Thursday, June 1, 2017

Postpartum Abdominal Wall and Pelvic Floor Muscle Dysfunction: Related Complications, Physical Therapy, and Safe Return to Exercise


Part I: Abdominal Wall and Pelvic Floor Muscle Dysfunction and Related Complications


Abdominal wall and pelvic floor muscle dysfunction is common in pregnancy as well as in the postpartum stage. However, once a mom is postpartum, she is always postpartum and abdominal and pelvic floor problems can continue for years. As many women can attest to, problems with these muscles can cause pelvic girdle and low back pain, pelvic organ prolapse, urinary and fecal incontinence, and rectus diastasis abdominis. This raises the questions, “What can go wrong with our abdominal wall and pelvic floor muscles during pregnancy and after delivery?” “How does the new mom safely return to exercise and fitness after childbirth?”

To have a better understanding of postpartum barriers for safely returning to exercise, let’s first review our anatomy. The top picture is looking at our belly while the bottom picture shows a side view:


Pelvic Guru.com


By OpenStax College - https://cnx.org/contents/FPtK1zmh@8.108:y9_gDy74@5, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=64291130

The most superficial layer of muscle is called the rectus abdominis. This is also known as the “6 pack muscle.” There is a left and a right rectus abdominis. It helps to flex our spine and posteriorly tilt our pelvis. Deep to it are the right and left external obliques, which work together to flex our spine. Unilaterally, the external oblique rotates our spine in the opposite direction. The internal obliques (right and left) are found deep to the external oblique muscles. Besides flexing the spine, they rotate the spine to the same side. If stiff, both the internal and external obliques can cause twists in our upper and lower back and pelvis. The deepest of the abdominal group is the transversus abdominis, which provides trunk stability and helps with trunk rotation. The linea alba, a fibrous structure that consists mostly of connective tissue, runs down the middle of the abdomen and separates the left and right rectus abdominis muscle. The internal and external obliques have attachments into the linea alba. 

The diaphragm and pelvic floor muscles are not part of the abdominal wall muscles, but function closely with them. The pelvic floor has several layers of muscles; some run front to back, connecting the tailbone to the pubic bone, while others run outward from the sacrum, coccyx, and midline to the pelvic bones. Thoracolumbar fascia connects these muscles to the low back. The deeper layer of muscles functions as a sling and supports the vagina, bladder, uterus, and rectum. The outer, or more superficial layer, surrounds the bladder, vagina, and anal openings. For more info on the pelvic floor, see my blog post on pelvic floor dysfunction.

This is our pelvic floor looking from above:

Pelvic Guru.com
The diaphragm muscle contracts and shortens when we breathe in and the pelvic floor muscles lengthen. During exhalation, the diaphragm lengthens while the pelvic floor muscles contract. The coordination of these muscles with exercise and exertion is often out of synch. We often breathe in or hold our breath while exercising or performing activities such as lifting a baby when we should actually be breathing out. When we breathe incorrectly like this, the increase in intra-abdominal pressure pushes out against the abdominal wall and pelvic floor muscles. Over time, this pressure can predispose pelvic organs to prolapse, cause urinary and fecal incontinence and pelvic pain, and worsen a rectus diastasis abdominis. Recruitment strategies for the diaphragm, pelvic floor, and transversus abdominis muscles often need to be retrained so that they contract and relax in a coordinated manner for normal breathing patterns, trunk function, pelvic organ support, continence, and transfer of loads to occur.

The picture on the left depicts a normal breath out. Note the rise of the pelvic floor. On the right, the pelvic floor is pushed out when holding your breath, a common, but incorrect, breathing strategy with exercise and exertion: 


 


Obstetricians often allow new moms to begin exercising at the 6 to 8-week checkup, but don’t offer much, if any advice on how to safely begin an exercise program. Not only does pregnancy and childbirth lengthen some muscles and shorten others, but it also can weaken and injure them. Hormones from pregnancy that persist for several months after delivery, especially in breast-feeding mothers, may further loosen ligaments and joints in the back and pelvis, two areas that are already stressed from pregnancy-related structural and postural changes. These changes may cause the new mom to be vulnerable to injury and incontinence when she attempts to begin postpartum exercise.

A diastasis rectus abdominis (DRA) is a separation between the right and left rectus abdominis muscle. It may worsen if exercise is commenced too soon after childbirth or performed incorrectly. As pregnancy progresses, the linea alba stretches and becomes thinner, leading to a split down the middle of the rectus abdominis. One study reported that 27% of women have a DRA in their second trimester of pregnancy and 66% have one in their third trimester. Thirty-six percent persist into the 5th-7th postpartum week (Boissonnalt & Blaschak 1988). Another study showed that 100% of women had a DRA by the 35th week of pregnancy and persisted for up to 6 months after delivery. In 2008, Coldron et al reported that the DRA distance significantly reduced by the 8th postpartum week, but there was no further closure by the end of the first year without any exercise training. Spitznagle et al in 2007 reported that in women with urogynegolocial dysfunction, 52% had a DRA. Sixty-six percent of these women had associated pelvic floor dysfunction leading to urinary incontinence, fecal incontinence, and/or pelvic organ prolapse.

