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Q&A With A Pelvic Physical Therapist

When I was a new mom, a pelvic physical therapist visited my Mommy-and-Me class one day to educate us on postpartum health and wellness. I was eager to learn more about this topic because I didn’t feel very knowledgeable about it after my very brief 6-week postpartum exam with a nurse practitioner who focused mainly on discussing breastfeeding and contraception.

As a new mom, I dismissed many postpartum-related discomforts, aches, and pains thinking they must be a “normal” part of the healing process, especially when I heard other women share similar stories.  

That day in Mommy-and-Me I learned that COMMON does not equal NORMAL.

Just because many of my friends had experienced the same pain I was experiencing did not mean that this was normal. I would have NEVER learned this or some other critical things regarding women’s health had it not been for this visit from the pelvic physical therapist.

I was also surprised to learn that standard postpartum practice in parts of Europe include a visit with a pelvic physical therapist in ADDITION to the 6-8 week postpartum check with an OBGYN.

This extra measure not only provides a more comprehensive picture of a woman’s postpartum health but can also be a critical step in addressing COMMON but ABNORMAL postpartum pain or other women’s health dysfunctions. 

My goal in sharing the following interview with my pelvic physical therapist is to spread knowledge about an underrepresented topic in pregnancy and motherhood and empower women to advocate for their health and wellness.  If even one person is better informed after reading this post, it will have served its purpose.

Below are my questions and answers with Katie Hunter, a licensed PT, DPT. Katie was my physical therapist throughout and after my second pregnancy.

  1. What are some physical symptoms during pregnancy or after that make women good candidates for pelvic physical therapy/rehabilitation? Who would you recommend seek pelvic rehabilitation?

The most common pregnancy-related conditions treated by physical therapists are:

  1. Lower back and sacroiliac joint (SIJ) pain
  2. Neck and shoulder pain
  3. Muscle weakness limiting activity
  4. Pre-existing conditions where women can no longer take medications

The most common pelvic floor disorders seen after pregnancy are (in no particular order):

  1. pelvic organ prolapse – dropping of the pelvic organs
  2. stress urinary incontinence  – urine leakage with exertion (coughing, sneezing, laughing, exercise, etc.)
  3. fecal incontinence – stool leakage

There is mixed research on the prevalence of these conditions and whether or not the body will naturally heal as these symptoms spontaneously resolve.  However, the rate of spontaneous resolution decreases after 3-months post-partum.  What that means, is that if you are suffering from any of these conditions for over 3-months after delivery of your baby, you should seek assistance from a professional.

I personally believe that all women should have at least one appointment with a physical therapist after their 6-week follow-up with their ob/gyn.  Many women talk with friends and family members for advice and are told what they are feeling is “normal”.  Which may be true at the time but, if not addressed, can often persist for years and these women still think their symptoms are “normal”.

Other postpartum conditions are diastasis rectus abdominis, lower back pain, and pelvic pain conditions. 

Along the same lines as above, if you are experiencing pain or discomfort for longer than 3-months postpartum, then you should seek help from your doctor or a physical therapist.  This includes pain with intercourse/tampon use, pain with sitting or standing, and pain with movement and exercise.

  1. What advice would you give to women trying to navigate differing opinions from healthcare providers and fitness professionals / personal trainers when it comes to diagnosis and treatment?

Technology and readily accessible information have served us well but, have also made everyone feel like an expert.  The best advice I can give is: if it doesn’t feel right, it probably is not right for you.  

Healthcare providers rely on research and proven evidence to guide their expert opinion.  This is good but, can also be limiting.  We have to remember that every person is different and we need to treat them as individuals.  A true expert combines evidence with clinical judgment and experience.  As a pelvic health PT, I use my experience as a guide for what I consider to be “normal” and “abnormal”.  

If a woman is telling me that something does not feel right, I consider that something really may not be right.  A limitation I hear and see from the medical community is telling patients “That’s normal. I wouldn’t worry about it.”  While it is comforting as the patient to hear this, in my opinion, it still does not hurt to fully examine the patient and confirm that everything is normal.  Or to refer that patient to an expert in that field to confirm with an objective examination.

In regards to fitness instructors and personal trainers, there are many experienced exercise gurus out there who are more equipped to train people than doctors and physical therapists.  My only reservation is, again, if it doesn’t feel right, it is probably not right.  

If an exercise instructor/trainer is having you do an exercise that hurts, makes you leak, or causes you to feel pressure in your pelvis, then stop immediately.  Tell them about these symptoms and see if the exercise can be modified to stop the symptoms.  The biggest limitation in these situations often lands on the woman/person experiencing the problem.  

I always warn people against “pushing through” the problem.  

It is a common misconception that these are just signs of weakness and that if you keep pushing, you’ll get stronger and they will go away.  Oftentimes, these are not just because of weakness, and that person needs a consultation with a physical therapist.

If your symptoms are positional or movement-related, physical therapists are now advocating to get PT prior to consulting with a medical doctor: http://getpt1st.com.

  1. What advice would you give to postpartum women who want to jump back into fitness classes and vigorous exercise after the standard 6 or 8 weeks after childbirth?

