Advanced Medical – Header – 600×120 – Unicorn
postpartum-physical-therapy

Postpartum Physical Therapy: An Orthopedic Perspective

There is a lot more to the postpartum gap than diastasis recti. There’s a knowledge gap between women’s health and orthopedic physical therapy, there’s a communication gap between obstetricians and physical therapists, and there’s a gap between what’s considered “fully recovered” from pregnancy and the demands today’s athletic woman places on her body.

We need postpartum physical therapy to bridge these gaps.

My story

Not very long ago I was a United States Army physical therapist, working (and loving) long hours, traveling back and forth to the Middle East, jumping out of airplanes as an added job requirement, and running 40-50 miles per week for the pure joy of it. My orthopedic (and sometimes traumatic wound care) patient population during my time in the U.S. Army was a dream population- predominantly Infantry, then Special Forces. The chance to help them was an incredible honor.

With a fast patient care pace, virtually unrestricted by administrative and insurance barriers, I became very confident in my abilities as a physical therapist. Life was good.

But one thing was missing: I couldn’t get pregnant. My husband of 10 years was also military and we had a difficult time being in the same geographical location. Years of trying had passed. I decided to take a leap of faith, leave the Army, and once again move in with my husband. Two weeks later I was pregnant.

My first pregnancy, albeit high risk, was relatively normal. Though I was not able to run during my pregnancy, I continued to exercise daily until the morning I went into labor at 39 weeks. I had a healthy 8 lb, 3 oz baby boy via vaginal delivery with a second-degree vaginal tear.

As a lifelong athlete and former NCAA Division I runner, one of my first questions for the OB the following morning (through my bloodshot and bleary eyes) was, “When can I start running again?”

His answer, right in line with the American Congress of Obstetricians and Gynecologists (ACOG) guidelines, was that since I had sustained some substantial tearing during delivery, I should refrain from any kegel exercises or transversus abdominis contractions for 2 weeks, then gradually begin running again. Simple as that. Right?

Maybe it was my optimism that took over, my desperation to run again, or perhaps the sleep deprivation, but I ditched everything I knew as an orthopedic physical therapist and followed my OB’s advice. Well, to be honest, I was actually a bit more conservative, waiting a whopping 3 weeks and 5 days to start running again.

My body felt unfamiliar, and in the process of my heroic effort to run again, I injured my thoracic spine. I was mostly continent – at least not incontinent enough to seek help from a women’s health physical therapist (plus, the nearest one was at least a 45-minute drive from my home). And, I figured, some incontinence was common after pregnancy. It was pretty much normal. It had to be…

I was at a new low – slower than ever, hurting, leaking, and angry at myself for being an idiot about getting back to exercise after pregnancy. Truthfully, as an orthopedic physical therapist, I thought I knew about recovering and resuming exercise after every kind of musculoskeletal injury. However, my extensive orthopedic knowledge left me naive about postpartum physical therapy. I didn’t know the first thing about exercise after pregnancy.

There is a huge gap between orthopedics and women’s health and I had just fallen in.

The gap between orthopedics and women’s health

Why was this happening? If your physical therapy school was like mine, pelvic health and postpartum physical therapy was covered only briefly – as a footnote to our otherwise meticulously thorough curriculum.

If you want to know more about the pelvic floor, you’ll have to learn about it some other time, but not here, in physical therapy school. If you have a patient with a pelvic floor problem, you’ll have to get that patient out of your office and into a pelvic health PT’s office, pronto. And they shouldn’t come back until they have that problem-we-won’t-speak-of-again sorted out. Then you can get right back to treating their back or their shoulder or their knee, which surely has nothing to do with their pelvic floor.

Frustrated, I took to the literature to fill my own gap in knowledge. And, as so often happens when I learn new information, my mind drifted back to those patients who I struggled to help.

To those patients, I had asked: Any change in bowel or bladder? And who had answered that they sometimes had small leaks, or that when they had to go they really had to go or they might not actually make it? Since I was looking to rule out cauda equina, I noted the information and moved on.

How many of those patients had a subtle pelvic floor dysfunction preventing full recovery from their orthopedic issue?

How many mothers had I seen – even mothers of 4-year-olds, or mothers of teenagers, who had back pain? Of those, how many had I checked for diastasis recti? How many had pain with sex or leaks with exercise? How often did they urinate throughout the day or night? I will never know.

