 By Dr. Anna Burns, PT, DPT
South Shore Pelvic Health There are so many things to consider when pregnant, and physical activity is one of them. In the old days, women were advised to “take it easy” while pregnant. However now, the Center for Disease Control and Prevention recommends that pregnant women get at least 150 minutes of moderate-intensity aerobic activity every week. A growing body of research has shown that exercise is associated with decreased fetal distress during delivery, higher APGAR scores, decreased risk for gestational diabetes, and decreased risk for preeclampsia. In a recent study of runners, strength training during pregnancy led to decreased musculoskeletal pain and postpartum stress urinary incontinence. Recovery begins in pregnancy! Body Changes A woman’s body changes significantly during pregnancy. Her blood volume increases by 50%. Her resting heart rate increases by 15-20 beats per minute. Her respiration rate increases by 10-20%. Her joints become more lax due to pregnancy hormones. Her body temperature is slightly higher. Her posture changes with an increase in the curve of her low back, forward tipping of her pelvis, backward shifting of her rib cage to compensate for an altered and growing center of mass. As a result, gait mechanics change and balance can become more challenging. Ideally, a pregnant woman should be able to do any exercise she had been doing prior to pregnancy with a few modifications. If you were previously sedentary, adopt a mild to moderate intensity routine. If you were previously active, you can adopt moderate to high intensity routine. Exercise should be performed at least three times a week. You should always talk to your obstetrician or midwife before starting an exercise routine. If you have a heart rate monitor, you can use the following heart rate guidelines for activity level: If you are younger than 30 years old, heart rate range targets are (in beats/minute): LIGHT INTENSITY: 102-124 MODERATE INTENSITY: 125-146 VIGOROUS INTENSITY: 147-169 If you are 30 years or older: LIGHT INTENSITY: 101-120 MODERATE INTENSITY: 121-141 VIGOROUS INTENSITY: 142-162 There are just a few things to AVOID during exercise while pregnant: Laying on your back for more than 3 minutes after 20 weeks Exercising in a hot, humid environment, whether it’s outside or at hot yoga Performing inversion poses or any position where the hips are above the shoulders (handstands, prolonged bridges, etc.) Exercises that put pressure on the abdomen during mid-to-late pregnancy Over-stretching muscles If you lift weights, here are a few guidelines and suggested modifications: Decrease your lifting load to 60-75% of your pre-pregnancy “one rep max.” Modify asymmetrical movements such as a split snatch or a split jerk. Decrease the width of the stance or perform these without the split positioning at all. If your belly gets in the way with lifting, lift from blocks instead of the floor. Switch out front squats for back squats, as the front squats increase your intra- abdominal pressure (which is already increased by the presence of the fetus). Regardless of the type of exercise you participate in, watch for symptoms that signal you should STOP exercising and contact your healthcare provider immediately: Bleeding or leaking fluid from the vagina Feeling dizzy or faint Shortness of breath before starting exercise Chest pain Headache Muscle weakness Calf pain or swelling Regular, painful contractions of the uterus Don’t let pregnancy leave you sitting around eating bonbons! The more active you can stay, the better you and your baby will feel, both during pregnancy and after delivery! References: Blyholder, Liga & Chumanov, Elizabeth & Carr, Kathleen & Heiderscheit, Bryan. (2016). Exercise Behaviors and Health Conditions of Runners After Childbirth. Sports Health: A Multidisciplinary Approach. 9. 10.1177/1941738116673605. Clapp, J.F. III. The Course of labor after endurance exercise during pregnancy. Am J Obstet Gynecol. 1990 Dec;163(6 Pt 1):1799-805. Mack, C.F., Morgan, C., & Rohde, M. (2019, January). Science Meets Practice: Running vs. Sports Performance Training in Pregnant and Postpartum Females. Presented at the Combined Sections Meeting of the American Physical Therapy Association, Washington, DC, USA. Rohde, M., and Mack, C.F. (2019, January). Sports Performance Programming for the Pregnant and Postpartum Female Athlete. Presented at the Combined Sections Meeting of the American Physical Therapy Association, Washington, DC, USA.
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 Can I crunch again?
