Running after Baby without the Runs

ITCHING TO GET BACK TO THE GYM AFTER COVID-19 CRAZYNESS IS OVER?

YOU MIGHT BE BURSTING AT THE SEAMS TO GET OUT, BUT IS YOUR POST-BABY BODY READY?

I get it, you just had a baby and you’ve been patiently (or painfully) waiting for the ‘right time’ to get back to your pre-baby fitness routine. For you, this may mean attending yoga class, spin class, HIIT, Cross-Fit training, or hitting the pavement for a run. Whatever your fitness goals, here is some advice when getting back to exercise after having your baby...

First, let's define the post-partum period

In the literature, the post-partum period is considered the first 6 weeks after pregnancy, during which time women have been encouraged to focus on gradually getting back to walking and strength training of the pelvic floor muscles. I wish I could tell you that everything goes back to normal after 6-8 weeks, and that you are given the green light to go back to your exercise routine at that time. I’m afraid it’s not always that simple. Every new mom's experience is unique. Plus, who came up with 6 weeks anyway?

Tissue healing is generally considered to take between 6-8 weeks, this explains why the post-partum period is considered to last this long. The graph below shows the process. I want you to notice in the graph that overlap in the healing phases exists, and notice that after 6-8 weeks the tissues are at 50% of normal tissue strength and still going through a process of maturation and remodeling.

• Nerve injury to the pelvic floor muscles has been demonstrated in %30 of women at 6 weeks post-partum, and of those only %35 recovered by 6 months (South MM, Stinnett SS, Sanders DB, et al. Levator ani denervation and reinnervation 6 months after childbirth. Am J Obstet Gynecol 2009;200:e1-7:519.

• Women postcaesarian section must also be aware of the time required for complete repair of the abdominal fascia. Abdominal fascia is the white connective tissue layer that supports the abdominal wall and it regains only 51%-59% of it original strength by 6 weeks post-surgery, and by 6-7 months has only 73%-93% of its original tensile strength (Ceydeli A, Rucinski J, Wise L. Finding the best abdominal closure: an evidence-based review of the literature Curr Surg 2005;62:220-5).

Next, take a deep calming breath, and know you should not be comparing your recovery to your girlfriend’s! We are not all the same, and the science is not precise when it comes to how long recovery takes – so don’t be so hard on yourself if you are not at HIIT class or running like your friend was at 8 weeks post-partum! (You will later see that she shouldn’t have been in my opinion anyway!).

A common-sense approach is needed that considers:

· the unique elements of every new mom’s past physical activity level

· the new mom's pregnancy and childbirth experience

· their lactation & family demands

· and their long term fitness goals need to be considered to provide a flexible and individualized program to return to sport.

So, what is the advice? How do you make a safe return to the exercises you love?

What does the evidence say?

1. Post-natal women can benefit from individualized assessment and guided pelvic floor rehabilitation for the prevention and management of pelvic organ prolapse, the management of urinary incontinence and for improved sexual function.

2. Return to running is not advisable prior to 3 months postnatal or beyond this if any symptoms of pelvic floor dysfunction are identified prior to, or after attempting, return to running.

What should you do? Here is your guide:

Week 0 to 2:

• Pelvic floor exercises (once catheter removed)

• Lifting restricted to the weight of your baby

• Start with gentle strolls of 5-10 minutes

Week 2 to 4:

• Add basic core exercises (the bridge, bent knee drop out, the clam)

• Add basic stretches including for the chest, buttock muscles, hamstrings, calf and hip flexor muscles

Week 4-6:

• Increase duration and frequency of basic core exercises

• Gentle walk increased gradually up to 20 minutes

Week 6-8:

• Introduce squats, lunges – still no impact!

• Moderate walks increasing in duration and intensity up to 40 minutes

• Progression to power walking

• Increased duration, frequency, intensity of low impact core exercises

• Introduce light hand weights during core and lower limb exercises

• Introduce low impact exercise (stationary bike, elliptical). Stationary bike should only be introduced if comfortable sitting on the bike seat

• Commence scar mobilization (for either C-section or perineal scar)

Weeks 8 to 12:

• Introduce swimming (if lochia/bleeding has stopped and there are no issues with wound healing)

• Spinning – if comfortable sitting on spinning saddle

Return to running/impact exercise @ 12 weeks postnatal and beyond:

• Graded return to running

• When increasing running intensity, increase the duration of the run before the intensity

• Monitor signs and symptoms, modify or cease the program and seek help from a pelvic health physiotherapist as appropriate to assist you in your return to your fitness goals.

What are the signs of pelvic floor and/or abdominal wall dysfunction to watch for?

· Urinary and/or fecal incontinence

· Urinary and/or fecal urgency – when you get a sudden strong need to go and have difficulty holding

· Heaviness/pressure/bulge/dragging in the pelvic region

· Pain with intercourse

· Difficulty having a bowel movement with a feeling of obstruction

· Pendular/hanging abdomen, doming of the abdominal midline, separated abdominal muscles and/or decreased abdominal strength and function

· Low back or pelvic pain

If you experience incontinence on normal daily activities – you are NOT ready to start exercise that involved impact and should seek professional help from your doctor and a pelvic health physio if possible.

If you experience the above symptoms during or after exercise – you are NOT ready for that level of exercise and need to modify or cease that activity for now.

My final advice: see a pelvic health physiotherapist for a full postnatal check from 6 weeks postnatal.