Here is a schematic of the abdomen showing the different types of DRAs.


PelvicGuru.com
The following are two photos of women with a rectus diastasis abdominis, one from the front and one from the side:
                 
https://learnwithdianelee.com/product/diastasis-rectus-abdominis-a-clinical-guide/
https://learnwithdianelee.com/product/diastasis-rectus-abdominis-a-clinical-guide/

This woman has a 2 finger-width RDA:

http://dianelee.ca/article-diastasis-rectus-abdominis.php

Diastasis rectus abdominis is found in other patient populations beside pregnant and postpartum women. Men can develop a DRA, too! It generally occurs because of impaired myofascia and worsened with non-optimal strategies of movement and abdominal wall function. Activities that lead to DRA include those that increase the intra-abdominal pressure, such as exercises performed with poor technique, breathing patterns, and abdominal activation strategies (i.e., various core exercises, sit-ups and crunches, and pilates exercises). The increase in intra-abdominal pressure increases the stress on the linea alba which may stretch and weaken it, causing the rectus abdominis to split in the middle. Those with protruding bellies place a strain on the connective tissue, which may lead to DRA, too. Genetics is also known to play a role in the development of DRA.

Urinary incontinence, pelvic organ prolapse, and pelvic and low back pain
are common complaints during and after pregnancy. Stress urinary incontinence (SUI) affects roughly 50% of women with pelvic floor muscle weakness, injuries, and perineal tearing, which may occur during pregnancy and childbirth. Urine leaks out with exercise, coughing, laughing, sneezing, and even when running or jumping on a trampoline with kids. Another type of incontinence, urge incontinence (UI), is commonly seen in older women. There is a frequent urge to urinate, even if the bladder is not full. Causes of urge incontinence include surgery, nerve damage, and gynecological conditions such as fibroids. Some women will have a combination of urge and stress urinary incontinence. Research studies show that 92% of women who experience urinary leakage at 12 weeks postpartum continue to have issues 5 years later. Another study followed 7,882 women for 5-7 years after delivery. At 7 years postpartum, 45% were incontinent. Over the course of the study, 27% of the incontinent women became continent and 31% of the continent women became incontinent. Many women think that any form of urinary incontinence is normal, will resolve on its own, and shy away from mentioning their symptoms to their health care provider. It is not normal and is often resolved with proper early intervention! Sapsford (2004) found muscle activation problems between the abdominal and pelvic floor muscles and diaphragm in incontinent patients while Thompson et al (2008) reported different patterns of abdominal wall, pelvic floor, and chest wall activity during pelvic floor muscle contraction in incontinent women. Proper pelvic floor and abdominal muscle training under the guidance of physical therapists has been found to be approximately 80% effective in improving or resolving bladder control problems.


Pelvic organ prolapse of various degrees is found in up to 50% of moms. This is a condition where either the bladder descends into the vagina, the rectum drops into the back vaginal wall, or the cervix and uterus descend into the vagina. In those who have had a hysterectomy, the upper part of the vagina can drop into or through the lower vagina:

PelvicGuru.com

One of the roles of the pelvic floor muscles is to support the pelvic organs. When weakened or torn in a vaginal birth, the muscles’ ability to support these organs in their normal position is compromised and may cause them to descend into or through the vagina. Other common causes of a weakened pelvic floor leading to prolapse include heavy lifting, poor exercise technique, chronic coughing, constipation and chronic straining, protruding abdomen, prolonged second stage of labor, surgery, and women with more than one child. Proper pelvic floor muscle training in combination with abdominal wall training has been found to be helpful to limit progression of prolapse.

Low back, pelvic, and pelvic girdle pain is present in up to 42% of pregnant women. Sacro-iliac (SI) and symphysis pubis pain are the most common areas of pain and generally resolve after childbirth. However, pain can carry over into the postpartum stage. Low back pain and urinary incontinence are sometimes found together; Smith et al (2007) reviewed over 28,000 records of women and found a strong association between low back pain and urinary incontinence. Hormonal influence causes hypermobility in the pelvis and low back, which then may cause symptoms. Pain can occur when muscles stiffen or shorten while others lengthen as a result of postural changes during pregnancy. These postural changes can weaken abdominal and other muscles as well as impair their ability to activate properly, which may lead to non-optimal movement patterns, poor pelvic stability, and pain with activities such as lifting a baby and walking. Proper exercise training of the abdominal wall and pelvic floor muscles is often beneficial in reducing or eliminating low back and pelvic girdle pain.
         