Diastasis recti and pelvic floor dysfunction have certain and clear implications for low back pain and a functionally unstable core can ultimately lead to musculoskeletal injuries at more distal sites, such as the shoulder, knee, elbow, or even the TMJ. To affirm this, one recent study revealed that risk factors for degenerative musculoskeletal injuries among mothers include pre-pregnancy body-mass index (BMI), increased parity, and pregnancy-related weight changes.

Approximately 50% of women still have diastasis recti after giving birth. For many of these women, the problem does not self-resolve after 8 weeks. These women often require intervention to assist in recovery. Among American women, about one in four have some kind of pelvic floor dysfunction. For new mothers, the number is higher: 58% of moms who delivered vaginally have a pelvic floor dysfunction, as do 43% of those who delivered via C-section.

Diastasis recti and incontinence are, quite possibly, the two most obvious pregnancy-related dysfunctions. Due to lack of awareness, the feeling that these issues are just another part of motherhood, and embarrassment surrounding these topics, many of these women do not know how or where to seek help. The lucky ones will find themselves in the capable hands of a women’s health physical therapist.

And what about everyone else? What about the rest of the body – also affected by pregnancy? What about women like me, who have a subtle case of stress incontinence? Whose problems seem mostly orthopedic or performance-based? What if they don’t happen to be a physical therapist and what if they don’t know there’s anything beyond Pinterest to help them recover?

There are over 4 million babies born in the US every year. There are, according to APTA’s June 2016 data, 333 physical therapists specialty board certified in women’s health. That’s quite a gap.

The communication gap between the OB and the physical therapist

Pregnancy affects a woman’s body literally from head to toe. Post-pregnancy dysfunctions in more distal regions, such as the lower extremity, are often considered separately from the postpartum condition. However, there is a strong likelihood that seemingly unrelated musculoskeletal complaints after pregnancy are closely linked to the effects of the pregnancy.

Pregnancy’s effects are whole-body:

  • 20% of women experience a permanent change in shoe size due to changes at the medial longitudinal arch
  • Joint reaction forces at the patellofemoral joint increase by 120% with stand to sit starting in the second trimester
  • The Q-angle increases
  • Strength and activation patterns of the hip musculature are altered during gait
  • Pelvic width increases by 10-15%
  • Pelvic tilt and lordotic curvature are impacted (lordosis is nearly equally increased and decreased across the patient population during pregnancy and surprisingly significantly decreased in the postpartum period)
  • All abdominal muscles are weakened and lengthened
  • The functional link between the transversus abdominis and the pelvic floor is broken
  • The ribcage increases in A-P diameter by up to 6 cm
  • Rotation is restricted in the thoracic spine
  • The diaphragm moves superiorly 4 cm
  • The brain actually shrinks in size (by 2.2%-6%)
  • The pregnant woman gains, on average, 25% of her pre-pregnancy body weight.

So, while recovering from all of those changes, the 6-week checkup with the obstetrician is what everyone is waiting for, with bated breath, to get full clearance to resume exercise. The 6-week checkup after vaginal delivery lasts just a few minutes and includes an internal pelvic exam and a uterus palpation.

The OB checks any incision or sutures, the uterus, ovaries, cervix, and breasts. There is no FMS. No hop test. No manual muscle test, even of the transversus abdominis. No discussion about the relationship between exercise and postpartum fatigue and postpartum depression (exercise is helpful). No discussion about the relationship between breastfeeding and exercise. And yet, permission to exercise without restrictions is so often granted.

I’m certainly not faulting OBs – they have a different focus area for this examination and a different scope of practice. Their minds operate in life and death for mother and baby, incisions, ovaries, and uteruses. Not quad sets, squat progressions, and core strength. Whose job does that sound like?

Often OBs struggle to answer the patient’s questions about resuming exercise and would appreciate help to make it easier. Can you imagine how much we could improve the process of postpartum recovery if we sat down with our local OB for some cross-level knowledge sharing?

