[7]

 
Illustration of the anterior abdominal wall demonstrating the anterior rectus sheath, linea alba, linea semilunares, and the ventral muscles.

Illustration of the anterior abdominal wall demonstrating the anterior rectus sheath, linea alba, linea semilunares, and the ventral muscles.

 

WHY SHOULD I PAY ATTENTION?

DRAM in itself does not cause pain, but its presence, size and duration has been linked to pelvic and lower back pain. It can also lead to the weakening of the pelvic floor, leading to pelvic floor dysfunction. It has been found to weaken abdominal muscles[8] and disturb their functions in lumbo-pelvic stability[9]. This can then cause issues with the pelvic area, back and overall bodily stability in the future if left untreated.

WHEN SHOULD YOU ACT?

There is yet to be a consensus on the method used to measure the gap between abs – calipers, finger widths or ultrasound – and how big the gap should be, but >2cm is generally considered DRAM[10]. Individual personal history and physical examination must also be considered when diagnosing DRAM.[11] Physical examination is usually sufficient, but further confirmation can be made using ultrasound, CT or MRI[12].  

Diastasis is usually diagnostic during post-natal care.

HOW DO I FIX IT?

Consult your physiotherapist or osteopath for more exercise and management programs that specifically target DRAM. In the case of severe functional or cosmetic concerns, consult a plastic or general surgeon for more information.[13]

 

RESOURCES

[2] Nahabedian, MY, Brooks, DC (2017). Rectus abdominis diastasis. Available at: https://www.uptodate.com/contents/rectus-abdominis-diastasis.

[3] Mommers, E., Ponten, J., Al Omar, A. K., de Vries Reilingh, T. S., Bouvy, N. D., & Nienhuijs, S. W. (2017). The general surgeon's perspective of rectus diastasis. A systematic review of treatment options. Surgical endoscopy, 31(12), 4934-4949. doi: 10.1007/s00464-017-5607-9.

[4] Rett, MT, Braga, MD, Bernardes, NO, & Andrade, SC. (2009). Prevalence of diastasis of the rectus abdominis muscles immediately postpartum: comparison between primiparae and multiparae. Brazilian Journal of Physical Therapy, 13(4), 275-280. doi: https://dx.doi.org/10.1590/S1413-35552009005000037.

[5] Gruszczyńska, D, Truszczyńska-Baszak, A (2018). Exercises for pregnant and postpartum women with diastasis recti abdominis – literature review. Advances in Rehabilitation, (3), 27-35.

[6] Rett, et. al 2009.

[7] Benjamin, DR, van der Water, AT, Peiris, CL (2014). Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy. 2014 Mar;100(1):1-8. doi: 10.1016/j.physio.2013.08.005.

[8] Liaw LJ, Hsu MJ, Liao CF, Liu MF, Hsu AT (2011). The relationships between inter-recti distance measured by ultrasound imaging and abdominal muscle function in postpartum women: a 6-month follow-up study. J Orthop Sports Phys Ther 2011 Jun ; 41 (6): 435-43. doi: 10.2519/jospt.2011.3507

[9] Khushboo D, Amrit K, Mahesh M. Correlation between diastasis rectus abdominis and lumbopelvic pain and dysfunction. Indian J Physiother Occup Ther 2014, 8 (1): 210-4. http://www.i-scholar.in/index.php/ijpot/article/view/46939

[10] Benjamin, DR, van der Water AT (2016). Measurement methods to assess diastasis of the rectus abdominis muscle (DRAM): A systematic review of their measurement properties and meta-analytic reliability generalisation. Manual Therapy 2016 Feb; 21:41-53. doi: 10.1016/j.math.2015.09.013.

[11] Nahabedian, MY (2018). Management Strategies for Diastasis Recti. Seminars in Plastic Surgery 2018; 32(03): 147-154. doi: 10.1055/s-0038-1661380

[12] ibid.

[13] Mommers, EHH, Ponten, JEH, Al Omar, AK, de Vries Reilingh, TS, Bouvy, ND, and Nienhuijs, SW (2017). The general surgeon’s perspective of rectus diastasis. A systematic review of treatment options. Surgical Endoscopy 2017; 31(12): 4934–4949. doi: 10.1007/s00464-017-5607-9

Maria Ugrinovski