Depression and anxiety can limit ability to care for one’s self, limit ability to care for a new baby or developing fetus, and can cause mood swings, impaired concentration, and sleep disturbance. Disorders of depression and anxiety are common in the perinatal period (immediately before and after birth) with depression rates around 20% and perinatal anxiety present in about 10% of women. These mood disorders greatly diminish quality of life for mother and baby. Medication may be effective, however, side effects are often unknown, and potentially adverse for the perinatal patient. Many women worry that using medication to treat these disorders may harm the fetus, negatively affect mother child bonding, and poorly influence child development. As health care providers, being aware of alternative treatments for depression and anxiety is essential. Having alternative treatments can allow our patients to combat these common perinatal problems which will improve quality of life, improve bonding between baby and mother and improve the overall perinatal experience. In the general population, positive mental and physical health benefits have been continually demonstrated by yoga participants in current research. Can yoga be an effective, alternative treatment to help perinatal patients improve mental health and well-being?
A recent 2015 systematic literature review published in the Journal of Holistic Nursing reviewed 13 studies to examine existing empirical literature on yoga interventions and yoga’s effects on pregnant women’s health and well-being. The conclusion of the review found that yoga interventions were generally effective at reducing depression and anxiety in perinatal women and the decrease in depression and anxiety was noted regardless of the type of outcome measure used and results were optimized when the study was 7 weeks or longer. Other positive secondary findings noted with the regular yoga participation in the perinatal participants were: improvements in pain, anger, stress, gestational age at birth, birth weight, maternal-infant attachment, power, optimism, and well-being. What is yoga and what form of it may help battle perinatal depression and anxiety?
Yoga by definition is a Hindu philosophy that teaches a person to experience inner peace by controlling the mind and body. Merriam-Webster defines yoga as a system of exercises for attaining bodily or mental control and well-being. All styles of yoga include some combination of physical poses, breathing techniques, and meditation-relaxation techniques. Hatha yoga is the most common form completed in the United States and consists modernly of various postures, breathing, and meditation. In the 13 reviewed studies, all interventions consisted of different forms of yoga and the overall conclusion of the systematic review was the decrease in depression and anxiety was significant no matter the form of yoga completed. Physical and emotional issues such as hormonal changes, sleep deprivation, inability to handle new tasks, self-worth, and body issues, during the perinatal period can contribute to increased anxiety and depression. As health care providers we need to have alternative treatments to help our perinatal patients’ battle depression and anxiety. Yoga is a promising alternative to medication to help decrease depression and anxiety. Additionally it may be helpful for management of pain, anger, stress, gestational age at birth, birth weight, maternal-infant attachment, power, optimism, and well-being.
Interested in learning more about how you can apply therapeutic yoga in your practice? Check out "Yoga as Medicine for Pregnancy this April in Washington, DC!
Sheffield, K. M., & Woods-Giscombé, C. L. (2015). Efficacy, Feasibility, and Acceptability of Perinatal Yoga on Women’s Mental Health and Well-Being A Systematic Literature Review. Journal of Holistic Nursing, 0898010115577976.
As pelvic rehabilitation providers, it may be safe to assume a lot of us are treating adults with bladder and bowel dysfunction. Often we get questions from these patients about treatment for children with voiding dysfunction. How comfortable are we treating children for these problems and what would we do? Pediatric voiding dysfunction and bowel problems are common and can have significant consequences to quality of life for the child and the family, as well as negative health consequences to the lower urinary tract if left untreated. No clear gold standard of treatment for pediatric voiding dysfunction has been established and treatments range from behavioral therapy to medication and surgery.
A randomized controlled trial in 2013 that was published in European Journal of Pediatrics, explores treatment options for pediatric voiding dysfunction. Pediatric voiding dysfunction is defined as involuntary and intermittent contraction or failure to relax the urethral striated sphincter during voluntary voiding. The dysfunctional voiding can present with variable symptoms including urinary urgency, urinary frequency, incontinence, urinary tract infections, and abnormal flow of urine from bladder back up the ureters (vesicoureteral reflux).