These are common questions I get from my clients every day. The answers are different for everyone depending on the issues they have within their Deep Core System. Some of the more common problems that can occur after having a baby are a weakening or stretching of the abdominal wall connective tissue causing a separation of the outermost abdominal muscle (Diastasis recti), urinary incontinence, pelvic organ prolapse, and other dysfunctions of the pelvic floor muscles from scarring, tightness, or lack of control and coordination. All these problems can be managed, in part by learning how to properly control pressure placed on the abdominal wall or the pelvic floor muscles. What is the Deep Core System anyway? Let' start there. The Deep Core System is a canister of muscles, connective tissue and organs between the rib cage and pelvic girdle. It is a pressurized system that when works together helps to:
Primarily for the purpose of this blog we will discuss the 4 deep core muscles and the skeletal structures to give you a simple understanding. The Diaphragm which is a Dome shaped muscle sits up underneath the rib cage and aids in respiration and is the top of the canister.
The Transverse Abdominus starts at one side of your spine and wraps all the way around the front of your body creating a Corset and attaches on the other side of the spine.
Neutral Alignment is Key The Diaphragm is the top of this tube-shaped canister, the pelvic floor the bottom, the transverse and multifidus the front, sides and back. I personally like to think of it more like an Extra-large plastic Easter egg because lining up the top and bottom keeps all the good stuff inside. These muscles connect the rib cage (top of the egg) to the pelvic girdle (bottom egg) deep inside underneath the exterior core or 6 pack muscles. Traditional core exercises Traditional core work tends to focus on the exterior Core muscles like with crunching, bicycles and any exercise where you are in a flexed and flat backed position. This can increase pressure down into the pelvic floor and increase intra-abdominal pressure. If the pelvic floor muscles are not strong enough to counter act the forces more dysfunction can occur. In addition, the Deep Core system becomes under trained, overlooked and forgotten with traditional fitness style core exercises. Add having a baby or two, gaining weight around the middle and further stretching out that deep core system and making its job twice as hard and often times the hip muscles, exterior core and back muscles start to work overtime and create an imbalance in the system. In a front-loaded position like a plank, if the transverse abdominus muscle isn’t strong enough to compress and hold up the weight of the organs in the presence of a Diastasis recti then more stretching and weakening of the abdominal wall connective tissue can occur. Again, the hips and exterior core may take over to compensate or one might hold their breath which again will increase pressure in the system. So HOW do you get these deep muscles working again?
In Summary The overall answer is everyone is different in whether they will safely be able to return to these exercises and how long it will take them. They may or may not be right for everyone and that is OK.... These are some of the concepts I teach to my patients. Obviously each person’s ability to return to crunching, planks and other exercises that put pressure on the system will depend on their ability to control the pressure and together we find strategies that help you obtain that control, restore core strength and return to being functionally fit.  Author Nadine Adams, MSPT, CPT, is a Pelvic Health Physical Therapist at Peak Physical Therapy in Norwell. www.peaktherapy.com  Eleven years ago tomorrow I left my almost 20 year award winning career as a VA social worker to heal my life from the effects of childhood paralytic polio and trauma. Throughout my life, I have been blessed to meet earth angels to help me overcome adversity and challenges in my life. During these past 11 years, I've explored and experienced many different healing modalities. I bless each and every one I met along with the invaluable soul lessons I learned along the way. After a serious knee injury in December of 2014, I was introduced to the benefits of chiropractic care. After my chiropractor left to practice in China, I didn't pursue chiropractic care as part of my health and wellness regimen. Last year, while at a Business Networking International meeting, I "just happened" to meet Dr. Lizzie Sobel. I was most impressed with her presentation at the meeting about her style of chiropractic care, her passion for her work especially as she talked about a technique she uses to help turn babies who are presenting as breach to allow for a vaginal delivery. While she specializes in family chiropractic care - pregnant moms, post partum moms and their babies, she is dedicated to helping people of all ages in all phases of life experience their health and wellness best. Since last July I have been partnering with Dr. Lizzie on my health and wellness journey. I was able to run the Bermuda Half Marathon in January uninjured and enjoy every mile along the way. My body is recovering well with the help of weekly chiropractic treatment sessions. As a survivor of paralytic polio and trauma, I've been running and working out with a lot of imbalances in my body. As we align my body each week, reset my nervous system, encourage spinal fluid to flow I am healing the effects of paralytic polio and trauma. I am in awe of the art and science of chiropractic care. I had throbbing pain in my scapula for a few days prior to my appointment. Dr. Lizzie noted that the scapula on my right side was 2 inches higher on my left side. It was pulling on the muscle attachment causing pain! As she used her instruments to encourage the bone back to its natural alignment and used soft tissue manipulation to ease the pain, the scapula was able to return to its natural alignment in line with my left side. The adjustment held and the pain was gone! Each