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A physical therapist is best suited to assess, treat and help a woman manage the musculoskeletal and urogenital changes of the postpartum woman in the 4th trimester and beyond.  This review of postpartum exercise literature will assist the therapist in understanding current guidelines and recommendations that support the timing and requirements for returning to fitness, exercise and sport.   The seven articles reviewed discuss current strategies for abdominal wall, general strength required for injury prevention, and return to sport activities.

Some women, including high level and recreational athletes face a balance, learning how to care for a newborn and the desire to restore her fitness to prenatal health status.  For people who have to return to competition, physical jobs or those who use exercise for stress relief, this timetable may be accelerated. These needs exist alongside the challenges of sleep deprivation, a physical changes from pregnancy, and recovery from childbirth  that can require rest, and rehabilitation. Exercise goals in postpartum women vary, as do the current evidence based recommendations for returning to sport.

Photo by Ronnie George on Unsplash

Registration is Now Open!

The Birth Healing Summit is a free on-line opportunity for practitioners to learn from experts who discuss how to help moms  heal their body, mind and/or spirit more completely after birth. You can listen from the comfort of your own home or wherever you may be!

The summit takes place April 8 -16, 2019. 
Join the summit with this link. Registration is FREE!

I'm delighted to be part of this Summit. I'll be covering the Clinical Pearls of Prolapse Examination and providing a list of free access references regarding up-to-date examination of prolapse and levator ani avulsion
Here is the link for the full list of Birth Healing Summit 2019 presenters and topics.

Don't miss the opportunity to learn more about postpartum recovery.

Terminology and Technique for Pelvic Floor Rehabilitation

The time has arrived to correctly describe and effectively use the Valsalva maneuver--and the all-important Vaginal Vacuum that can accompany the maneuver--in pelvic floor rehabilitation. How one performs the Valsalva breath holding technique is an important consideration in pelvic floor health and rehabilitation. The Valsalva maneuver was introduced as a medical procedure in 1704 by an Italian physician to expel pus from the middle ear. Over the years, the Valsalva maneuver has been used in medicine for everything from changing cardiac rhythms to testing for disc herniation. 

Valsalva vs. Strain Maneuvers and the Pelvic Floor (PF)

First, we need to define Valsalva versus Strain from a pelvic health and rehabilitation perspective. Clarifying these definitions is a beginning, improving the understanding of the effect of managing Intra-Abdominal Pressure (IAP) in pelvic floor dysfunction (PFD).

The Valsalva maneuver is a moderately forceful attempted exhalation against a closed airway. The 2017 International Urogynecologic and Continence Societies (IUGA/ICS) joint Terminology Report for the conservative and non-pharmacological management of female pelvic floor dysfunction defines the Valsalva maneuver as "the action of attempting to exhale with the nostrils and mouth, or glottis closed. Valsalva is usually performed with digital closure of the nose, as when trying to equalize pressure in an airplane." Properly used, the term “Valsalva maneuver” does not address the pelvic floor.

In contrast to the Valsalva maneuver, the strain maneuver is a forceful bearing down which can cause excessive perineal descent. We use a strain maneuver to test for pelvic organ prolapse, but it is otherwise discouraged in most of our patients with prolapse or incontinence. Straining/bearing down as defined in the above IUGA/ICS terminology report “may have a similar meaning to Valsalva; however, in practice, straining/bearing down may be interpreted as meaning pushing downward and trying to relax the pelvic floor, as when defecating.” A strain maneuver therefore does address the pelvic floor.

In reality, the Valsalva maneuver does affect the pelvic floor. During the Valsalva maneuver the pelvic floor elevates. I term this elevation the Vaginal Vacuum. For more information on pelvic floor elevation during the Valsalva maneuver, see Talasz et al., 2012 which states that “the Valsalva maneuver reflects an expiratory pattern with diaphragm and pelvic floor elevation, whereas during straining the pelvic floor descends.” Also see Baessler et al., 2017, who demonstrated that Valsalva maneuver is associated with better bladder neck support and a stiffer pelvic floor.

Vaginal Vacuum Technique (VVT)

I consider using the Vaginal Vacuum breath holding technique when the primary presenting pelvic floor muscle diagnosis (Spitznagle et al., 2017) includes a force production deficit with or without movement pattern coordination or IAP impairments. In my practice, patients with some pelvic floor muscle awareness and without pelvic floor muscle overactivity respond the best to the VVT.

