Postpartum Core/Pelvic Floor Strengthening and Return to Sport · 2018-03-05 · 1. Isolate pelvic floor contraction (no glutes, abs, adductors) Looking for “up and in” motion

POSTPARTUM CORE/PELVIC FLOOR STRENGTHENING AND RETURN TO SPORT

CHELSEA HOLT, PT, DPT

CU SPORTS MEDICINE AND PERFORMANCE CENTER

BOULDER, CO

OBJECTIVES

Present and describe musculoskeletal issues present after pregnancy and delivery

Address current evidence regarding physical therapy treatment of these common presentations

Discuss potential problems with current method of postpartum return to activity/sport

Describe role and importance of physical therapy to return to high level of sport after pregnancy

COMMON POSTPARTUM MSK COMPLAINTS

Low back/SIJ pain

Hip pain

Thoracic/rib pain

Neck pain/headache

Carpal tunnel

Diastasis recti abdominis (DRA)

Pelvic floor muscle dysfunction/stress urinary incontinence (SUI)

Pelvic organ prolapse (POP)

Pelvic pain

WHAT HAPPENS TO THE CORE DURING PREGNANCY?

Diaphragm: descent restricted

Transversus abdominis: stretched out

Pelvic floor muscles: increased workload

Multifidi: little to no effect (although some effect on length potentially due to increased lumber lordosis)

DIASTASIS RECTI ABDOMINIS (DRA)

100% prevalence at gestational week 35 (Fernandes et al, 2005)

50-60% 6 weeks post-natal

39-45% 6 months post-natal (Fernandes et al, 2005 and Sperstad, 2016)

Kamel, et al (2017) demonstrated that a 3x/week, 8 week gentle abdominal exercise program that included abdominal approximation with scarf (with or without NMES applied to abs) had significant positive effects on participant’s BMI, waist circumference, and inter-recti distance.

EXERCISE/MOVEMENT PRECAUTIONS FOR SEVERE DRA

Avoid twisting/reaching activities

No higher level abdominal exercises (i.e. full sit-ups, leg drops/lifts)

Make sure getting up from lying down via log roll method

May need manual splinting during coughing or sneezing

PELVIC ORGAN PROLAPSE

As many as 50% of all parous women have some degree of clinical prolapse and 10-20% exhibit symptoms (Milsom et al, 2009)

Personalized pelvic floor muscle training (PFMT) for 16 weeks to 6 months is effective for improving pelvic organ prolapse symptoms

PFMT group vs. control group demonstrated significant improvement in prolapse stage and reduced frequency of symptoms (Braekken et al, 2010)

Exercise precautions:

Avoid impact exercises due to increased risk for further prolapse

Perform abdominal/core strengthening exercises with hips/legs elevated on step or physioball

Prolapse symptoms may not appear until years after prolapse has occurred

PELVIC FLOOR MUSCLE DYSFUNCTION AND INCONTINENCE

Pregnancy and vaginal delivery considered main risk factors for developing stress urinary incontinence (SUI)

Urinary incontinence (UI) rates of 34% were found in women 3 months postpartum (Wilson et al, 1996)

Mørkved and Bo (1999) reported 42% incontinence rate during pregnancy, which dropped only to 38% at 2 months postpartum

Prevalence of SUI at 43 months after first delivery was 38.6% (Ng et al, 2017)

MØRKVED ET AL, 2003

A 12-week supervised, intensive pelvic floor muscle training program significantly decreased reported UI at 36 weeks pregnant, as well as 3 months postpartum.

The program prevented UI in 1 in 6 women during pregnancy and 1 in 8 women after delivery

Pelvic floor muscle training program

8-12 max PFM contractions

6-8 sec holds

+3 fast twitch contraction at end of each max PF contraction

2x daily for 3 months

*Best results when instructions and feedback given by PT

NEELS ET AL, 2018

Looked at 382 women 1-6 days postpartum

Assessed pelvic floor muscle contraction (PFMC) and Contractions of Other Muscles and other MOVments(COMMOV)

Contraction of rectus abdominis, gluteal muscles, adductor muscles, pelvic tilting, straining or breath holding

66% previously informed about PFM

25% pregnancy info meeting

21% prenatal PT

29% earlier delivery

On first eval, 59% demonstrated correct PFMC. After 1-2 educational, 1-on-1 sessions with physiotherapist, 90% performed correct PFMC

When COMMOV were present (57%), the ability to perform correct PFMC was significantly lower—only 20% demonstrated correct PFMC

NEELS, CONT.

Most common COMMOV were tightening rectus abdominis, breath holding and gluteal activation

Women who had been educated and had a 1-on-1 session regarding correct PFMC prior to delivery performed significantly less COMMOV after delivery

Multiparous women demonstrated better PFM control only if they had underwent individual PFM session in the past

COORDINATION/PELVIC FLOOR PROGRESSION

1. Isolate pelvic floor contraction (no glutes, abs, adductors)

Looking for “up and in” motion with no pelvic tilting, glut activation, or “bulging” of abdominals

2. Able to activate AND relax pelvic floor

Make sure there are no spasms of the pelvic floor musculature

3. Coordinate pelvic floor and deep abdominals

TA marching, bent knee fallouts, clamshells, heel slides, SLRs

4. Transition to functional activities

Lifting mechanics: squatting, hip hinging, lunging, RDLs

EFFECTS OF PREGNANCY OF THE ARMY PFT (WEINA, 2006)

Amount of time needed for postpartum soldiers to return to pre-pregnancy fitness condition, as evidence by Army PT scores ranged from 2-24 months, with a mean of 11 months.

Soldiers reported that they didn’t feel like they were ready to return to activity at 6 weeks.

Something to think about when returning postpartum women back to prior level of sport.

POSSIBLE RETURN TO SPORT (RTS) TESTING CRITERIA

Not a lot of research currently for RTS postpartum

Following test was found to be reliable at detecting stress incontinence and may be useful for making the decision (Berild et al, 2012):

Cough and Jump Stress Test

Bladder emptied with catheter and filled with 300 ml saline

Patient standing, cough 3x as forcefully as possible

Performs 20 jumping jacks

Pad was worn and weighed for amount of incontinence

IN CONCLUSION…

A woman’s body goes through a massive change during pregnancy and delivery that takes time and exercise to undo.

PT can help during and after pregnancy with many common complaints.

There is more to pelvic floor PT than a Kegel

Time to return to exercise/sport should be decided on a case-by-case basis and should require a thorough eval.

Consider referral to PT for postpartum women prior to them returning to high-impact sport.

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Berild G, Kylseng-Hanssen S. Reproducibility of a cough and jump stress test for the evaluation of urinary incontinence. Int Urogynecol J. 2012; 23: 1449-1453.

Braekken IH, Majida M, Engh ME et al. Can pelvic floor muscle training reverse pelvic organ prolapse and reduce prolapse symptoms? An assessor blinded, randomized, and controlled trial. Am J Obstet Gynecol. 2010; 203:170.e1-7.

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Ng K, Cheung RY, Lee LL, et al. An observational follow-up study on pelvic floor disorders to 3-5 years after delivery. Int Urogynecol J. 2017; 28: 1393-1399.

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THANK YOU!