week I let Dr. Lizzie know what areas need attention although she goes through the entire body with her keen hands and eagle eyes to adjust areas that could lead to injury or pain. Her gentle touch, her balancing out of the body and paying attention to specific "trouble" spots leave me feeling relaxed with a sense of peace and comfort being in my body. That is quite a testimony for someone who has experienced over 25 surgeries, a spinal cord injury and severe trauma as a child. Dr. Lizzie also prides herself in providing education to her patients about their bodies, the work and for self care practices at home. Tomorrow marks 11 years since I left the VA to heal my life. I am delighted to shine the spotlight on chiropractic care that has become an integral part of my healing journey. Eleven years later -- I celebrate healing! Be sure to visit Dr. Lizzie's website by following this link. She has offices in Copley Square Boston and Walpole. If you are on the South Shore, be sure to check out Seaside Chiropractic by following this link. To your health and wellness From my heart to yours, Mary Author Mary McManus, once known as “Easy Out Alper” in gym class, contracted paralytic polio at the age of 5 but managed to run the 2009 Boston Marathon at the age of 55. When Mary was diagnosed with Post-Polio Syndrome, a progressive neuromuscular disease in December 2006, she decided she was not going to take the diagnosis sitting down. In May 2007, Mary took a leap of faith leaving behind her award winning career as a Social Worker at the VA to heal her life. She got still and asked for Divine Guidance. Through the power of visualization, lifestyle changes and with fiery determination, Mary healed mind, body and soul. Mary’s quest to heal her life led her to the sport of running that tested her mettle while fueling her journey of transformation from a survivor of childhood paralytic polio and severe trauma at the hands of family members to a woman who embodies faith, grace under fire, courage, determination, endurance and resilience. Mary holds a BS in Communications from Boston University, an MSW from Boston College. Visit her website: www.marymcmanus.com
 "Wait, you can get massage when you're pregnant?" -- "Even in the first trimester?" Yes, and yes- more often than not. The key is receiving from a trained professional who knows the indications/ contraindications of Pre/Postnatal Massage and how to best accommodate mom and baby to provide a safe and effective treatment that has her feeling the most deeply relaxed she's been in a while- maybe ever. One of the many goals of Prenatal Massage is to help mom into a weightless experience- similar to floating in a pool only on a massage table. Where her body can be held and supported by a variety of bolsters and pillows to help her not have to hold her own body up- to truly be able to let go and receive- a rarity in a momma's life. The "momma nest" I call it as it's truly like building a nest behind and around her. A nest of support, just perfect for her. Most clients, even before the massage has begun, are already feeling incredibly relaxed experiencing the nest. It encourages a deep restful feeling. It also helps take the pressure off the body and encourage lymphatic drainage to reduce swelling. An experienced Licensed Massage Therapist with advanced training in Pre/Postnatal Massage will know how to position her client in the safest most effective ways to keep blood flow to the baby strong and prevent vasovagal responses. A vasovagal (dizzy/ fainting) response can occur if a mom is all the way flat on her back with legs flat for extended time as the weight from the uterus/ baby can put pressure on important arteries. Having mom propped up in a semi reclined with knees elevated or side lying position encourages a healthy blood flow to mom & baby. Normally, I spend a little less time with mom on her right side as the blood flow to baby is slightly less in this position. Unless mom has specific recommendations from her provider to not be in certain positions, these positions are safe. Treatment is optimized when we are able to work on all areas of the body- head, neck, shoulders, back, hips, arms, legs and feet. YES feet too! That is another question I've received a lot - the myth of avoiding foot massage during pregnancy. There are specific labor points to avoid during pregnancy and to activate these points deep consistent pressure is applied in a rhythmic way. General massage on the ankles and feet, safe and feels amazing! Back pain, hip pain, rib pain, sciatic pain, neck shoulder tension- the list goes on for all the ways physically massage can help prep for and recover from labor/ birth. Receiving prenatal massage on a regular basis contributes to a healthier pregnancy, feelings of well-being, reduction of stress, better sleep, and improvement in energy. Physical touch is one of the first languages we speak and important to go back to when feeling stressed, overwhelmed, scared, or overexerted as it is one of the most primal of needs. Prenatal massage can also help contribute to smoother, shorter labors. The less restricted and more aligned you are in your body the "easier" time baby can have on the descent. "Does this also apply for cesarean birth?" Of course. I've supported many moms up until and during recovery from planned and unplanned Cesarean births. "I'm so uncomfortable and restless at night, have restless leg syndrome or cramping- can massage help?" Yes to all. Pre/postnatal massage can greatly help support mom into more restful sleep as the less pain, swelling, or cramping occurring the easier it is to relax. Another aspect I offer to my clients is "sleep position coaching"- just a quick run through of how to best support sleep positions as the bodies needs change. Many times it's finding the right supports for your body which is not always the enormous pregnancy pillow. Sometimes it's multiple pillows with different densities and wedges. It may seem like a lot in the beginning but once you get the hang of transitioning (side to side) it becomes