Most pelvic rehabilitation practitioners are familiar with coaching a pre-contraction of the pelvic floor (termed the “Knack”) prior to a symptom-provoking cough. The Vaginal Vacuum Technique is designed to be a symptom reduction breathing technique.  It is a short duration Valsalva breath hold used with a symptom-provoking activity like a lift or a push. The VVT can be accompanied by pelvic floor activation either reflexively or with coaching pelvic floor cues.  

To identify if the patient has a reflexive Vaginal Vacuum effect, instruct the patient in a brief, sub-maximal breath hold on exhalation to be directed upward against a closed throat and mouth, (clearing your ears on the airplane-- Valsalva maneuver) and observe for the response of stiffening or lifting of the pelvic floor.

Non-responders may need coaching. I suggest adding a contraction cue for the pelvic floor or providing more training in the coordination of this technique. Patients with significant PFD may need to use both the Knack and the VVT to manage IAP. For some, this Valsalva breathing technique may never produce an elevation of the pelvic floor.

Management of IAP with the Vaginal Vacuum Technique

Management of IAP is an important treatment consideration in patients with PFD.  Breath holding, often unavoidable when pushing or lifting heavy loads, can be performed with different pelvic floor responses.  The Valsalva maneuver can be of value in pelvic floor rehabilitation. Terminology is important, and I encourage you to reverse the trend of using Valsalva as a term to describe a straining/bearing down maneuver in clinical practice. I also encourage you to perform terminology fact checks: look closely at research publications for their specific descriptions of the Valsalva maneuver.

Finally, try the VVT during your initial patient assessments and use it as an additional self-care behavioral strategy to manage IAP.  Clinically, many patients have reported improved quality of life--an ability to lift or push with fewer symptoms. I hope your patients do too.”

To learn more about advanced pelvic floor examination and the importance of managing IAP visit my  professional continuing education teaching  page.

Physical therapists are in a unique position to evaluate and treat pelvic organ prolapse with movement, exercise, and breathing assessments. Some women want to get to the top of the stairs, others to the top of Mt. Rainer without symptom aggravation. The physical therapy goals are to minimize symptoms, continue activity and maximize functional performance.  We assess pelvic floor muscles and prolapse stages, evaluate global muscle/joint function, breathing patterns, and functional activity patterns.  The articles reviewed reinforce the fact that no single solution will be effective for every patient. A comprehensive approach should consider patient goals, current scientific evidence, and examination findings.

Although these studies provide information about functional activities and Intraabdominal pressure (IAP), differences in the way IAP was measured make it difficult to compare results. They also address the utilization of behavioral interventions such as the “Knack” maneuver and breathing pattern terminology. My goal is to keep women moving and exercising to their maximum potential. Keeping current on the research is a vital component of patient care.

I hope you enjoy these literature reviews. If you are a physical therapist, I offer continuing education training in comprehensive prolapse examination and up-to-date treatment strategies in my Boost Camp Series.

These literature reviews were developed with Thanh-Thao Truong, SPT as part of an independent study project at the University of Washington, Department of Physical Medicine, School of Physical Therapy.

The term “The Fourth Trimester” has been described for years, relating to a new baby’s first three months. You can find scores of articles about meeting a baby’s needs in the fourth trimester, with advice on everything from swaddling to feeding to sleep.

But what about the women?

For years, the primary focus has been on the health of the newborn, which is only one part of the package deal of childbirth. Historically, the women received a 15 minute postpartum checkup at six weeks, a screen for postpartum depression, and maybe, if they were lucky or persistent, referrals for physical therapy or other resources.

With the introduction of the fourth trimester for women, that’s beginning to change. New guidelines from the American College of Obstetrics and Gynecology (ACOG), increased information about the potential for long-term changes to a woman’s body after pregnancy, and a call from women themselves for better care is leading to a push for improved postnatal care.

What Kind of Care Should Be Included in the Fourth Trimester?

According to the ACOG guidelines, women should have their first contact, either by phone or in person, with their OB within the first three weeks after delivery. A comprehensive postnatal visit should happen soon after, and include a screening for the woman’s “mood and emotional well-being; infant care and feeding; sexuality, contraception, and birth spacing; sleep and fatigue; physical recovery from birth; chronic disease management; and health maintenance.”   It also looks at postnatal care as an ongoing process, not something that begins and ends at a six-week visit. It encourages referrals to care providers, like women’s health physical therapists, who can address the woman’s physical recovery from childbirth, as well as lactation consultants, therapists or specialists in postpartum complications and management.

