Postnatal Care 5: 12 weeks and beyond (return to running)
As discussed in a previous blog post stress urinary incontinence is defined by “The involuntary loss of urine on effort or physical exertion, or on sneezing or coughing” (IUGA/ICS 2010 terminology report).
It is known that 1 in 3 women experience some urinary incontinence after having a baby and this common postnatal pelvic health issue can be a great barrier in return to exercise, especially high impact activities such as running.
Running is associated with a sudden rise in intra abdominal pressure. It has also been reported that ground reaction forces of between 1.6 and 2.5 times bodyweight can occur when running at a moderate speed. Presently it is unknown if or how much of this is absorbed through the lower limb on impact and therefore it is assumed that some, if not all, of those forces are also transmitted to the pelvic floor.
Therefore, the strength and speed of a pelvic floor muscle contraction is very important to carry out its role effectively in pelvic organ support and continence during high impact activity. It also helps reason why weak, less co-ordinated muscles in postnatal women may not achieve the level of function needed to maintain these roles and highlights the importance and indication for adequate rehabilitation.
As highlighted in previous blog posts, the first 12 weeks following delivery is a time for your body to heal and regain its strength, particularly in the abdominal and pelvic floor muscles following all the changes that occur. It is understood that the dispensability of your pelvic floor increases during pregnancy and significantly after vaginal delivery. Recovery of the levator ani muscle (deep layer of the pelvic floor) and associated connective tissue and nerves generally is not maximized until 4-6 months postnatal. Bladder neck mobility increases after vaginal delivery. And following caesarean section delivery ultrasound investigations have shown that the uterine scar thickness is still increased at 6-weeks postnatal. This is further supported by the understanding that abdominal fascia has only regained 51%-59% of its original tensile strength by 6-weeks and 73%-93% of its original tensile strength at 6-7 months postnatal. (Ceydeli et al. 2005).
For these reasons it is recommended following an initial low impact exercise timeline from 0-12 weeks (refer to previous blogs for examples) followed by return to running between 3-6 months postnatal if appropriate. To determine the appropriateness for the individual it is recommended that all women, regardless of how they deliver, seek out a pelvic health assessment with a specialist physiotherapist to evaluate strength, function and co-ordination of the abdominal and pelvic floor muscles.
The importance of the assessment is further highlighted if any of the following signs and symptoms are experienced prior to, or after attempting, return to running:
Heaviness/ dragging in the pelvic area (can be associated with prolapse)
Leaking urine or inability to control bowel movements
Pendular abdomen or noticeable gap along the midline of your abdominal wall. (This may indicate Diastasis Rectus Abdominis (DRA))
Pelvic or lower back pain
During the assessment there are particular measures and assessments that are undertaken to evaluate fitness to return to running and if this screening is passed a graded return to running plan can commence e.g. couch to 5K.
If the screening is not passed, meaning if the woman was to return to high impact exercises she would be at risk of pelvic organ prolapse or urinary incontinence based on the findings then a rehabilitation programme would begin to address dysfunctional areas and other options would be discussed such as the use of pessary.
If you would like to seek out additional information on the pelvic floor anatomy, incontinence, and prolapse you can head to out previous blog or https://www.continence.org.au.
For individual advice, education and assessment please book in to see Amanda or Claire at Body Align Physio for a Pelvic floor assessment.
References:
Ceydeli, A., Rucinski, J. and Wise, L. (2005) Finding the best abdominal closure: an evidence-based review of the literature. Curr Surg 62, 220–5.