second nature. The relaxation effects from the massage also help to ease sleep challenges. "Can I receive if I'm considered a High Risk Pregnancy?" Usually yes, but it depends, and sometimes no. This is something to always consult with your provider about. Being considered High Risk is a pretty broad category. Knowing the reasons why you're high risk is important. I have worked with many high risk pregnancies for a variety of reasons with provider consent. It's an important question to ask as receiving massage can have a great impact on the comfort of your pregnancy, reducing stress levels, and postpartum recovery. And again, making sure you're going to a knowledgeable professional in Pre/Postnatal Massage so that any modifications needed can be made. "How often is best to come in for Pre/Postnatal Massage?" Again, It all depends on your specific needs. I've worked prenatally anywhere from weekly, to bi-weekly, to monthly. Most common is bi-weekly- coinciding perfectly with Chiropractic care. Weekly is usually when the needs are greater or you're getting really close to giving birth. Ideally we can work up until the day before delivery. I'm also trained to provide in-labor massage and postnatal we can work together as soon as you're comfortable to receive. Checking with your provider is recommended in case there are any further modifications needed or important things to know. There are many additional ways Pre/Postnatal Massage can benefit the mind/body/soul connection- the ones listed today are the most common ones and questions I've received. Any further more specific questions feel free to reach out and as always check in with your provider.  Author Ashleigh Dundas is the owner of Massage Loft New England in Norwell, MA.
To connect with her please visit: https://www.massageloftne.com/  What is a doula? How can a doula help all birthing and newly postpartum women? A birth doula is defined as being a continuous support person to a laboring woman and her partner, providing non-judgmental, emotional, physical, and informational support. What does this mean? This means that a doula is the support person, hired by you and not your provider, who usually provides 1-2 prenatal visits in your home to go over your plans for birth and how she can best be a part of your birth team, stays with you during labor and through the birth of your baby(ies), and provides 1-2 postpartum visits in your home, as well as giving you unlimited phone/email support. She provides physical comfort measures (such as massage, position changes, breathing, and relaxation techniques) to guide you through the labor process. She is the person in the room who knows birth and what is normal and what isn’t, and can reassure you and your partner when something doesn’t go as you hoped. She provides information to you so you and your partner can make informed decisions about your care. Most importantly, she empowers you. We, as doulas, believe in the amazing strength women have and are there to remind you every step of the way. Birth doulas also improve birth outcomes. Studies (read more here: https://evidencebasedbirth.com/using-a-doula-for-pain-relief/ ) show that continuous support from a doula leads to a 31% decrease in the use of pitocin (synthetic oxytocin), 28% decrease in the risk of a cesarean, 12% increase in the probability of a vaginal birth, as well as a decrease in the use of pain medications or the need for newborns to be admitted to a special care nursery. Finally, use of a doula leads to more positive birth experiences. A postpartum doula offers support similar to a birth doula, but in the client’s home after the baby is born. She is an expert in newborn care, breastfeeding and bottle feeding support, and postpartum mental health. She will also offer practical support to help you get through those early days, such as baby laundry and food prep. Finally, they can be a big help with sibling support and that transition into the 4th trimester. Postpartum doulas offer two kinds of shifts: daytime and overnight. A daytime shifts usually consists of a 3-4 hour shift where your doula will help with the day-to-day needs. Sometimes, it’s just holding your baby so you can nap or shower! Sometimes, it’s going with you on errands so you have an extra set of hands. Sometimes, it’s sitting with you while you nurse your baby and actively listening to your struggles and successes. Overnight shifts are really about helping new parents get the rest they need. We stay in the same room as your baby(ies) and change them, feed them (if bottle feeding), burp them and get them back to sleep. Having a new baby takes its toll on your body, so being able to catch up on sleep, even just one night a week can be so helpful, both physically and emotionally. Studies show that postpartum doulas help reduce postpartum mood disorders, improve breastfeeding success, and provide superior outcomes in adjusting to life with a new baby (www.dona.org/what-is-a-doula/benefits-of-a-doula/). Our doulas offer you the best in unbiased and compassionate suppport. You don’t have to do it alone. We can help you along this amazing journey through parenthood! Author Jocelyn Albertson is the owner of New World Doula Services, LLC. She is a Certified Birth and Postpartum and Infant Care Doula a Certified Childbirth Educator and Certified Postpartum Placenta Specialist. To learn more about her services or contact Jocelyn please visit her website: http://www.newworlddoula.com/  I blame Hollywood celebrities for the downfall of woman safely recovering from childbirth. Women are constantly seeing a barrage of images where celebrities give birth and then a few days later they look as if they’ve never been pregnant. As a result, women and men alike have this vision of women going back to their pre-pregnancy body within weeks or even days after childbirth. We know intuitively that it is unrealistic, they are a unicorn in the vast landscape of postpartum recovery. However, we still hold faith that if they can get their body back quickly, so can we. They’re not superhuman after all.