What Does This Mean for Women?

In short, it means more comprehensive care. It means looking at the prolonged health of the woman, beyond the baby. It means addressing and treating the physical changes brought on by childbirth and expanding the ways to help women recover over the next months. It places a focus on physical, mental, social support and access to therapies, including physical therapy for new moms. It means a long overdue focus on the health of the woman.

Full disclosure for this post. I’m a PT, but Women’s Health is not my specialty. I’m also a mom to two young-ish kids living in a small town. Practically speaking, this means that most of the people I see every day have young kids, and because it’s a small community, most also know I’m trained as a PT. As a result, they ask me questions about injuries.

Sometimes, the questions are in my specialty—orthopedics—but more times than I can count, I’m asked about an injury relating to childbirth, from prolapse to torn Pelvic Floor muscles, to pubic symphysis pain to pain with sex to urinary incontinence.

Each time I get one of these questions, I suggest a visit to a Women’s Health PT. I explain that while I can offer general advice, there are Physical Therapists who specialize in pelvic floor dysfunction and pain, incontinence and the issues that can arise with pregnancy and childbirth.

Here are the responses I get:

“What does that even mean??”

 “Embarrassing!”

 “My husband/partner wouldn’t like that.”

 “Um, nobody but my husband/partner.”

 “That’s kind of weird.”

 “I’m not sure I want to be that up-close-and-personal with a PT.”

 “Does that even help?”

 “What if I run into the PT at the grocery store?”

 “I’m too busy with my baby. What would I do with her?”

 “Too expensive!”

 “I don’t even want to talk about that.”

 “What if the PT is a guy?”

I want to address these concerns, and to beg you all to please, please think about Pelvic Floor PT. It will help you.

It’s embarrassing!

You just had a baby, arguably not the most modest of experiences. I get that Pelvic Floor PT is different. So is getting your first breast exam, having sex the first time, learning a new language, and trying a new hobby. Yet all of those things can also help you lead a healthier, happier life.

Every person I’ve ever met who chooses to practice as a Women’s Health PT is truly dedicated to improving women’s lives. They will answer your questions, make you feel comfortable, explain what they are doing and why, and make it a generally pleasant experience. And believe me, they’ve heard and seen it all before. I can’t promise you won’t still feel a little embarrassed at first, because it’s new to you. But like many things that take you a little outside of your comfort zone, it’s worth it.

And honestly, what’s more embarrassing? Sharing your concerns with a sympathetic ear who can also help you get better, or peeing through your bridesmaid’s dress because you laughed too hard at a wedding? 

My husband/partner wouldn’t like it/thinks it’s weird

I think a lot of women use this as another way to avoid being embarrassed. Hey, I’ve used my husband as a get-out-of-activity-free card, too. If it’s really about being embarrassed, see my previous answer.

For the people who are really concerned about their partner’s/husband’s opinion of it, maybe this will help: Pelvic Floor PT can help your sex life, and that means it can help your partner’s sex life too. One of the very common problems after kids (or injury) is painful sex. Women’s Health PTs are trained to help address the physical issues that cause this.

If you need help because of incontinence, there can still be a benefit to your sex life. The pelvic floor muscles that support your bladder are also active during sex. Stronger muscles and better motor control decrease incontinence. Imagine the effect of stronger muscles and better control on your sex life. 

It’s expensive!

Yes, it is. Every PT I know wishes that co-pays were lower and care more accessible. But  PT is much less expensive than surgery. It’s money spent to improve the quality of your life and put you on a path towards life without pain. Did you know that there is an entire industry built around selling incontinence products? The ads are all over TV. In the long run, I’m betting PT is less expensive than becoming a perpetual purchaser of incontinence products.

Work with your PT. Together you can find a treatment plan that will help you and work within your financial means.

What do I do with my baby?

Again, I understand this is a concern. If you have childcare or family or friends who can watch your little one during your appointment, great, use it. If you don’t, bring your baby along. Some Women’s Health practices have bouncy chairs and boppy pillows for your baby. Ask what’s available when you make your appointment.

What if the PT is a guy?

Blunt honesty? I’ve never seen it. I’m sure there are a few men who do pelvic floor PT. There are certainly male ob/gyns and male urologists. But it’s pretty uncommon. And it’s up to you. Much like you choose a physician, you choose your PT. It’s ok to prefer a woman (or a man, if that’s what makes you comfortable). That said, I’m going to reiterate that these are highly trained and skilled professionals who are providing a needed service. You can expect the same treatment if it was a man or a woman. So, if the idea of a male ob/gyn doesn’t seem strange, maybe a male PT in this field won’t either? But let me know if you find one. Because they are a rare breed.