The 2013 study compared 60 children over one year who were diagnosed with dysfunctional voiding into two treatment groups. One group received behavioral urotherapy combined with PFM (pelvic floor muscle) exercises while the other group received just behavioral urotherapy. The behavioral urotherapy consisted of hydration, scheduled voiding, toilet training, and high fiber diet. Voiding pattern, EMG (electromyography) activity during voids, urinary urgency, daytime wetting, and PVR (post-void residue) were assessed at the beginning and end of the one year study with parents completing a voiding and bowel habit chart as well as uroflowmetry with pelvic floor muscle sEMG (surface electromyography) was administered to the child for voiding metrics.
All parents and children in both groups received education about urinary and gastrointestinal tract function as well as healthy bladder habits, effects of high fiber diet, scheduled voiding, and normal mechanics of toilet training. For the group that completed PFM exercises and education, they participated in 12 sessions (2x/week for 30 minutes) to learn the PFM exercises under the guidance of a single physical therapist. There was bimonthly follow up for both groups throughout the 12 months to ensure retention and application of the behavioral urotherapy.
The goal of the PFM exercises for the children was too restore the normal function of the PFM’s and their coordination with abdominal muscles. The exercises that the children completed, included exercises with and without a swiss ball. The exercises without a swiss ball included breathing with the diaphragm, Transversus Abdominus muscle isolation, hip adductor squeeze (isolation), bridging with PFM relaxation, and cat/camel to improve lumbopelvic coordination. Swiss ball exercises included seated PFM contraction and relaxation exercise with a seated lift and relax, supine bridge with roll out on the ball with PFM contraction, and supine swiss ball lift with the legs and pelvic contraction. (Pictures and more details about how the exercises were carried out in the article itself.)
The conclusion of the study was that the functional PFM exercises with swiss ball combined with behavioral urotherapy reduced the frequency of urinary incontinence, PVR (post void residue), and the severity of constipation in children with voiding dysfunction. The children in the combined group showed improvements with voiding pattern, reduced EMG activity during voids, reduced urgency, reduced daytime wetting, and improvements with more complete emptying with voids (reduced PVR).
The Functional PFM exercises are easy to teach and easy for children to complete. They are a safe, inexpensive, and effective treatment option for children with dysfunctional voiding. PFM exercises combined with behavioral urotherapy seems to be a logical treatment option for treating pediatric voiding dysfunction.
To learn more about pediatric bowel and bladder dysfunction and treatment for it consider attending Dawn Sandalcidi's Pediatric and Pelvic Floor Dysfunction course. The three opportunities in 2016 are Pediatric Incontinence - Augusta, GA April 16-18, Pediatric Incontinence - Torrance, CA June 11-12, and Pediatric Incontinence - Waterford, CT on September 17-18.
Seyedian, S. S. L., Sharifi-Rad, L., Ebadi, M., & Kajbafzadeh, A. M. (2014). Combined functional pelvic floor muscle exercises with Swiss ball and urotherapy for management of dysfunctional voiding in children: a randomized clinical trial. European Journal of Pediatrics, 173(10), 1347-1353.
Occasionally, as pelvic rehab providers, we will encounter the question from our patients, “Do vaginal weights help with urinary incontinence and pelvic floor performance?” The premise behind the use of vaginal cones or balls is that holding them actively in your vagina with your pelvic floor muscles helps to increase the performance (strength and endurance) of the pelvic floor muscles, assisting in reduction of urinary incontinence.
A recent systematic review (Midwifery, 2015) explores this topic for a specific population of post-partum women with urinary incontinence. The question to be answered was “Does the vaginal use of cones or balls by women in the post-partum period improve performance of the pelvic floor muscles and urinary continence, compared to no treatment, placebo, sham treatment or active controls?”. This review had extensive search criteria. The types of participants in the studies analyzed were post-partum women up to 1 year (when starting interventions) of any parity, that underwent any mode of birth or birth injuries, and had or did not have urinary incontinence. Exclusion criteria were pregnant women, anal incontinence, and major genitourinary/pelvic morbidity. Any frequency, intensity, duration of pelvic exercises with the devices, and any form, size, weight, or brand of vaginal balls or cones were considered. Participants could undergo any type of instruction, either from a health care provider, or self-taught from written materials.
