An article by: Michele Wojciechowski | December 2017
At Swedish Medical Center in Seattle, Washington, on any given day you might see certified lymphedema therapist Peg Maas, PT, DPT, performing lymphatic massage on a patient. But it's not because the woman has cancer, although she is a cancer survivor. It's because she's pregnant.
Specifically, Maas is seeing the patient because of fluid retention due to pregnancy. "I've had women who have been pregnant after having cancer and have had fluid management problems from their lymphedema," she explains. "We do lymphatic massage and compression the same as we do when women aren't pregnant. We don't leave the swelling alone and just say, ‘You're going to be puffed up because you're pregnant.' It's not just fluid, and it puts women at greater risk of infection."
Maas' experience is 1 example of what physical therapists (PTs) who focus on women's health can do to treat patients with and without specialized conditions during and after pregnancy. For this article, PT in Motion interviewed 5 PTs who all are board-certified clinical specialists in women's health physical therapy.
Often during pregnancy, women experience discomfort, pain, and even urinary incontinence. Frequently, physicians who treat them—whether general practitioners or obstetricians—give similar advice: "It's because you're pregnant. It will go away after you give birth."
But that's not what research shows, states Valerie Bobb, PT, DPT, ATC, director of the women's health program at the Baylor Institute for Rehabilitation in Dallas, Texas. "Research has shown that for 80% of women, if pain or urinary incontinence hasn't resolved itself 3 months postpartum, it's not going to," she says. A study published in BJOG: An International Journal of Obstetrics and Gynaecology found, for example, that among women who reported having urinary incontinence at 3 months, "76.4% reported having it at 12 years."1
"Some leaking is normal for 3 to 4 weeks postpartum, as the pelvic floor got stretched out from pushing out the baby," says Bobb. "We want women to know, however, that overall leaking really is not common or normal."
Bobb explains that in helping women postpartum—and for any urine incontinence rehab—she doesn't view the pelvic floor muscle in isolation, "because that's not how it functions. We may start there, to get the brain connected back with the muscle, but then we incorporate that muscle back into patients' daily lives. We get them to perform actions such as squatting, picking up the baby, lunging, sit-to-stand, and rolling over, because we're retraining that muscle in functional activities."
Preventing or ameliorating incontinence before childbirth can stave off problems postpartum. "I love helping women understand that you don't have to leak and can maintain continence during pregnancy," says Susan Clinton, PT, DScPT, co-owner of Embody Physiotherapy & Wellness in Sewickley, Pennsylvania. "We teach them strategies in movements as well as in not holding their breath. We help them understand where their pelvic floor muscles are and teach them how to engage those muscles during pregnancy."
Clinton, a board-certified clinical specialist in orthopaedic physical therapy as well as in women's health, says it's important for women to know that if they have stress urinary incontinence during pregnancy, they're at risk for the incontinence to continue postpartum. Helping women avoid pain and incontinence during pregnancy "can really change the situation postpartum," she says.
During pregnancy, the most common areas where women experience pain are the pelvic girdle, lumbar region, and hips, says Sandi Gallagher, PT, of Oregon Health & Science University in Portland. She chairs the Certificate of Achievement in Pregnancy/Postpartum (CAPP-OB) Committee for APTA's Section on Women's Health. "In pregnancy, women are more predisposed to these conditions because of the ligamentous laxity that results from hormonal changes, and because a woman's center of gravity and body mass are changing," Gallagher explains. "So, any muscle weakness or joint instability that she had coming into the pregnancy increases her difficulty meeting the increased demands of her body's changes."
"Women who have had multiple babies are at higher risk for pelvic girdle pain, as are those with hypermobility, an increased body mass index, and/or history of trauma to the pelvis," adds Bobb. "They've been told this pain will go away. But when they are no longer pregnant, it will not go away."