I didn’t even know that was a thing.

This is the response that makes me crazy. I’ve yet to hear of a patient after spinal surgery or ACL repair say that they didn’t know PT was “a thing.”

If you are reading this and you are a doctor, a nurse, a mid-wife, a doula, a birth coach, a lactation consultant or in any other way involved in the childbirth experience, please tell your patients Women’s Health PT exists. You will help thousands of women.

Women, tell your friends.

Like I said, my background is not in Women’s Health. It’s orthopedics. People leave a variety of orthopedic surgeries with follow-up instructions that include a referral to physical therapy. After orthopedic injuries, they also get PT referrals.

It’s routine. It’s standard. It’s so common that there’s nothing strange or noteworthy about it.

That’s the kind of awareness that Women’s Health PT needs.

It's not always easy to look at your sexuality issues head-on. Sometimes medical conditions create limitations or cause pain with vaginal penetration.  Your healthcare provider may have suggested a vaginal dilator. What are they and who uses them?

This is the first in a series of posts designed for women that have been advised to use a dilator or are currently working with a vaginal dilator. Dilators can be used to keep the vaginal tissues pliable and healthy or to help return the vaginal opening and canal to a size that is functional for the patient’s sexual activity preferences.

Vaginal dilators have been used in my practice since the late 1980’s as a component of pelvic floor rehabilitation therapy for sexual function. Also known as vaginal trainers or spacers, vaginal dilators are designed to stretch or expand the vaginal opening, tissues and musculature. They have helped hundreds of patients return to or begin penetrative sexual activity, a common goal for many women. This tool can help improve comfort during vaginal penetration, and this can translate into an increased quality of sex life for women and their partners. Physical therapists trained in Women’s Health are ideal health care providers to work with dilator introduction and progression. We have the ability and time to evaluate and treat the pelvic girdle and vulvar regions, and the pelvic floor muscles.

Women who suffer from several categories of medical conditions benefit from the use of vaginal dilators. I have categorized the conditions into 4 types based on my clinical experiences using dilators.

The first group involves women with conditions that have created anatomical changes within the pelvis. This includes genetic conditions, (Mullerian Agenesis or Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome), a surgery (after hysterectomy, prolapse repair, or gender reassignment surgery), a response to medical treatments (Graft-versus-host disease -GvHD) and cancer patients with sexuality issues after radiation, breast cancer treatments, and surgically induced menopause.

The second group includes women with medical conditions that can cause painful or restricted vaginal penetration or intercourse. This category includes but is not limited to, Vulvodynia, Vestibulodynia, Vulvovaginal atrophy, Vaginal Stenosis, Lichens Sclerosis, Painful Bladder Syndrome, Interstitial Cystitis, perineal tears, episiotomy and pelvic pain after childbirth.

The third group includes women with chronic pelvic pain who have either pelvic girdle (the SI joint, coccyx, pubic region) and/or bladder and bowel symptoms. Often in this case, the dilator is used as one way to stretch the pelvic floor muscles.

A fourth group includes women who have not been able to have a pelvic gynecological exam, wear a tampon during their menses, or be sexually active with vaginal penetration despite desire and multiple attempts. This condition is known as vaginismus. Often women with vaginismus need to learn to control muscle responses, focus on insertion techniques and understand the neuroscience of pain, fear and anxiety. Those women have additional needs address in the blog Vaginal dilator tips and overview for vaginismus patients by physical therapist Tracy Sher, MSPT.CSCS.

When working with patients where dilator techniques have been recommended, I frequently encounter many patient emotions. Knowing which dilator to use and having clear directions supports women in their process of recovery. With the support of physical therapy they frequently move from being embarrassed, confused and discouraged to confident, inspired and empowered. Many women reach their goal of pain-free vaginal penetration.

For more information, download Types of Vaginal Dilators , a free educational handout which describes several dilator types, sizes and features.

The first step is choosing the right dilator for your condition. If you have been advised to use a dilator, I suggest you seek the help of a physical therapist. We have the knowledge and skills to support you to meet your goals!

Photo by mag3737

The International Urogynecology Association has Patient Education Material in eight languages. Here are a few samples of great free patient education information. If you need them in Spanish or other languages visit www.iuga.org/?patientinfo

These resources have information and graphics for practitioners learning about pelvic floor problems and for patients.