Of the searched studies, all were randomized or quasi-randomized controlled trials. The primary outcomes of the searched studies were pelvic floor muscle performance (strength or endurance) and/or urinary incontinence, both assessed with a valid or reliable method. 37 potentially useful articles were reviewed out of 1324 based on the search criteria, but only one article met all of the inclusion criteria and was included in this review with 192 relevant participants (Wilson and Herbison).
In the included study, the group that used vaginal cones (compared to control group) showed a statistically significant lower rate of urinary incontinence. However, when compared to the pelvic exercises group, the continence rates were similar at 12 months post-partum between the cone group and the exercising group. At 24-44 months post-partum, continence rates amongst all groups were similar, but follow-up rates were very low.
As pelvic rehabilitation providers, it is our job to promote pelvic health and assist our post-partum patients with their pelvic impairments, providing them with options to meet their goals. This review does not make a scientific statement of a preferred mode of pelvic exercise, however, it gives us one more option to consider when teaching patients about how to improve pelvic muscle performance to increase urinary continence following child birth. Pelvic exercise enhances pelvic performance, so if your patient would prefer to use vaginal cones or balls to do their pelvic exercise versus completing pelvic exercises without them, do what works best for the patient. One can argue that any pelvic exercise is better than none in improving performance. The use of vaginal cones or balls may be helpful for urinary continence in post-partum women, and provides us with one tool more when promoting pelvic health in our patients.
Oblasser, C., Christie, J., & McCourt, C. (2015). Vaginal cones or balls to improve pelvic floor muscle performance and urinary continence in women post-partum: A quantitative systematic review. Midwifery, 31(11), 1017-1025.
Wilson, P. D., & Herbison, G. P. (1998). A randomized controlled trial of pelvic floor muscle exercises to treat postnatal urinary incontinence. International Urogynecology Journal, 9(5), 257-264.
As pelvic rehab providers, we may find it easy to talk to our patients about sexual function when it is a patient who comes to us with a sexually relevant problem or directly related diagnosis, such as dyspareunia or limited intercourse participation due to prolapse symptoms. However, are we talking to our other patients about sexual function? Are they talking to us about it? What about our orthopedic patients - are we routinely asking them about how their problem can affect their sexual function? Some recent studies found that 32% of patients planning to undergo a Total Hip Replacement (THR) had reported concerns about difficulties with sexual activityBaldursson, Wright. Was the fact that they could not participate in sexual activity due to the hip pain a driving factor when considering the hip replacement, maybe? Just because a patient doesn’t ask, does not mean that they don’t want to know how their orthopedic injury affects sexual function. Resuming sexual function is an important quality of life goal that is included on few outcome assessment forms, however, there are some that address this subject such as the Oswestry Disability Index for Low Back Pain. Discussion of this topic should be addressed more routinely than it is.
A good example of an orthopedic patient who may appreciate the discussion of their injury and sexual function may be a patient undergoing a total joint replacement. A patient who undergoes a total hip replacement (THR) likely has movement precautions for a set amount of time and we should educate these patients about when to resume sexual activity and what positions may be more comfortable and safe for them with their new hip. It would be terrible for a patient to suffer a hip dislocation or implant failure during sexual activity because they returned to sexual activity prematurely or did not think about their movement precautions. Our patients are thinking about it, but sometimes may be too embarrassed to bring it up. So as a physical therapist, bringing it up in a professional way can help ease the awkwardness your patient may be feeling about the topic. As physical therapists we generally have more time with the patient than the surgeon and this can help create a comfortable space to discuss these topics.
It is important to remember that just because a patient is not in our office for a directly related sexual problem, it is still important to at least open up the dialogue about sexual health. One study in 2013 had patients complete a questionnaire on their sexual function after undergoing a total hip or total knee replacement and 90% reported improved overall sexual functionRathod, et al.. We should try to make the conversation part of our routinely delivered information for a total joint replacement, for example when telling our THR patient, you can resume driving at 3-6 weeks (or when cleared by surgeon), you have Range of Motion precautions of avoiding internal rotation, hip flexion past 90 degrees, and hip adduction (crossing the legs) for the length specified by your surgeon (if it was a posterior approach THR), and you can resume sexual function at 3-6 weeks (or when cleared by the surgeon), or when you feel ready after that. It is important to give the patient some kind of guideline about when they can expect to resume sexual activity, however, always emphasize that it should be resumed when the patient is ready so they don’t feel pressured before they are ready. Also as pelvic rehab practitioners we can offer them guidance about what positions may be best for them when returning to sexual activity to put less strain on the prosthesis and hip as well as help them be comfortable. To continue with our example for THR (posterior approach) their precautions are likely to restrict hip flexion past 90 degrees, hip internal rotation, and adduction, so for a man or woman following THR lying on their back would be a safe position.
