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DRAM Part 2: Exercises to do post-partum

11 April, 2019

Who are those two cutie-pies with me? (No Dior for me, that’s my mother’s top I’ve borrowed!)

I feel so sorry for Meghan at this stage of her pregnancy. I remember that in the last few weeks of my pregnancies, I was definitely not up for one or two photos of me and my (massive) pregnant belly, let alone one or two thousand! And I certainly never mastered walking in pencil thin stilettos in ordinary life, let alone pregnant life.

Nice sensible flats for me (action shot of Snoopy, the dog who was never still)

I would love to be a fly on the wall every morning as she gets out of bed and faces yet another round of engagements – there must be the occasional day when she’d love to say “Not today Harry- I just can’t do it!” But the time is fast approaching when there is going to be a fanfare and pronouncement of another Royal Baby arriving and another round of aghast amazement or outright belittling condemnation of however Meghan presents herself on the steps of the place where she’s just had the baby. It’s usually a lose-lose situation if you’re a young female Royal. I just for once wish everyone would give these women a break and just say Congratulations! instead of the usual negative palava.

When you look at the photos of us (the royal ‘we’) pregnant, you can see there is quite a strain placed on the abdominal muscles as the weeks close towards the end of pregnancy. We know the abdominal muscles are important for trunk movement, pelvic stabilization, and restraint of the abdominal contents (1)  – what an amazing adaptation to be able to stretch to such an extent and yet for many women, return to mostly what they were like originally. But sadly for some women there is significant separation and also micro-tearing of the fascia and skin which also contributes to a tummy which causes grief for the woman. The research is certainly pointing to the fact that ante-partum activity level may have a protective effect on DRAM and we know that exercise improves post-partum symptoms of abdominal separation. (1) Interestingly, research from Mota also highlights that women with DRAM were not more likely to report lumbopelvic pain than women without DRAM. (1)

The reason for this blog and pregnancy talk is that I promised a second follow-up blog to the DRAM blog that Martine wrote a few months ago and so I asked my Megan (Megan Bergman who works with me at Sue Croft Physiotherapy) to write Part 2.

Megan’s blog follows…

In a previous blog Martine explained diastasis or separation of the rectus abdominus muscles and some lifestyle tips for helping to manage this.  In clinic we have many women asking ‘what are the exercises I can do to flatten my tummy and can I get rid of the separation’?

When looking at these 2 questions it is important to understand a couple of concepts.

Firstly, separation is a normal adaptation of the abdomen to allow for the growth of a baby.  Every woman has a different pregnancy experience and different background which means that everyone’s restoration of function is different, and post pregnancy ‘normal’ may look quite different from pre-pregnancy. So we individualise treatment based on what we find at assessment. 

Secondly, you can achieve good strength and control through your abdominal canister even though the muscles may remain (slightly to moderately) separated. Many women have residual separation that you cannot see. What we are interested in is function

What do we mean by this?

If you imagine the two rectus abdominus muscles with a stretched piece of stiff tissue between them (the linea alba) that allows the muscles to sit out to the sides away from the midline of the tummy creating the separation.  If you contract the rectus muscles and draw them closer together that stretched piece of tissue will bunch up and become loose.  So, although your muscles are closer together, there is now loose tissue in between. This can be a point of weakness in the abdominal canister, and the rectus abdominal muscles do not contract as well as they should.  Additionally what many women will demonstrate is a doming effect in the abdomen (the two rectus muscles popping up in the middle). 

There is a deeper muscle called transversus abdominus (TA) which runs like a corset and pulls perpendicularly to the other abdominal muscles. The research is somewhat conflicting about the importance of TA with some studies reporting that a pre-contraction of the transversus muscle can generate tension in the linea alba which visually prevents the doming effect and functionally prevents looseness in the tissue (2). And yet other studies show that the inter-rectus distance (IRD) widens compared to rest along the length of the linea alba with the pre contraction of TA. Abdominal crunch has been considered a ‘risk exercise’ for development of diastasis recti but other studies have shown that the IRD narrows with a small abdominal crunch.

So what do we do?  We individualise the treatment. When we prescribe the early exercises we assess what does an exercise do to that patients tummy and say “Yay” or “Nay” to that exercise and then progress as the strength/IRD narrows/ function improves. This therefore means some may do a small crunch with a good positive effect and others may not. Some may activate TA and others won’t. 

How do we activate the transversus?

Imagine you are putting on a pair of jeans and you’ve forgotten to out your undies on.  As you do the zip up you are gently drawing in around the pubic hairline (to keep the hair away from the zip). In doing this contraction you notice a very gentle tightening in your lower abdomen but you can still breathe and your upper tummy is still relaxed.

In all exercises ensure you just keep breathing, (don’t breath hold) draw in the transversus and pelvic floor and then perform the movement (this allows the diaphragm to move up and the pelvic floor and abdominals to contract well). If you can do this and continue to breathe while exercising you can perform a wide variety of exercises.

The following exercises are gentle and slow in the early days but need to increase in speed, intensity and difficulty as you get stronger. These are for the early days.

Leg slides

Progress from TA activation to adding in alternate leg slides. 

Gentle head lifts

Lie on your back, gently tighten your low tummy, vagina, anus and gently in at belly button and bend one knee up at a time, so that both knees are bent. Then lift your head up and hold for 3 seconds and lower your head back down.

