By Bryn Zolty, PT, DPT
*This article is based on Return to running postnatal-guidelines for medical, health and fitness professionals managing this population. Tom Groom, Grainne Donnelly and Emma Brockwell
Most orthopedic injuries have protocols after surgery for rehabilitation prior to returning to sport. However, there is not a set protocol for women after giving birth to return to their prior level of activity safely. Many women have very limited knowledge of their pelvic floor or ability to strengthen the muscles to support their organs and keep them from leaking urine or bowel movements. Very frequently, women are not even aware of pelvic organ prolapse (POP). POP occurs when the pelvic floor muscles are weakened and the bladder, uterus, or rectum can start to press into or drop out of the vagina.
The research shows that women should wait until 3-6 months postpartum to return to running. For women anxious to return to running, that seems forever! The reason to wait is based on healing time. For vaginal births, the pelvic floor muscles are stretched greatly, and the levator hiatus (pictured below) can take as long as 12 months to become closer to baseline. In addition, the pelvic floor muscles, connective tissue and nerve healing is maximized by 4-6 months (Staer-Jensen et al. 2015). That means that women should seek a pelvic floor physical therapist after vaginal births as soon as they are cleared in order to maximize their ability to heal these tissues.
In both cases, vaginal or cesarean, the recommendation is to have a pelvic health physical therapist evaluate the pelvic floor and abdomen prior to returning to high impact exercise. High impact exercise in female athletes was found to have a 4.59 fold increase in risk of developing pelvic floor dysfunction compared to low impact (De Mattos Lorenco et al 2018). Running has been associated with a rise in intra-abdominal pressure and increased ground reaction force between 1.6 and 2.5 times bodyweight when running at a moderate pace (Gottschall and Kram 2005). These statistics are not to show that women should avoid high impact exercise, but should make sure women are physically prepared to return to sport.
The article concluded that return to running should occur 3-6 months postpartum in the absence of the following symptoms:
Other symptoms in addition to those listed above, that if experienced a woman should seek out a physical therapist include:
In addition, there are recommendations on the amount of strength and endurance in the pelvic floor and fascial support that should be present for running to prevent pelvic floor dysfunction. These measurements can be evaluated by a pelvic floor physical therapist.
The full article can be found for free here.
Goom, Tom & Donnelly, Grainne & Brockwell, Emma. (2019). Returning to running postnatal – guideline for medical, health and fitness professionals managing this population.
By Michelle Dela Rosa, PT
Hesselman S, Högberg U, Råssjö E‐B, Schytt E, Löfgren M, Jonsson M. Abdominal adhesions in gynaecologic surgery after caesarean section: a longitudinal population‐based register study. BJOG 2018; 125:597–603.
Written by Bryn Zolty, PT
If I just had a baby can I return to running? I’m leaking - can I do exercise that involves jumping? My doctor says I have a prolapse - can I lift weights at the gym? As pelvic physical therapists, we hear these questions every day. It is very common to wonder if after having a baby, a surgery, or if you have pain in the pelvis, if it is okay to engage in activities that can push pressure down into the pelvis.
While more research is needed to better answer these questions, there are a couple of studies available that have measured the pressure in the vagina with functional tasks, yoga poses, and other exercises in attempts to answer these questions. Here is a little of what they found with a group of women ranging in age from 20-51:
These numbers can surprise people. How can a crunch be so bad if the average pressure is 23.8 and a normal daily occurrence like coughing is 98? As a therapist, my focus is drawn to the large ranges within each activity. What is the woman doing differently to crunch at a pressure of 8 compared to the woman at a 75?
As therapists we evaluate how you move and conduct each of these activities. As pelvic physical therapists we look closer at your movement, alignment, breathing, coordination, and muscle tone in relation to the pelvis. All these factors play a role in the pressure your body places on the pelvic floor. This pressure is known as the intra-abdominal pressure. This is how one woman can have very low pressure on her pelvic floor while another woman has high pressure during the same activity. The key is how they complete the task.
Back to the question, can I do a crunch? Can I return to strenuous exercise? Our goal is to teach you how to do movements or activities properly while minimizing the negative impact on the pelvic muscles. A pelvic physical therapist’s job is to evaluate the movement or activity that gives you pain or makes you leak and improve it.
How do we do this? Let’s take a squat for example. If a patient comes in because she leaks urine while squatting, we would explore all the possibilities.
After having babies, surgeries, or injuries our bodies change. Some of these changes can lead to incontinence or pain. A pelvic physical therapist is a great clinician to discuss these changes along with your goals for fitness or everyday activities. Whether it’s cueing on alignment or movement strategies, breathing, releasing or strengthening, it is our goal to help you reach yours.
From the Glottis to the Pelvic Floor: Making Clinical Connections. Julie Wiebe, PT, MPT,BSc, and Susan Clinton, PT,DScPT,OCS,WCS,FAAOMPT.
Cobb WS, Burns JM,Kercher KW, Matthews BD, Norton HJ,Heniford BT. Normal Intra-abdominal Pressure in Healthy Adults. 2005; Journal of Surgical Research 2005; (129):231-235.