As physical therapists it is our job to provide guidance. Instead of telling people what not to do, helping them find a safe way to do things they want to do to maintain function should always be our goal. Sexual activity participation is definitely an important function for quality of life that is often overlooked and not discussed, so talk to your patient about it, they will likely appreciate it.
One useful tool to learn more about positioning for sexual activity is the Herman & Wallace product “Orthopedic Considerations for Sexual Activity.” It provides a great list of positions with pros and cons of each position, and is a helpful visual aid for your patients to help them return to sexual function safely with consideration of their respective injuries.
Baldursson, H., & Brattström, H. (1979). Sexual difficulties and total hip replacement in rheumatoid arthritis. Scandinavian journal of rheumatology, 8(4), 214-216.
Wright, J. G., Rudicel, S. A. L. L. Y., & Feinstein, A. R. (1994). Ask patients what they want. Evaluation of individual complaints before total hip replacement. Journal of Bone & Joint Surgery, British Volume, 76(2), 229-234.
Rathod PA, Deshmuka AJ, Ranawat AS, Rodriguez JA. Sexual function improves significantly following total hip and knee arthroplasty: a prospective study. Program and abstracts of the 2013 meeting of the American Academy of Orthopedic Surgeons; March 19-23, 2013; Chicago, Illinois. Poster P023.
Episiotomy is defined as an incision in the perineum and vagina to allow for sufficient clearance during birth. The concept of episiotomy with vaginal birth has been used since the mid to late 1700’s and started to become more popular in the United States in the early 1900’s. Episiotomy was routinely used and very common in approximately 25% of all vaginal births in the United States in 2004. However, in 2006, the American Congress of Obstetricians and Gynecologists recommended against use of routine episiotomies due to the increased risk of perineal laceration injuries, incontinence, and pelvic pain. With this being said, there is much debate about their use and if there is any need at all to complete episiotomy with vaginal birth.
The primary risks are severe perineal laceration injuries, bowel or bladder incontinence, pelvic floor muscle dysfunction, pelvic pain, dyspareunia, and pelvic floor laxity. Use of a midline episiotomy and use of forceps are associated with severe perineal laceration injury. However, mediolateral episiotomies have been indicated as an independent risk factor for 3rd and 4th degree perineal tears. If episiotomy is used, research indicates that a correctly angled (60 degrees from midline) mediolateral incision is preferred to protect from tearing into the external anal sphincter, and potentially increasing likelihood for anal incontinence.
This remains controversial. Some argue that episiotomies may be necessary to facilitate difficult child birth situations or to avoid severe maternal lacerations. Examples of when episiotomy may be used could include shoulder dystocia (a dangerous childbirth emergency where the head is delivered but the anterior shoulder is unable to pass by the pubic symphysis and can result in fetal demise.), rigid perineum, prolonged second stage of delivery with non reassuring fetal heart rate, and instrumented delivery.
On the other side of the fence, many advocate never using an episiotomy due to the previously stated outcomes leading to perineal and pelvic floor morbidity. In a recent cohort study in 2015 by Amorim et al., the question of “is it possible to never perform episiotomy with vaginal birth?” was explored. 400 women who had vaginal deliveries were assessed following birth for perineum condition and care satisfaction. During the birth there was a strict no episiotomy policy and Valsalva, direct pushing, and fundal pressure were avoided, and perineal massage and warm compresses were used. In this study there were no women who sustained 3rd or 4th degree perineal tears and 56% of the women had completely intact perineum. 96% of the women in the study responded that they were satisfied or very satisfied with their care. The authors concluded that it is possible to reach a rate of no episiotomies needed, which could result in reduced need for suturing, decreased severe perineal lacerations, and a high frequency of intact perineum’s following vaginal delivery.