PelvicGuru.com

Part II: Safe Return to Exercise and Physical Therapy


Many postpartum moms are usually in a hurry to regain their pre-pregnancy figure and fitness. When given the thumbs up by their obstetrician to begin an exercise program at the 6th to 8th postpartum week, moms may attempt to engage in the same high intensity routines they performed prior to their pregnancy, join boot camp classes for new mothers, or resume running or other high-level activities. If there are pelvic floor and abdominal wall weaknesses, muscle imbalances, and/or poor muscle activation strategies, then these moms may actually cause or delay resolution of their urinary incontinence, pelvic organ prolapse, and/or rectus diastasis abdominis!

How do you know if you are ready to safely resume exercise? Here are two self-checks of your pelvic floor and abdominal wall muscles as advocated by prominent Canadian physiotherapists and educators, Diane Lee and LJ Lee:

1. Curl Up Test: Lie on your back with your knees bent. With your chin tucked in, lift your head and shoulders off the floor.

2. Leg Lift Test: Lie on your back, legs straight. Lift one leg off the ground 2-3 inches. Lower, and repeat with the other leg.

For each test, check to see if any of these occur:

* Feel your “6-pack muscles” (rectus abdominis) along the middle of your stomach. Is there a soft gap or hollowing like this?



http://dianelee.ca/article-diastasis-rectus-abdominis.php


* Is there doming as shown in this client?

http://dianelee.ca/article-diastasis-rectus-abdominis.php

* Do you have back or pelvic pain with either of the tests?
* Does your pelvic floor feel heavy? Is there any bulging, descent, or pressure when you feel your perineum?

If any of the above occurs, or if you have any of the following, your abdominal wall and pelvic floor function should be screened by a physical therapist prior to returning to exercise or sport following delivery of your baby:

* Ongoing pelvis, groin, back, or abdominal pain
* Leak urine, stools, or gas when you laugh, cough, jump, sneeze, lift, walk, run, or perform other activities
* Leak urine or stool when you feel an urge to urinate
* Have a feeling of pressure or bulging in your vagina or rectum
* Bulging of your abdomen during any exercise
* Difficulty doing any of your usual activities due to pain, leakage, or pressure
* Have any other symptoms that concern you

A physical therapist will review your medical history and current complaints with you. She will then assess the factors contributing to your pain complaints, DRA, and abdominal wall and pelvic floor muscle dysfunction. Your breathing patterns and ability to activate and relax your abdominal and pelvic floor muscles will be evaluated. Your alignment, biomechanics, movement strategies, and ability to transfer forces between your pelvis and spine with movements and tasks that you are having difficulty with will be analyzed (i.e., lifting your baby out of her crib or weight bearing on one leg when walking). Meaningful goals for you and your recovery will be mutually established.

Physical therapy intervention
begins with education on your physical therapy diagnosis, exam findings, and treatment plan. Early treatment usually includes practice normalizing breathing patterns so that you are not holding your breath or inhaling and pushing out the abdominal wall and pelvic floor with exertion while exercising or lifting your baby from the floor.
 

Postural and alignment changes from pregnancy usually persist into the immediate postpartum period and longer. These changes alter how you live and move in your body. Altered alignment such as spinal twists and rotations, even in the mid and upper chest, can influence your ability to transfer loads between the trunk and pelvis effectively. These twists may hinder your ability to move and recruit the abdominal and pelvic floor muscles efficiently and correctly. Once these “drivers,” or contributors of muscle dysfunction are identified and treated, the ability to contract appropriate muscles, transfer loads, and move properly is greatly enhanced.

Research studies tell us that patients with low back or pelvic girdle pain, even if resolved, can cause altered muscle recruitment strategies. Let’s take, for example, a new mom with a 6 week old baby. While pregnant, she had pelvic girdle pain and developed a RDA that did not spontaneously close. She begins baby boot camp and performs numerous repetitive abdominal exercises, including sit-ups and hundreds several days a week with a goal of quickly obtaining a flat tummy. Without optimal pelvic floor and transversus abdominis muscle activation strategies, this mom will most likely overuse her rectus abdominis 6-pack muscle or upper abdominals (obliques), potentially worsening her RDA (or incontinence and/or pelvic organ prolapse).
In addition, her abdominal wall profile may show a lower belly bulge due to the increased lower intra-abdominal pressure caused by oblique muscle dominance from an exercise program using incorrect muscle activation strategies.