"During pregnancy, every system of the body sort of morphs and then morphs back again," notes Karen Litos, PT, DPT, owner of No Mom Left Behind Physical Therapy in Okemos, Michigan. "Just because you're pregnant doesn't mean you have to live with acute back pain. It's treatable through physical therapy."
"Just as they're told about incontinence, women also are told that pelvic girdle and low back pain are normal and will go away after they have their babies. That's setting them up to be miserable during pregnancy—which I don't believe should happen," says Clinton. "Women are strong and resilient. They should be able to remain that way during pregnancy. But the literature is pretty clear that if women are having pelvic girdle pain early on in their pregnancy that isn't treated, often it can become quite severe in the last trimester. Thirty percent of women who have untreated pelvic girdle pain during pregnancy later become chronic pelvic pain patients."
Another condition for which Gallagher sees women during and after pregnancy is coccyx pain. A PT can help a woman with this by suggesting she lie on her side instead of on her back. "Changing positioning while lying down, and during labor, helps the coccyx to move," she explains. "Much of the pain comes from the coccyx being compressed and unable to freely move."
"We can treat any pain pregnant women are experiencing: neck, shoulder, back, mid-back, or hip pain," Bobb says. "The body is subject to pain during pregnancy, and a significant predictor for it is if the woman has a preexisting condition. Previous back or shoulder surgery, for example, predisposes a woman to pain. As PTs, we are musculoskeletal experts. Part of our job is to teach our patients how to reengage their body and to move again in a way that makes sense with what is happening during pregnancy. We want our patients not only to be able to move but also to be able to move well."
It's crucial, Clinton says, to teach women that they needn't be afraid if they're having pain. As long as their physician says everything is okay, they can work with their PT to alleviate the pain. "We can teach them how to move, lift, and stand," she says. "If they're hurting while sitting or standing, we can help them find a different way to do those things. We encourage that kind of creativity of movement. We help them get stronger."
And, Clinton continues, PTs teach women that exercise during pregnancy is healthy. "Unless something serious is going on during pregnancy, there isn't any reason a woman shouldn't exercise," she says.
"The American College of Obstetricians and Gynecologists recommends 30 minutes of moderate- intensity exercise most days of the week throughout pregnancy," Litos notes. "Women who exercise throughout pregnancy recover faster and lose their weight faster. They're at a reduced risk for problems with their pregnancy, and their babies are healthier."
"The primary thing PTs do is neuromuscular reeducation—fancy words for exercise, but we are reeducating those muscles. We use exercises that often focus on back muscles, the core muscles, and sometimes pelvic floor strengthening, depending on the patient," Bobb explains. "We educate patients about body mechanics. If a patient has other young kids at home, we teach her how to lift and carry them while minimizing repetitive stress. We make sure she understands not to hold a child on the same side all the time but, rather, to switch back and forth.
"We don't do a lot of modalities," Bobb continues. "The general consensus is that there isn't enough research on how ultrasound or electrical stimulation might affect the fetus." Depending on the patient, Bobb may use heat or ice, being careful not to let the patient's core temperature increase too much or let a heat source get too close to the fetus. If her patients are going to use heat on their own, Bobb educates them to take precautions such as using extra towels in layers and never putting a hot pack on their bellies.
Bobb also uses aquatic therapy with patients who are pregnant. "Being in the pool at chest level takes off 70% of your body weight," she notes. "So, for our moms who have painful back and pelvic girdle issues, aquatic therapy can be extremely helpful until they can tolerate more land therapy."
There are practical considerations, as well. "We help them work exercise into their days," says Litos. "Some women are working long hours and have other children at home. You have to show them how they can move through the day while minimizing the strain on their backs, and how they can gradually increase their exercise each day. Ninety percent of what I do is educate pregnant women about what they can do."
Per Maas's example, PTs also treat pregnant women who have specific conditions. For instance, Bobb says that patients with multiple sclerosis or Ehlers-Danlos syndromes (genetic connective tissue disorders) are at greater risk for pain and other complications.