Yes, a recent study in the Journal of the American Medical Association by Friedman, it showed that the routine use of episiotomy with vaginal birth has declined over time likely reflecting an adoption of the American Congress of Obstetricians and Gynecologists recommendations. This is ideal, as it remains well established that episiotomy should not be used routinely. However, indications for episiotomy use remain to be established. Currently, physicians use clinical judgement to decide if episiotomy is indicated in specific fetal-maternal situations. If one does receive an episiotomy then a mediolateral incision is preferred. The World Health Organization’s stance is that an acceptable global rate for the use of episiotomy is 10% or less of vaginal births. So the question still remains, (and of course more research is needed) to episiotomy or not to episiotomy?
Amorim, M. M., Franca-Neto, A. H., Leal, N. V., Melo, F. O., Maia, S. B., & Alves, J. N. (2014). Is It Possible to Never Perform Episiotomy During Vaginal Delivery?. Obstetrics & Gynecology, 123, 38S.
Friedman, A. M., Ananth, C. V., Prendergast, E., D’Alton, M. E., & Wright, J. D. (2015). Variation in and Factors Associated With Use of Episiotomy. JAMA, 313(2), 197-199.
Levine, E. M., Bannon, K., Fernandez, C. M., & Locher, S. (2015). Impact of Episiotomy at Vaginal Delivery. J Preg Child Health, 2(181), 2.
Melo, I., Katz, L., Coutinho, I., & Amorim, M. M. (2014). Selective episiotomy vs. implementation of a non episiotomy protocol: a randomized clinical trial. Reproductive health, 11(1), 66.
Milk duct blockage is a common condition in breast feeding mother’s that can cause a multitude of problems including painful breasts, mastitis, breast abscess, decreased milk supply, breast feeding cessation, and poor confidence with decreased quality of life. A recent study in 2015 in The Journal of Women’s Health Physical Therapy1, showed that physical therapy (PT) maybe a helpful treatment for the lactating mother experiencing milk duct blockage when conservative measures have failed. Common conservative measures typically recommended are self-massage, heat, and regular feedings. The World Health Association, the American Academy of Pediatrics, and Academy of Breast Feeding Medicine, all recommend breast feeding as the primary source for nutrition for infants. There are many benefits to both the mother, and the infant, when breast feeding is used as the primary source for nutrition in infants. Having blocked milk ducts make it difficult and painful to breast feed and can lead to poor confidence for the mother and a frustrated baby as the milk supply could be reduced or inadequate. The primary health concern for blocked milk ducts is mastitis. Mastitis is defined as an infection of breast tissue leading to pain, redness, swelling, and warmth, possibly fever and chills and can lead to early cessation of breast feeding.
A blocked milk duct is not a typical referral to PT, however, this study outlined a protocol used for 30 patients with one or more blocked milk ducts that were referred to PT by a qualified lactation consultant. This study was a prospective pre/posttest cohort study. As an outcome measure, this study utilized a Visual Analog Scale (VAS) for 3 descriptive areas: pain, difficulty breast feeding, and confidence in independently nursing before and after treatment. The treatment protocol included moist heat, thermal ultrasound, specific manual therapy techniques, and patient education for treatment and prevention of the blockage(s). The thermal ultrasound and moist heating provided the recommend amount of heat to relax tissue around the blockage. Ultrasound also provided a mechanical effect that assists in the breaking up of the clog and increased pain threshold for the patient to improve tolerance to the manual clearing techniques. Next, the specific manual therapy was provided to directly unclog the blockage(s), and lastly the education provided was to help the patient identify and clear future blockages to prevent recurrence. 22 of the 30 patients were seen for 1-2 visits, 6 were seen for 3-4 visits, and none of the mother’s condition progressed to infective mastitis or developed breast abscess’s.
The results of the study showed the protocol used was helpful to ease pain, reduce difficulty with breast feeding, and improve confidence with independent breast feeding for lactating women that participated in the study. Although treatment of blocked milk ducts in lactating mothers is not a common PT referral, this study shows that PT may be one more helpful treatment for a patient experiencing this problem that is not responding to traditional conservative treatment. Since breast feeding is important to both mother and infant and is the primary recommended source for infant nutrition, it is important that a lactating mother receives quick, effective treatment for blocked milk ducts to prevent onset of mastitis and breast abscess that lead to early cessation of breast feeding. The cited study recommends that women who suspect a blocked milk duct or are having problems with breast feeding always seek care from a certified lactation consultant first, and that PT may be a referral that is made.