My best advice is to take it slow.  Once you have been cleared at your 6-week follow-up for exercise, this is definitely the time to start getting back into activity.  I typically recommend a daily light to moderate-level walk to start.  

From there, I encourage core stabilization exercises.  Mat Pilates and yoga are great methods of utilizing your body weight to strengthen and stabilize the core.  Naturally, I encourage caution with taking group exercise classes as so many factors play a role in how hard we end up pushing ourselves when we are in a group.  But again, always remember: if it hurts, causes you to leak, or increases pressure in your pelvis – don’t do it!! Seek help from a professional on what you may be doing wrong or appropriate modifications you can take.

From there, it is all about continuing to challenge the body, build strength and endurance, and slowly work your way back to your prior level of function or pre-baby body.

  1. I know pregnancy impacts women in vastly different ways, but is there an exercise that you would recommend universally that ALL pregnant women (regardless of fitness level) should be doing to take care of their pelvic health? How about an exercise that you would recommend universally to ALL postpartum women?

One exercise that ALL pregnancy and post-partum women can practice is breathing.  

Almost all patients that walk through my door are chest breathers.  I believe this comes from societal ‘norms’ to keep the belly sucked in.  This has led to a population of chest breathers which is associated with stress and anxiety.  Almost every patient I treat, I teach diaphragmatic breathing for deep, relaxation breathing.  This leads to a healthy mindset, core, circulatory and respiratory systems.

Diaphragmatic breathing: you can perform this in any position but, I usually start lying down with your knees bent.  Place one hand on your belly and one hand on your chest.  Take an inhale through your nose and try to make the hand on your belly rise higher than the hand on your chest.  The idea is to puff up the abdomen like a balloon without force or strain.  Exhale through your mouth and let the belly fall back to rest.  Practice 3-5 breaths, 3-5 times per day.  This exercise is a great go-to if you are feeling stressed or anxious.  

  1. In your experience, what is one of the biggest misconceptions that women have regarding pelvic health?

The biggest misconception is that Kegels are the best exercise for all.  

I hear women over and over tell me that their doctors recommended to “just do your kegels”.  I believe this misconception is being phased out; but, I still hear it.  Kegels are not one-size fits all.  They are also not always done correctly.  Many women squeeze their abs, glutes, and leg muscles thinking they are doing a proper kegel.  Other women think that holding their breath and bearing down is a kegel.  And after all of these kegels-gone-wrong, it may not even have been the right exercise for them.

 I would recommend seeking an evaluation by a pelvic PT specialist if you are considering a kegel program.  Especially after childbirth.  This is the only way to confirm if kegels are the right exercise for your and that you are doing them properly.

  1. It’s no secret that childbirth and life after childbirth are very physically demanding. Bending, kneeling, lifting, and twisting are very much a part of moms’ daily lives. What things can we do to help alleviate the strain that this daily “wear-and-tear” takes on our body, especially as we recover from childbirth?

Using good body mechanics with all of this bending, kneeling, lifting, and twisting will definitely save you from physical aches and pains.  Here are some tips on how to maintain good body mechanics:

  • For prolonged standing, stand comfortably with your ribcage stacked over your pelvis, shoulders stacked over your ribcage, and head stacked over your shoulders; you should not be working extremely hard in this position and if you are, you may have muscle tightness or weakness somewhere that needs to be addressed.
  • Standing equally and evenly on both legs; likewise, sit equally and evenly on both sit bones.
  • Lift from your legs, not from your back: try to keep your back in a neutral position (not excessively rounded either backward or forward) while hinging from your hips and your knees.
  • When lifting, have your feet facing the direction of the object you are lifting; do NOT twist and lift.
  • Avoid standing on one leg if you do not feel stable; including getting in and out of the car/shower/tub and putting on pants/socks/shoes.
  • Engage your core muscles when bending, lifting, pushing/pulling, and getting in and out of bed.
  1. I know with my own childbirth experiences, I have often thought maybe I could have done something to prevent some pregnancy and postpartum issues. Is there any way women can prevent pelvic issues with pregnancy and childbirth?

It is hard to start making changes to your body once you are already pregnant.  The rate of change the pregnancy itself is making on your body will exceed the change you can make with exercises.  I do teach my patients to become familiar with their pelvic floor and abdominal muscles before, during, and after the pregnancy.  If you become familiar with these muscles before delivery, it will make for an easier recovery after.  

Being familiar with what your body could do before will help you understand what you cannot do as a result and when to seek assistance.  This includes all types of pelvic floor muscle control (i.e. kegels and relaxation), transverse abdominis muscle activation, diaphragmatic breathing, and coordination of all core muscles together.

From my clinical experience, women who are physically active prior to pregnancy and labor/delivery typically return to exercise quicker and with greater ease.  The recommendation for safe exercise during pregnancy is based on your fitness level prior to pregnancy.  And exercise itself helps to improve overall health, reduce risk of disease, reduce stress and depression, and prepares women for the physical demand of labor and delivery.  So, prior to getting pregnant, I always encourage starting a moderate-intensity workout routine.   

You can learn more about Katie here.

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