O’Dell KK, Morse AN,Crawford SL, Howard A. Vaginal Pressure during lifting, floor exercises, jogging, and use of hydraulic exercise machines. International Urogyneocology Journal, 2007;18: 1481-1489.
Written by former staff physical therapist, Aisling Linehan, PT
Infertility is on the rise and as pelvic floor physical therapists we want to do our part to help our patients get pregnant. According to this study, 15% of couples will struggle with infertility. Reasons for infertility can be broken down to ovulation disorders (27%), male factors (25%), tubal disorders (22%), unexplained factors (17%), endometriosis (7%); and “other factors” (4%). Pelvic floor physical therapists specialize in manual & movement therapy. It makes sense that the type of infertility that we can help with is “mechanical”.
Release of fascial and ligamentous restrictions can decrease pressure on blood vessels, thereby optimizing the vascular phase and improving the efficacy of the lymphatic system. Better blood flow basically means better “detox” and waste management by the body. The body, in turn, is better able to perform important processes such as reproduction. It is also important to note that reproduction is not essential in keeping a person alive; thus, if the body feels under threat in any way reproduction is not a priority. Check out the study to see how pelvic floor PT can help you get pregnant.
Not sure if you want to try pelvic floor PT yet? Stop by on Thursday night to try our gentle relax and renew yoga class. Getting your body in a more parasympathetic state can help you mentally and physically prepare for bringing new life into this world.
Written by Michelle Dela Rosa, PT
A 2015 systematic literature review showed that yoga was not only effective in decreasing depression and anxiety in perinatal women, but also improved: pain, anger, stress, gestational age at birth, birth weight, maternal-infant attachment, optimism, and well-being. If you are pregnant or just had a baby and are unsure how to progress with exercise, our therapists who are also certified yoga instructors can help you make the leap into fitness.
Sheffield KM, Woods-Giscombé CL. Efficacy, Feasibility, and Acceptability of Perinatal Yoga on Women's Mental Health and Well-Being: A Systematic Literature Review. Journal of Holistic Nursing 2015:34(1)64-79.
Written by Michelle Dela Rosa, PT
In 548 Dutch working women, almost half reported pelvic girdle pain at 12 weeks postpartum. Pregnancy-related predictors for pain included: history of low back pain, elevated somatization, 8 or more hours of sleep/rest per day, and uncomfortable postures at work. Pregnancy and postpartum-related predictors for pain included: disability and pelvic girdle pain at 6 weeks, elevated somatization, higher birth weight of the baby, uncomfortable postures at work, and number of days on bed rest. The authors discussed that a woman with PPGP should be cared for to prevent more serious postpartum disability (Stomp-van den Berg et al, 2012).
Another study looked at the type of delivery and pelvic girdle pain in 10,400 women with singleton pregnancies. A planned cesarean section was associated with 2-3x the rate of pelvic girdle pain at 6 months postpartum. The authors recommended vaginal birth for women with PPGP, unless there is a serious medical reason (Bjelland et al, 2013). In a study done by the same lead author, postpartum women had high recovery rates from pelvic girdle pain, but those who reported significant emotional stress during pregnancy had an independent correlation with continued pelvic girdle pain (Bjelland et al, 2013).
A final study looked at the relationship between exercise and PPGP. Pregnant women who exercised more than 2x per week reported a lower rate of pelvic girdle pain, and those who exercised 1-2x per week reported less low back pain and depression. The authors concluded that exercise during pregnancy could lower the risk for pelvic and low back pain (Gjestland et al, 2013).
Bjelland EK1, Stuge B, Engdahl B, Eberhard-Gran M. The effect of emotional distress on persistent pelvic girdle pain after delivery: a longitudinal population study. BJOG. 2013 Jan;120(1):32-40.
Bjelland EK1, Stuge B, Vangen S, Stray-Pedersen B, Eberhard-Gran M. Mode of delivery and persistence of pelvic girdle syndrome 6 months postpartum. Am J Obstet Gynecol. 2013 Apr;208(4):298.e1-7.
Gjestland K1, Bø K, Owe KM, Eberhard-Gran M. Do pregnant women follow exercise guidelines? Prevalence data among 3482 women, and prediction of low-back pain, pelvic girdle pain and depression. Br J Sports Med. 2013 May;47(8):515-20.
Stomp-van den Berg SG1, Hendriksen IJ, Bruinvels DJ, Twisk JW, van Mechelen W, van Poppel MN. Predictors for postpartum pelvic girdle pain in working women: the Mom@Work cohort study. Pain. 2012 Dec;153(12):2370-9.
Written by Michelle Dela Rosa, PT.
1000 healthy, young women (age 16-30 in Melbourne, Australia were surveyed about continence. 6.2% of women reported urinary leakage with stress, 4.5% with urge, and 1.9% with both stress and urge. Women were also more prone to UI if they reported a history of bedwetting beyond 5 years of age.
Past Medical History: 2 vaginal births, insomnia since last birth 3 years ago.
Physical Therapy Treatment: Manual therapy to pelvic floor and abdomen; review of proper bowel evacuation and stool formation; breathing mechanics; postural education and exercise; LE stretching; core strengthening exercises; HEP.
Results: Complete bowel evacuation 1-2x per day without straining or altered mechanics after 8 visits.