Cooper, B. B., & Kowalsky, D. S. (2015). Physical Therapy Intervention for Treatment of Blocked Milk Ducts in Lactating Women. Journal of Women’s Health Physical Therapy, 39(3), 115-126.
Commonly in physical therapy we treat patients with osteopenia or osteoporosis, however, they are usually in our office for another diagnosis such as back, hip, or pelvic pain as the primary complaint and we learn about the osteoporosis from health history review. Physical therapy is an opportunity to provide them with not just relief from their primary complaint, but a chance to learn from a professional how to move in a more healthy way and learn the right ways to exercises to make a regular routine that can help them to protect their body and even slow or stop bone mineral density loss. This is important as the primary concern for a patient with the diagnosis of osteoporosis is risk of fracture (especially of the hip or spine) due to minimal trauma because of low bone mineral density. So let’s make sure we are giving patients comprehensive exercise programs that address their primary complaint, however be comprehensive and include exercise modes that may reduce fractures and may improve bone mineral density.
An interesting article by Palombaro et al1 in 2013 from Physical Therapy discusses a Cochrane review by Howe et al2 and applies the findings from this review to an example patient similar to the participants reviewed in the study. The goal of the article is to link evidence in the literature with how we practice as PT’s. The topic explored in the systematic review by Howe et al was exercise for the management of osteoporosis in women postmenopause and which exercise approaches reduce the loss of bone mineral density or reduce chance of fractures in women who are healthy postmenopause. The systematic review2 included 43 randomized controlled studies of postmenopausal women age 45-70 where the intervention groups included exercises that improved aerobic capacity or improved aerobic capacity and muscle strength and had a comparison group completing “usual activity: or placebo intervention. The duration of exercise lasted from 6 months to 2 years in the various studies. The results of the review demonstrated decreased bone loss (of the spine or hips) in groups who performed any type of exercise compared to the control groups. The review also performed additional sub group analysis to take into account the various types of exercise programs in the studies and found favorable effect for all types of exercises completed (dynamic, low force, high force, weight bearing, or non-weight bearing) all had favorable effect on bone density. The take home message from this systematic review is that exercise programs combining various forms of exercises lasting 6 months to 2 years resulted in reduced risk for fracture, and a slightly beneficial effect on bone mineral density of the spine, trochanter, and neck of the femur in postmenopausal women with osteoporosis.
At the end of this article1 the authors give a case of an active, postmenopausal female patient with history of osteopenia without a fracture seeking PT for an unrelated complaint. The authors took the findings from this review and showed the relevance of the findings, applying it to the patient and the outcome of care for this patient when giving her an exercise program. We can implement findings from this review simply to the common question posed by our patients… “what exercises should I be doing to help with my osteoporosis?”
Exercises for a patient with osteoporosis should be forms of exercises that may improve bone density by loading bones (weight bearing exercise) and by increasing muscle mass (strengthening resistive exercise) to produce mechanical load and stress to the bone. Also as we age we tend to experience changes with not just a reduction of bone mineral density, but also a reduction of muscle mass. Additionally complicating the natural progression of aging are balance and gait changes leading to impaired physical performance. We should be giving our patients a comprehensive exercise program including safe weight bearing exercises and a strengthening program. Common examples of weight bearing exercises include regular walking, jogging, jumping, dancing, and racquet sports. Common examples of strengthening activities would include use of resistive exercises for upper and lower body with bands, free weights or resistive equipment. All of these classifications of exercise were considered as beneficial in the review.
To learn more about helping postmenopausal patients, consider joining Michelle Lyons, PT, MISCP for "Menopause Rehabilitation and Symptom Management". This course will be taking place March 19, 2016 - March 20, 2016 in Atlanta, GA. Another great resource to consider is "Geriatric Pelvic Floor Rehab: Modifying Treatments for Seniors and Older Patients" with Heather S. Rader, PT, DPT, BCB-PMD, taking place January 16-17, 2016 in Tampa, FL.