The gap between “fully recovered” and today’s female athlete

Fifty years ago, the ACOG guidelines’ advice to resume exercise gradually after pregnancy may have been adequate to achieve “full recovery”. However, 45 years ago something shifted and the implementation of Title IX was a catalyst for that change. Women’s athleticism took off like a shot in 1972 and has been accelerating ever since with high school and collegiate sports, recreational venues such as CrossFit, the Warrior Princess Mud Run, the Diva Race Series, and among mothers in Stroller Strides, Stroller Warriors, and Moms Run This Town.

With the high physical demands of today’s athletic women (over 80% of whom will become mothers in their lifetime), the advice to resume exercise gradually is simply not enough. Instagram and Pinterest are not enough to fill the gaping chasm between the ACOG guidelines and the demands today’s athletic women will place on their bodies.

It’s time to help. Orthopedic physical therapists are just the professionals to step up our knowledge and lend a hand to the development of postpartum physical therapy.

Check out this specialty spotlight on pelvic health physical therapy to get an inside look at the career of a pelvic health physical therapist.

Educate yourself to bridge the gaps

Here are some programs to help you get started with pelvic health and postpartum physical therapy:

  • You can, of course, get the skinny on my website, Everymom Athletics . Soon you’ll be able to earn CEUs for the information you learn on my site through a course offered by ContinuingEducation.com.
  • If you’re just getting started, a short, initial starter course through Allied Health International, taught by Beth Shelley, is a great option.
  • Julie Wiebe’s courses are live and online. She opened my eyes to the link between pelvic health and ortho/sports rehabilitation. She’s an amazing instructor.
  • Evidence in Motion offers a Pelvic Health Certification course that is a blend of online collaboration and courses, as well as on-site instruction for weekend intensives. The course runs for 1-3 years, depending on your availability.
  • Herman Wallace Foundation courses, also available live and online, offer a path to a pelvic rehabilitation certification. Online courses are available through MedBridge, and NGPT has a special discount on MedBridge.
    Students can save even more, by using the code NEWgradstudent (note, no CEUs can be awarded if you claim student status).
  • The APTA Section on Women’s Health (SoWH) (education tab) offers courses live and online, with a pathway to the Certificate of Achievement in Pelvic PT (CAPP-Pelvic), which includes training in internal pelvic examination. The APTA also offers a Certificate of Achievement in Pregnancy/Postpartum (CAPP-OB), which focuses on pregnancy and postpartum care, but does not include training in internal pelvic examination.

References

1. ACOG Committee Opinion No. 650. Obstetrics & Gynecology. 2015;126(6):e135-e142. doi:10.1097/aog.0000000000001214.

2. Bush HM, Pagorek S, Kuperstein J, Guo J, Ballert KN, Crofford LJ. The Association of Chronic Back Pain and Stress Urinary Incontinence: A Cross-Sectional Study. J Womens Health Phys Therap. 2013;37(1):11-18. doi:10.1097/JWH.0b013e31828c1ab3.

3. Bliddal M, Pottegård A, Kirkegaard H. Association of Pre‐Pregnancy Body Mass Index, Pregnancy‐Related Weight Changes, and Parity With the Risk of Developing Degenerative Musculoskeletal …. Arthritis & …. 2016. doi:10.1002/art.39565.

4. Benjamin DR, 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):1-8.

5. Romano M, Cacciatore A, Giordano R. Postpartum period: three distinct but continuous phases. J Prenat Med. 2010;4(2):22-25.

6. Sahakian J, Woodward S. Stress incontinence and pelvic floor excercises in pregnancy. Br J Nurs. 2012;21(18):S10-S15.

7. Segal NA, Boyer ER, Teran-Yengle P, Glass NA, Hillstrom HJ, Yack HJ. Pregnancy Leads to Lasting Changes in Foot Structure. Am J Phys Med Rehab. 2013;92(3):232-240.

8. Takeda K. A Kinesiological Analysis of the Stand-to-Sit during the Third Trimester. J Phys Ther Sci. 2012;24:621-624.

9. Foti T, Davids JR, Bagley A. A Biomechanical Analysis of Gait During Pregnancy. J Bone Joint Surg. 2000;82(5):625-632.

10. Bewyer KJ, Bewyer DC, Messenger D. Pilot data: association between gluteus medius weakness and low back pain during pregnancy. Iowa Orthop J. 2009;29:97-99.