"With my patients with Ehlers-Danlos, we're working on body mechanics, because the hormones are making them even more flexible," says Bobb. "They're going to have looser shoulders, neck, and abdominal muscles."
For patients with multiple sclerosis, in addition to working on body mechanics and strengthening, Bobb discusses typical new-parent equipment such as a stroller. It can't be too heavy, because the new mom will need to lift it at times. "You don't want her lifting a 30-pound stroller," Bobb notes. Another common item to discuss is an appropriate changing table so that women are not bending over excessively. None of this is included in physical therapy clinical practice guidelines, she observes, because research isn't being conducted on those subjects. Absent that research, "As experts on women's health, we have come together with a consensus on this information, based on our observations that it's working."
In her practice, Litos educates pregnant mothers-to-be who are obese. "Our job is to show them what they can do to prevent excessive weight gain through nutrition, daily exercise, and, possibly, referrals to dietitians or nutritionists," says Litos. "I teach them about biomechanics—what exercises will help them with pain—and give them stretching and strengthening exercises.
"The biggest problem I encounter with this population is women who haven't lost their excess weight from their first pregnancy and then become pregnant again," Litos continues. "Research has shown that these women are at high risk not only for gestational diabetes in that second pregnancy but also for conversion to type 2 diabetes later in life. Their babies are at higher risk for developing obesity, diabetes, and cardiovascular problems later in life, as well," Litos notes. "Pregnant women with obesity also may have preterm babies as a result of gestational hypertension. Or, they can go the opposite route and have babies who are macrosomic [larger than usual] and difficult to deliver. Those babies also have a future risk factor for obesity. This is why helping moms exercise and not gain a lot of weight is important."
While Gallagher admits it's rare for pregnant patients to ask for help with positions to assume during labor, she often brings it up. For example, during a discussion on managing pain and musculoskeletal impairments, Gallagher will suggest different positions to assume during labor.
"If they and their providers are comfortable with alternatives, I'll tell them about lying on their side or being on their hands and knees," she says. "This allows for more free movement of the pelvis and sacrum. When you're lying on your back, that movement is limited."
Gallagher adds, "Working with some positioning concepts during pregnancy can help reduce the risk of injury to the coccyx during delivery."
Litos says different positions and breathing techniques also can help avoid perineal tear, as well as ease labor and delivery.
PTs even can help women with breastfeeding issues after delivery. According to Maas, this makes perfect sense: "I'm a tissue specialist. I understand how tissue responds to inflammation, and I understand what's supposed to flow through it. Most important, I understand how to promote healing," she says.
When women are breastfeeding, "the amount of blood flow to their breasts is about twice the normal volume, and some of that is used to produce milk," Maas explains. Milk flows from all the places in the breasts, but it exits only through the nipple to feed the baby. To bring milk to the nipple, new mothers must experience a hormonal process in the breasts called a "let-down response."
"Adding to women being really stressed these days, some will breastfeed while talking on the phone or checking email, which interferes with this response, Maas says. "As a result, women can develop clogged ducts or infections if the milk isn't draining properly. That's called milk stasis. If there's stasis and inflammation, it actually changes the flavor of the milk, making it saltier. Then the baby doesn't want to drink from the breast, and the mom becomes upset."
Maas works closely with a lactation consultant. But she tells patients that she sometimes may give them different advice from what they receive from their lactation consultant or other providers. "Lactation consultants often teach a really deep compression massage that squeezes the breast from near where it attaches to the body," says Maas. But she cautions that deep massage may "leave a trail of inflammation, which adds to the fluid that needs to go back the other way."
In addition, Maas sometimes checks for fluid transportation in her patients' breasts by using ultrasound, checking bra fit, and observing how the women are holding their breasts when they're pumping or feeding their babies.