1 Palombaro, K. M., Black, J. D., Buchbinder, R., & Jette, D. U. (2013). Effectiveness of exercise for managing osteoporosis in women postmenopause. Physical Therapy, 93(8), 1021-1025.
2 Howe, T. E., Shea, B., Dawson, L. J., Downie, F., Murray, A., Ross, C., ... & Creed, G. (2011). Exercise for preventing and treating osteoporosis in postmenopausal women (Review).
Diastasis of the Rectus Abdominis Muscle (DRAM) is the separation of the two rectus abdominis muscles along the linea alba and is very common during and after pregnancy as the rectus abdominis and linea alba stretches and thins. Patients with DRAM are often sent to seek non-surgical management for DRAM from a physical therapist (PT). Typically these patients are either at the end of their pregnancy or adjusting to round the clock care of an infant. They can be sleep deprived, and have a full schedule of doctor’s appointments, having difficulty finding childcare, making attending PT somewhat challenging. Furthermore, they may have difficulty finding the time for a home exercise program (HEP). As PT’s we often struggle with making sure to give the patient exercises that will accomplish the goal of improving DRAM, however, making sure the HEP is not so extensive or time consuming that it becomes unmanageable. Is something as easy as abdominal bracing with exercise effective for reducing DRAM in post-partum women? A recent study published in 2015 in the International Journal of Physiotherapy and Research explores just this topic(Acharry).
Women with DRAM tend to have a higher degree of abdominal and pelvic region pain(Parker). Also women with DRAM may be more likely to have support related pelvic floor problem such stress urinary incontinence, fecal incontinence, or pelvic organ prolapse. The linea alba and rectus abdominis play an integral role in maintaining the anterior support of the trunk, these structures work together with pelvic girdle, posterior trunk muscles, and hips in maintaining stability when we shift weight (or transfer load) such as with standing, squatting, walking, carrying, and lifting. Therefore postural stability may be impaired with these daily tasks. Lastly, the abdominal muscles and fascia protect and support our organs so women with DRAM may have compromised support and protection of visceral structures.
Pregnancy is the most common cause of DRAM and studies widely range from 50-100% of women experiencing DRAM at end stage pregnancy. Natural reduction and greatest recovery of DRAM usually occurs between day 1 and week 8 after delivery. Various ways exist to diagnose DRAM. The gold standard for diagnosis is computed tomography but is sometimes considered impractical due to expense. Clinically a separation of 2.0-2.7cm or “two finger widths” of horizontal separation at the umbilicus or 4.5cm above or below while performing a hooklying (supine with knees bent) abdominal curl up is considered pathological separation.
Current guidelines for conservative treatment of DRAM are sparse with little established recommendations. The earlier referenced recent cross sectional study(Acharry) explores efficacy of abdominal bracing as a treatment for reduction of DRAM in post-partum females. The study included 30 females that were one month post-partum or more who had vaginal delivery with or without episiotomy. The average distance of the diastasis was measured before and after treatment using the finger width technique. The treatment included teaching the subject four abdominal exercises, and the subjects were encouraged to complete abdominal bracing while carrying out daily activities. The four exercises included 1) static abdominal bracing exercise, lying supine with arms crossed over the diastasis for support and then pulling abdominals inwards with an isometric contraction of abdominal muscles. 2) Head lift with bracing, in hooklying with arms crossed over diastasis, exhale, lift head and use hands (or a towel/sheet) to approximate diastasis towards midline. 3) Head lift and pelvic tilt with bracing, is the same as previous exercise only adding a posterior pelvic tilt. 4) Pelvic clock exercise with bracing, visualize a clock on the lower abdominals and complete gentle movements from 12-6 o’clock, 3-9 o’clock, 12-3-6-9-12 o’clock, in a clockwise fashion and then reverse the pattern in a counter clockwise pattern. All exercises were performed twice daily, with a repetition of 5-6 days per week, for 2 weeks duration. After completing the program for two weeks the distance of the diastasis was re-measured and the average DRAM distance decreased from 3.5 to 2.5 finger widths which was considered significant. The results of this study show abdominal exercise with bracing is effective for reducing DRAM in early post partal females.
As PT’s who treat DRAM we should encourage our patients to use abdominal exercises with bracing as well as encourage our patients to use abdominal bracing with their daily tasks such as standing, lifting, weight shifting, and carrying. A home exercise program such as the one in this study proved to be effective for reducing DRAM and included only four exercises making this a manageable home exercise program for our post-partum patients.