Pelvic rocking

Lie on your back, gently tighten your low tummy, vagina, anus and gently in at the belly button and bend one knee up at a time, so that both knees are bent. Slowly flatten your back into the bed by rocking your pelvis back, allowing your tummy to gently draw in. Repeat 3 to 5 times. Breathe and relax after this set.

Modified straight leg raise

Lie on your back, knees bent up, gently tighten your low tummy, vagina, anus and gently in at the belly button. Keeping your pelvis steady, draw your right leg to the chest and then straighten your leg out, holding the straight leg about 8cms (3 inches) off the bed/floor for a count of 3 and then go back to starting position. Repeat 5 to 10 times. As this becomes easier, do this exercise as described above but increase the number of straight leg raises to firstly 3 and then 5 if no discomfort. Remember always concentrate on the gentle tightening of your tummy and pelvic floor. Breathe and relax your muscles after this set. Look in a mirror for doming if you have that issue. Control it gently while continuing to breathe. 

Bent knee fall out

Lie on your back, with both knees bent up; gently tighten your low tummy, vagina, anus and gently in at the belly button; slowly lower your bent right leg to the side and slowly bring back upright again. Aim to stop your pelvis from rocking from side to side and check for doming as before. Repeat with the other leg. Do for 5 to 10 times. Breathe and relax after this set.

Modified clam

Lie on your side, with your knees bent and feet together, gently tighten your low tummy, vagina, anus and gently in at the belly button. Keeping your feet together, lift your top leg 8 cm (3 inches) off the other leg. Do not roll your pelvis backwards as you lift. Hold for 3 seconds and slowly lower down. Repeat with the other leg. Do 5 to 10 times. Your focus is on the abdominal muscles and pelvic floor in the beginning. Breathe and relax your muscles after this set.

 

Pelvic rocking in 4 point kneeling

Make sure you have enough tone in your abdominal wall before you go onto this gravity-dependent exercise. This is also a great postural stretch and is known as a ‘cat curl’. On all fours, hands under shoulders, knees under hips, maintain your lumbar curve, gently contract your low tummy, pelvic floor tension at the umbilicus and then stretch your back up, while dropping your head down – hold for 5 seconds then return back to the start position. Breathe and relax after this set. Repeat 5 to 10 times. 

Wall squat

Standing with your back against a wall, your feet are approximately 30 cm (12 inches) away from the wall. Most importantly, your heels should be under your knees so your lower legs are vertical. Gently tighten your low tummy, vagina, anus and gently in at the belly button and slowly slide your back down the wall 8cm (3 inches) and hold the position for about 5 to 10 seconds and then slide back up again. As the weeks go by you can increase the length of hold to strengthen your central muscles and your thighs. Do not go down to 90°. Do not do this exercise if you have knee pain. You can use a Swiss ball behind your back as well. Breathe and relax after this set.

Mini squat 

Stand tall with feet straight ahead and hands on hips. Gently tighten your low tummy, vagina, anus and gently in at the belly button and slowly bend to 45 to 60 degrees at hips / knee. Incline your trunk slightly forward, maintaining a gentle curve in the lower back. Squeeze gluts to come up – pushing through heels. Bring your trunk to upright and relax gluts and pelvic floor. Repeat 5 to 10 times. Once you are feeling stronger with this you can add some rotation and also weights.

There are many more exercises and progressions of these early ones to be performed when rehabbing your DRAM. If you aren’t sure and would like help finding your transversus muscle we have ultrasound at our clinic which allows you to see the muscle working and ensure you are doing the correct contraction. We also conduct one-on-one sessions in our small gym down stairs and then we have small group, Pelvic Health Physio-led strengthening sessions where your individual problems are assessed and then a programme prescribed. 

(1) Mota P, Pascoala A, Bo K (2015) Diastasis Recti Abdominis in Pregnancy and Post Partum period. Risk factors, functional implications and resolution. Current Women’s Health Reviews 11,59-67. Sourced 17/02/19 https://www.researchgate.net/publication/282271189_Diastasis_Recti_Abdominis_in

(2) Lee D, Hodges PW (2016) Behaviour of the Linea Alba During a Curl-up task in Diastasis Rectus Abdominus: An Observational Study. JOSPT 46(7): 580-589

Thanks Megan for this blog. These early exercises are designed to establish a response by the muscles to different pressures and movements through motor training. Initially you have to think carefully about switching the muscles on and give yourself biofeedback via a mirror, but eventually the muscles will respond in a more coordinated, background way.

You can see there is still some research to be done to clarify ‘which exercises actually do what’ to DRAM. Mota, in her comprehensive article, has summarised the situation: “There is an urgent need for more basic and experimental studies to understand the mechanisms of different abdominal exercises. In addition, high quality randomized controlled trials on the effect of different abdominal exercises to prevent and treat diastasis recti abdominis are warranted”. (1)

In the third part we will progress the exercises to harder, stronger, more functional exercises.

Ring the rooms on (07) 38489601 or 0407659357 if you would like an appointment with any of the physios who make coming to work such a pleasure for me. (Megan Bergman, Martine Lange, Jane Cannan, and Alexandra Schafer). Or if you have issues in another suburb or city, check out your local Pelvic Health or Women’s Health physiotherapist for help. You can search the Australian Physiotherapy Association’s website Find-a-Physio for names.

Please note all the illustrations for the exercises come from my books Pelvic Floor Essentials (2018) and Pelvic Floor Recovery: Physiotherapy for Gynaecological and Colorectal Repair Surgery. (2018)

And here are those two cuties all grown up and a new generation of cuties produced.

 

 

 

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