At Pelvic Plus Physio, this would include

· a detailed assessment o your posture, back, pelvic, pelvic floor and abdominal muscles.

· a readiness for impact screen prior to returning to impact exercise.

· regular follow up as required to get you back on track and meet your fitness goals through an individualized, progressive exercise program.

PELVIC PLUS PHYSIO - HELPING YOU FIND FREEDOM IN MOTION!

The Office Analogy

Its a new year, and this means a new project - my first blog! I chose a topic that my patients have given me a lot of good feedback for....

Any one of my patients would confirm that I like to use a lot of analogies when I treat. Education is an integral part of the process toward recovery, and, let's face it, pain is a complicated and not a very well understood process. One of my favorite analogies is that of 'The Office' to explain the interconnections in our body, and the communication that occurs between the different tissues in our body. At the risk of sounding cliche, it is true that everything in our bodies is connected. What interconnects different tissues is often a shared nerve connection, or because they are joined by a sheet of connective tissue, called fascia.

This educational process almost always starts on the initial patient visit. I like to start by showing how nerves that supply a certain section of our body can be the cause of a group of symptoms that are all related, symptoms that patients may never have thought were connected.

The conversation starts off something like this......

THE OFFICE

First of all, let's imagine a small section of a large company. This section or work unit has a group of employees and a manager. Each worker has a job that is unique to them, and it is the manager's job to monitor how each employee is doing their job, how productive the overall unit is, and to keep the boss of the company informed. As in any company, there is communication that happens along the lines of a hierarchy as depicted below: the top is the boss, the middle is the managers, and the bottom is the employees.

Now, let's picture a scenario where one of your co-workers, who we will call Bob, and Bob is having difficulty at home. His wife is cheating on him, a valid reason to be upset in my opinion, but he is talking about his problems non-stop at work. The other employees are sympathetic at first. Then Bob can't stop talking about his problems at work, this is getting distracting to the others, eventually Bob's problems are impacting his ability to do his job, his colleagues are having to take up the slack, and it doesn't take long for his co-workers to start getting annoyed. The work environment is becoming toxic, and the manager starts to notice that the level of productivity in his unit has gone down.

Now it is the manager's duty to inform the boss of what is happening in his work unit, so he/she sends an email all the way up to the top. The boss is now aware there is a problem in that sector of his company, and he is concerned. Now he is keeping a close eye on that unit, and the manager is under pressure to make things right, so he starts getting jumpy. The manager starts putting pressure on the workers to get back on track.

LET'S PUT THIS IN THE CONTEXT OF YOUR BODY

The boss = our brain

The manager = our nerves

The employees = muscles, joints, organs, connective tissues

The work unit = the injured or tender area

The following is an example of how this presents with back pain......

Your back pain = the work unit.

On examination, we see that you have very tender muscles, often called trigger points, the joints may be stiff, and you have abdominal discomfort with symptoms such as bloating, or constipation, and the connective tissues including skin and fascia can look and feel differently.

Your muscles, joints, organs, fascia = the employees

On further examination we will often find one common nerve that supplies the skin that runs fairly closely along all the symptomatic tissues we have identified, and this nerve is hypersensitive, meaning that normal touch at a point along the nerve branch is abnormally painful.

The peripheral nerve = the manager

The communication that happens via the nerves and occurs between different tissues in the body is called 'cross-talk'. Cross-talk is well known to occur between organ-to-organ, called viscero-visceral cross-talk. As an example of viscero-visceral cross-talk is frequent and painful urination in a healthy bladder when there is acute inflammation of the bowel.

Viscero-somatic cross-talk is when the lines of communication between muscles and organs. Examples of this would be back pain associated with constipation, or pelvic floor pain associated with endometriosis (a condition of the uterus).

There are different theories about the underlying mechanisms of cross-talk. Convergence or the coming together of neural pathways seems to be the common factor, but at what level in the nervous system this occurs is still unclear.

Inflammatory process = toxic work environment

In response to threat or injury, a series of chemical reactions occur that create inflammation, like a ‘toxic soup’ in the region that increases a peripheral nerve’s sensitivity that comes along with muscle spasm in our body's response to protect us.

The good news: Cross-talk can go both ways and you can change the input to the nervous system. One way is to help desensitize an irritated peripheral nerve, and this can be done through a manual technique called neuromodulation. This is a gentle, hands-on technique that shows the nerve that things are not that bad; we are essentially giving 'the manager' what it wants, and the manager responds by calming down. When the 'manager' is calm, the workers can also take a sigh of relief. Similarly, the tissues in the surrounding area can now relax. In your body, this can mean where there was a trigger point in a muscle that was found on evaluation is now significantly or fully resolved! This allows the underlying 'tissue issue' to be addressed, by identifying what is the main driver to the symptoms, be this a muscle, joint, organ, or connective tissue issue.

TAKE-AWAYS

• Everything is connected – either through a connective tissue or neurological connection. The driver to your systems can be anywhere along this two-way line of communication, and identifying the driver is key to addressing the issue. For example, when a person has back pain associated with periods of constipation, we should be addressing both conditions because we know that one influences the other.

• The message a nerve transmits can be changed from 'something is wrong' to ‘hey, things are actually not that bad, and maybe even ok’.

• Getting the team back on track - 'Bob' has taken the time he needs to sort out his personal problems, and has gradually resumed his usual duties, and overall productivity is on an upward trend. Similarly, the body can make a gradual return to previous activities and functions, while staying below the nerve's threshold to initiate a protective/inflammatory response.