Herman & Wallace offers a full series of peripartum courses called the "Pregnancy Series". To learn more about diastasis of the rectus abdominis muscle, join Holly Tanner, PT, DPT, MA, OCS, WCS, PRPC, LMP, BCB-PMB, CCI at Care of the Postpartum Patient in Seattle, WA this March 12-13, 2016!
Acharry, N., & Kutty, R. K. (2015). ABDOMINAL EXERCISE WITH BRACING, A THERAPEUTIC EFFICACY IN REDUCING DIASTASIS-RECTI AMONG POSTPARTAL FEMALES. Int J Physiother Res, 3(2), 999-05.
Parker, M. A., Millar, L. A., & Dugan, S. A. (2009). Diastasis Rectus Abdominis and Lumbo‐Pelvic Pain and Dysfunction‐Are They Related?. Journal of Women’s Health Physical Therapy, 33(2), 15-22.
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As pelvic rehab practitioners, it is common for our patients to ask us dietary questions pertaining to their unique pelvic floor symptoms. We often counsel on fluid consumption, bladder irritants, and fiber intake. At times, we even give our patients a bladder or bowel diary to better monitor nutritional status and habits. However, how often do we ask about vitamin D status? It is common knowledge that vitamin D deficiency contributes to osteoporosis, fractures, and muscle pain and weakness, but what is the role of vitamin D in overall health of the female pelvic floor. Is vitamin D supplementation something we as health care providers need to at least discuss? An article published in the International Urogynecology Journal (Parker-Autry) explores this topic. This interesting paper reviews current knowledge regarding vitamin D nutritional status, the importance of vitamin D in muscle function, and how vitamin D deficiency may play a role in the function of the female pelvic floor.
Vitamin D affects skeletal muscle strength and function, and insufficiency is associated with notable muscle weakness. Vitamin D has been shown to increase skeletal muscle efficiency at adequate levels. The levator ani muscles and coccygeus pelvic floor muscles are skeletal muscle that are crucial supporting structures to the pelvic floor. Pelvic floor musculature weakness can contribute to pelvic floor disorders such as urinary or fecal incontinence and pelvic organ prolapse. Pelvic floor muscle training for strengthening, endurance, and coordination, are first line treatment for both stress and urge urinary incontinence, fecal incontinence, pelvic organ prolapse, and overactive bladder syndrome. The pelvic floor muscles are thought to be affected by vitamin D nutrition status. Additionally, as women age, they are more prone to vitamin D deficiency and pelvic floor disorders.
This article reviews several studies, including small case and observational, that show an association between insufficient vitamin D and pelvic floor disorder symptoms and severity of symptoms. The recommendation from this review is that more studies of high quality evidence are needed to fully understand and demonstrate this relationship between vitamin D deficiency and pelvic floor disorders. However, the authors feel that vitamin D supplementation may be a helpful adjunct to treatment by helping to optimize our physiological response to pelvic floor muscle training and improving the overall quality of life for women suffering from pelvic floor disorders.
The Institute of Medicine has only made recommendations for dietary allowance for vitamin D and calcium for bone health. There is no consensus for adequate vitamin D levels for a condition specific goal (other than bone health), and the levels of vitamin D varied throughout the reviewed studies. It has been shown that very high levels of vitamin D are tolerated well, so supplementation of vitamin D seems to be very safe in low and very high doses.
As pelvic rehabilitation providers, it is our job to assess the whole person, however, we are not dieticians. As physical therapists we are musculoskeletal specialists and vitamin D affects muscle function. What our patients put in their bodies (wholesome nutritious food vs nutrient lacking artificial food) affects the quality of the cells they produce and tissues that are made, which can influence their healing. When reviewing health history, maybe consider discussing vitamin D status and possible supplementation with the patient, or with the patients’ primary care provider or naturopathic doctor. This team approach may provide more comprehensive health care, hopefully yielding more successful outcomes.
Parker-Autry, C. Y., Burgio, K. L., & Richter, H. E. (2012). Vitamin D status: a review with implications for the pelvic floor. International urogynecology journal, 23(11), 1517-1526.