However, these unrealistic expectations cause beliefs and behaviors that put the long-term wellness of postpartum women at risk. New moms, in a haze of hormones and sleep deprivation, try the newest fad diet and exercise programs promising to help them “get their pre-pregnancy body back”, as if it’s been lost in the mail. It’s considered a badge of honor to leave the house with your newborn as soon as you can slip real clothes on. Gone are the days where neighbors and friends ban together for meals being delivered, house being cleaned, and baby being tended. That’s now for the weak. I read messages from moms on social media bragging about lifting their 40 lb. toddler days after their c-section, or going to an amusement park at 2 weeks postpartum, or training for a road race starting at 6 weeks postpartum. All of this as if their core muscles hadn’t undergone a major trauma just 6 weeks before. Women are rarely encouraged to relax, accept help from friends and family, and give their bodies the time and attention necessary to heal. Why do we think that is? Is it because childbirth has become so commonplace, so publicized, so openly talked about? Hard to say, but I’m here to say we need to allow our moms time to rest and recover post childbirth whether they deliver vaginally or via c-section. Both methods of delivery impact the core system and need proper rehab to resume optimal function. It is not the standard of care for women to receive rehab after childbirth, far from it. And I’m hard-pressed to explain why. Many other injuries, surgeries, or conditions qualify for therapy, but not childbirth. Women are given the green light to resume exercise as tolerated at their 6 week postpartum check-up with no regard for their method of delivery, pregnancy complications, birth complications, or any other musculoskeletal complaints. If someone has a hip replacement, postoperative rehab includes consideration of the type of approach the surgeon used, what activities or movements they may need to avoid immediately after surgery, what type of activity that want to progress to, if they have any job requirements, and many more factors. All of this information shapes their rehabilitation program. As a society, we need to take better care of our mothers, and I’m not just saying that because I am one. Postpartum rehab should be standard of care for all mothers whether they have had a cesarean delivery or vaginal birth. Last year, American College of Obstetricians and Gynecologists (ACOG) announced their new recommendations for postpartum care. It involves recommending earlier and more comprehensive follow-up with mothers post childbirth and referral to physical therapy as appropriate. This is great news! But we all know real change will take time. Luckily, until appropriate postpartum care becomes a universal standard of care, women have the option to educate themselves and pursue their own course of postpartum rehab. Many states, including Massachusetts, have direct access to physical therapy and chiropractic care. This means you do not need a referral to see a physical therapist or chiropractor of your choice. Inner Strength Physical Therapy and Seaside Chiropractic frequently coordinate care to develop individualized physical therapy and chiropractic treatment plans for our clients. Pursuing postpartum rehab with practitioners that are well-versed in the changes that the female body goes through during pregnancy and childbirth can help to guide you toward a safe return to physical activity. We can help you learn to manage “mom problems” that, despite being common, do not need to be your normal. Moms do not need to live with incontinence, low back pain, pelvic pain, or mummy tummy. Pelvic floor physical therapy and chiropractic care can help! If you are a postnatal mom or are currently pregnant, educate and advocate for yourself! Make your health and well-being a priority! Author Alicia Bertoni-Hickey is the owner of Inner Strength Physical Therapy. To connect with her please visit: http://www.istrengthpt.com/ |
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