He is an example of a woman with oblique muscle dominance. Note the vertical lines on either side of her abdomen and belly pooch:

http://dianelee.ca/article-butt-grippers.php

http://dianelee.ca/article-butt-grippers.php

This mom would most likely benefit from participating in an inner core muscle training program. The initial goals are to train the deep stabilizing muscles (pelvic floor, transversus abdominis, lumbar multifidi, and diaphragm) to turn on at the right time with exercise and movements and then to sequentially progress so that the muscles are strong enough and have adequate endurance to be able to engage in more challenging exercises and activities that require higher muscular demands. For more information on inner core muscle training, see my blog post, Training and Strengthening the Deep Muscle System.

In addition to the above intervention, physical therapists help new moms move better in their bodies by improving movement strategies and functional strength. We work with moms on “meaningful task” activities that cause pain, incontinence, or vaginal/rectal pressure, such as lifting their baby from a crib. These tasks are initially broken into smaller movement components to ensure that all body regions are moving properly with optimal mechanics and muscle control and strength. Once this is achieved, movements are progressed with higher muscle performance demands until the full meaningful task movement is performed correctly.



In summary, pregnancy and postpartum body changes are part of being a new mom. The abdominal wall and pelvic floor muscles are often stretched, lengthened, and weakened and/or torn and injured during pregnancy and childbirth. These muscle impairments can cause or worsen problems such as diastasis rectus abdominis, incontinence, and pelvic organ prolapse. For many women, their muscle dysfunction spontaneously resolves in the early postpartum period and a safe exercise program can be initiated when given the green light by their obstetricians. However, there are those moms whose abdominal wall and pelvic floor muscle function fails to improve or only improves a bit. At the 6-8-week postpartum mark, they may still have pelvic, abdominal, or back pain at rest or when active, leakage issues, a hollowing or bulging of the abdomen with exercise or activities, and/or a feeling of pressure in their vagina or rectum. If this is you or someone you know, you or your friend would benefit from consulting a physical therapist for an assessment and appropriate intervention to help resolve pain complaints, regain control of bladder and bowel function, learn how to move freely in your body, and exercise safely.


https://www.goodfreephotos.com/albums/people/woman-doing-yoga-at-sunset.jpg
https://www.goodfreephotos.com/albums/people/woman-doing-yoga-at-sunset.jpg

References:

Boissonnault J S, Blaschak M J 1988 Incidence of diastasis recti abdominis during the childbearing year. Physical Therapy (68):7

Coldron Y, Stokes M J, Newham D J, Cook K 2007 Postpartum characteristics of rectus abdominis on ultrasound imaging. Manual Therapy. epub

"Diane Lee & Associates #102 - 15303 31 Avenue. South Surrey, BC V3Z 6X2." Diane Lee and Associates. N.p., n.d. Web. 21 May 2017. <http://dianelee.ca/article-diastasis-rectus-abdominis.php>.

"Diane Lee & Associates #102 - 15303 31 Avenue. South Surrey, BC V3Z 6X2." Diane Lee and Associates. N.p., n.d. Web. 21 May 2017. <http://dianelee.ca/article-dra-intouch.php>.
DiPaolo, Julia, Kim Vopni, and Samantha Montpetit Huynh. "Core Confidence for Motherhood." Bellies, Inc. N.p., n.d. Web. 21 May 2017. <http://www.belliesinc.com/>.

Lee, Diane. "Butt-grippers, Back-grippers and Chest Grippers - Are You One?" Diane Lee and Associates. N.p., n.d. Web. 21 May 2017. <http://dianelee.ca/article-butt-grippers.php>. 

Lee, Diane. "Diastasis Rectus Abdominis & Postpartum Health Consideration for Exercise Training." Diane Lee & Associates - Consultants in Physiotherapy - South Surrey, BC. N.p., n.d. Web. 21 May 2017. <http://dianelee.ca/>.

Lee, Linda Joy. New mums, new workouts. Course notes.

Lee, Linda Joy. The Thorax: Connect the Whole Body & Optimize Performance with ConnectTherapy and The Thoracic Ring Approach. Course notes.

Lee, Linda Joy. The Sports Pelvis & Hip: Recurrent Groin and Hamstring Problems – Find the Driver & Treat the Whole Person with ConnectTherapy. Course notes.

Rumer, Masha. "How New Mothers Can Avoid Injury When Starting to Exercise Again." The Washington Post. WP Company, 13 Dec. 2016. Web. 21 May 2017. <https://www.washingtonpost.com/lifestyle/wellness/how-new-mothers-can-avoid-injury-when-starting-to-exercise-again/2016/12/13/667d998c-bb02-11e6-ac85-094a21c44abc_story.html?utm_term=.54206c28f5c6>.

Spitznagle TM, Leong FC, van Dillen LR 2007 Prevalence of diastasis recti abdominis in a urogynecological patient population. Int Urogynecology J 18:3?