"If you're a physical therapist who wants to do this kind of work, you need to know your differential diagnoses well," Maas advises. "If a woman has an infection, we send her to another provider. Some women could present with a condition that might appear to be clogged ducts but actually is cancer. You need to know when to refer them to other health care practitioners."
Litos says every woman should have a physical therapy pelvic health checkup postpartum, especially if she had a tear and/or episiotomy (a surgical cut to enlarge the vaginal opening). "Women who have cesarean deliveries should have a postpartum checkup with a women's health PT, because no obstetricians I've worked with have talked with patients about scar mobilization, which can lead to adhesions, bladder pain, and pelvis pain as much as 2 years later," Litos says. "Problems with scar adhesions can persist well into the future, but they are easy to prevent."
Exercise is important after delivery, Gallagher notes. She often will focus on strength and stability, giving patients the most effective exercises they can do within a limited period of time. "They don't have time for a 30-minute exercise routine," she says. "That's why I focus on strengthening—it has some of the best evidence for effecting change."
She says it's possible to put appropriate stress on tissues while exercising, without over-stressing those tissues. Gallagher also educates women who have diastasis recti (abdominal separation). For most women, the 2 rectus abdominis muscles that have separated during delivery will resolve and close on their own. "There are exercises that can be done to improve the woman's motor control during the time that the diastasis is closing," she says.
But, because there hasn't been enough hard research on the best exercises, health care providers are left to their own opinions—some of which can be detrimental to patients, Gallagher warns. "When patients have seen someone who has told them they never should do a sit-up or run again, it breaks my heart," she says. "Physical therapists have the skills to examine, test, and find what activities each woman is capable of doing while maintaining closure of the diastasis. You can do this by observation: See what happens if she does a curl-up, a straight leg raise, or a transverse abdominis activation. Put all the pieces together, and avoid absolute statements about the correctness or incorrectness of certain exercises." [See "Mummy Tummy Misinformation" on page 20.]
The PTs interviewed for this article agree that more obstetricians and pregnancy-related health care providers need to know what PTs can offer their patients. Patients themselves need to know, too.
"I do not believe that most obstetricians are opposed to physical therapy," Litos says. "I think they're simply unaware of what we can do. We can change the entire life of a woman in just a few visits."
"I've had patients say they've never had another pregnancy because their first one was so miserable. If you decide not to have any more kids, that's a personal decision. But if it's because nobody was there to help you, that makes me sad," says Bobb. "We can help them."
Michele Wojciechowski is a freelance writer and frequent contributor to PT in Motion.
There's a lot of interest in exercises that women can and should do postpartum. Unfortunately, there's also a lot of misinformation. A recent example that began with a report on National Public Radio (NPR) on diastasis recti (abdominal separation) illustrates the point.
In August, an NPR correspondent reported on her experiences with a daily 10-minute abdominal exercise that its proponent, a personal trainer, claims will close separated abdominal muscles. The text version of the story appeared under the headline: "Flattening The ‘Mummy Tummy' With 1 Exercise, 10 Minutes a Day."
After the story aired, APTA's Section on Women's Health (SOWH) Vice President Carrie Pagliano, PT, DPT, contacted the association with a suggestion that the section and association point out some of the story's inaccuracies. SOWH President Patricia Wolfe, PT, MS, and APTA President Sharon Dunn, PT, PhD, drafted a letter to NPR calling several elements of the story "misleading to women seeking out help for diastasis recti." The letter explained that besides perpetuating the idea that a single short-duration exercise could be the quick-fix solution to diastasis recti, the story also contained factual errors about the kinds of exercises women postpartum should and shouldn't do.
In a follow-up report, NPR acknowledged that the story received a "huge response" and included quotes from the Dunn and Wolfe letter. NPR recapped the criticism it had received, provided more information on the exercise in question, and included descriptions of other exercises that could be helpful, as well as advice from Dunn and Wolfe that, "if done properly, the crossover crunches and bicycle crunches would actual help a woman restore the strength to all of her abdominal muscles."