11. Yamaguchi M, Morino S. Comparison of Pelvic Alignment among Never-Pregnant Women,Pregnant Women, and Postpartum Women (Pelvic Alignment and Pregnancy). J Women’s Health Care. 2016;05(01). doi:10.4172/2167-0420.1000294.

12. Gilleard WL. Trunk motion and gait characteristics of pregnant women when walking: report of a longitudinal study with a control group. BMC Pregnancy Childbirth. 2013;13(71):1-8.

13. Opala-Berdzik A, Bacik B, Kurkowska M. Biomechanical changes in pregnant women. Physiotherapy. 2009;17(3):51-55.

14. Hodges PW, Sapsford R. Postural and respiratory functions of the pelvic floor muscles. Neurourol and Urodynam. 2007;26:362-371.

15. Hodges PW, Butler JE, McKenzie DK. Contraction of the human diaphragm during rapid postural adjustments. J Physiol. 1997;505(2):539-548.

16. Smith MD, Coppieters MW, Hodges PW. Postural activity of the pelvic floor muscles is delayed during rapid arm movements in women with stress urinary incontinence. Int Urogynecol J. 2007;18:901-911.

17. Junginger B, Baessler K, Sapsford R. Effect of abdominal and pelvic floor tasks on muscle activity, abdominal pressure and bladder neck. Int Urogynecol J. 2010;21:69-77.

18. Pereira LC, Botelho S, Marques J. Are transversus abdominis/oblique internal and pelvic floor muscles coactivated during pregnancy and postpartum? Neurourol and Urodynam. 2013;32(5):416-419.

19. Madill S. Differences in pelvic floor muscle activation and functional output between women with and without stress urinary incontinence. September 2009.

20. Abduljalil K, Furness P, Johnson TN, Rostami-Hodjegan A, Soltani H. Anatomical, Physiological and Metabolic Changeswith Gestational Age during Normal Pregnancy. Clin Pharmacokin. 2012;51(6):365-396.

21. Gilleard WL, Crosbie J, Smith R. Static trunk posture in sitting and standing during pregnancy and early postpartum. Arch Phys Med Rehab. 2002;83(12):1739-1744. doi:10.1053/apmr.2002.36069.

22. Oatridge A, Holdcroft A, Saeed N. Change in brain size during and after pregnancy: study in healthy women and women with preeclampsia. American Journal of Neuroradiology. 2002;23:19-26.

23. Miller JM, Low LK, Zielinski R, Smith AR, DeLancey JOL, Brandon C. Evaluating maternal recovery from labor and delivery: bone and levator ani injuries. Am J Obstet Gynecol. 2015;213(2):188–e11. doi:10.1016/j.ajog.2015.05.001.

24. Larson-Meyer E. The effects of regular postpartum exercise on mother and child: review article. Int SportMed J. 2003;4(6):1-14.

25. Norman E, Sherburn M, Osborne RH. An Exercise and Education Program Improves Well-Being of New Mothers: A Randomized Controlled Trial. Phys Ther. 2010;90(3):348-355.

26. Meyer DL. Effect of Postpartum Exercise on Mothers and their Offspring: A Review of the Literature. Obes Res. 2002;10(8):841-853.

27. Adegboye AA, Linne YM. Diet or exercise, or both, for weight reduction in women after childbirth. Cochrane DB Syst Rev. 2013;(7):1-67.

28. Dewey KG. Effects of maternal caloric restriction and exercise during lactation. J Nutr. 1998;128(2S):S386.

29. Lovelady CA, BOPP MJ, COLLERAN HL, MACKIE HK, WIDEMAN L. Effect of Exercise Training on Loss of Bone Mineral Density during Lactation. Med Sci Sport Exer. 2009;41(10):1902-1907.

30. United States Census Bureau. Historical Table 2. March 2017. https://www.census.gov/hhes/fertility/data/cps/historical.html.

CovalentCareers 600×120 New Product

About Christine Iverson

Christine Iverson
I received my DPT in 2006 and spent the next 6 years as an Army PT. It was a tremendous honor- I spent 2 of those years with an infantry unit and 3 years as the PT for a Special Forces Group. After (finally) becoming a mom in 2013 I made it my mission to educate moms everywhere about exercise after pregnancy. I live in NC with my husband, son (b. 2013), and daughter (b.2015), and together we love to hike, run, and find excuses to be outside!

Leave a Reply

Send this to a friend