Diastasis Recti

DIASTASIS RECTI

Diastasis recti (the separation of the abdominal muscles) is a leading cause of pelvic floor dysfunction including incontinence, low back and pelvic pain, and prolapsed organs. All pregnant women experience a diastasis by 35 weeks weeks; however, 35-60% do not spontaneously recover [source].

On the internet, women can find a flood of exercise programs to reduce diastasis. Almost all of these, however, fail to consider transference of loads through the core and consequences of repetitive strategies that induce high intra-abdominal pressure.

Therapy utilizes strategies that consider the abdominal wall and its relationship to the rest of the body with emphasis on the pelvic floor and diaphragm. Diastasis recti can be rehabbed at any time, even years after giving birth. Although, the best results are obtained when intervention is provided almost immediately after delivery, before women are taking on loads with their body such as carrying baby.

Early intervention is ideally in the hospital and may include:

• Evaluation of Load Transfer
• Neuromuscular Reeducation
• Pelvic Floor Muscle/Abdominal Muscle Training (per protocol for lacerations)
• Core Stabilization 
• Education in Adaptive Techniques
• Education in Strategies for Load Transfer 

Taking the time after delivery to understand how the pelvic floor and abdominal muscles need to coordinate for load transference after pregnancy can reduce the occurrence of pelvic floor issues and provide lifetime benefits.  

Citations:

Mota, P., Pascoal, A. G., Carita, A., Bo, K. (2014). Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Manual Therapy. doi:10.1016/j.math.2014.09.002

Postpartum Urine Leakage

POSTPARTUM URINE LEAKAGE

Bladder leakage and overactive bladder is common after childbirth. 

It is estimated 30% of women experience accidental urine leakage at three months postpartum [source].

Research cites perineal tear, high body mass index, use of forceps, multiple deliveries, and vaginal delivery of an infant over 8.5 pounds as risk factors for postpartum bladder leakage. However, there is no one clear cause [source]. Women who delivered via cesarean experience postpartum bladder leakage and overactive bladder as well (though at lesser rates), which indicates that the stress of pregnancy on the pelvic floor muscles is a large contributor to postpartum bladder issues.

Urogynecologists recognize pelvic floor muscle training as effective to rehabilitate bladder leakage in the immediate postpartum period [source]. Therapy can begin immediately or weeks postpartum with obstetrician clearance. Treatment may include:

• Pelvic Floor Muscle Training
• Neuromuscular Reeducation
• Bladder Retraining 
• Biofeedback

Each woman experiences different symptoms, which is why individualized evaluation and care is needed to resolve postpartum bladder issues. 

Citations:

1. Glazener, C. M. A., Herbison, G. P., Wilson, P. D., MacArthur, C., Lang, G. D., Gee, H., & Grant, A. M. (2001, September 15). Conservative management of persistent postnatal urinary and faecal incontinence: randomised controlled trial. The BMJ.

2. Brubaker L. (2002). Postpartum urinary incontinence. BMJ (Clinical research ed.), 324(7348), 1227–1228.

3. Mørkved, S., & Bø, K. (1997). The effect of postpartum pelvic floor muscle exercise in the prevention and treatment of urinary incontinence. International urogynecology journal and pelvic floor dysfunction, 8(4), 217–222.

Accidental Bowel Smears or Gas

ACCIDENTAL BOWEL SMEARS OR GAS

The social and relational burden anal sphincter weakness causes to women is devastating.

Postpartum bowel smears and flatulence (accidental gas) are some of the most embarrassing postpartum symptoms women experience. More than 25% of postpartum women report bowel smears at six months postpartum and 40% reporting frequent accidental loss of gas, which almost always occurs during intercourse [source]. Anal sphincter injury from perineal tear is typically the cause of losing anal control.

Pelvic floor rehabilitation is up to 80% effective in the treatment of bowel smears [source].

Treatment may include:

• Pelvic Floor Muscle Training
• Neuromuscular Reeducation
• Bladder Retraining
• Biofeedback
• Compensatory Strategies
• Scar Mobilization and Massage
• Electrical Stimulation

Each woman’s issue is different. Individualized evaluation and care is the key to successful rehabilitation of postpartum bowel issues.

Citations:

1. Guise, J. M., Morris, C., Osterweil, P., Li, H., Rosenberg, D., & Greenlick, M. (2007). Incidence of fecal incontinence after childbirth. Obstetrics and gynecology, 109(2 Pt 1), 281–288. DOI: 10.1097/01.AOG.0000254164.67182.78

2. Scott KM. Pelvic floor rehabilitation in the treatment of fecal incontinence. Clinics in Colon and Rectal Surgery. 2014 Sep;27(3):99-105. DOI: 10.1055/s-0034-1384662.

Postpartum Constipation

POSTPARTUM CONSTIPATION

Constipation is a common pregnancy and postpartum issue that becomes a chronic issue when not treated properly.

Constipation that is developed during the pregnancy is typically caused by dyssynergia, discoordination of the abdomen and pelvic floor muscles. The pelvic floor muscles become hypertonic or tight and have a difficult time releasing a bowel movement.

There are three types of constipation, with the first type being the most common in pregnant and postpartum women.

1. Increased intra-abdominal pressure is accompanied by increased anal sphincter pressure.
2. Difficulty generating adequate pushing force (intrarectal pressure), with increased anal sphincter contraction.
3. Difficulty generating pushing force with incomplete anal sphincter relaxation.

Treatment may include:

• Pelvic Floor Muscle Training
• Neuromuscular Reeducation
• Visceral Manipulation
• Biofeedback
• Compensatory Strategies
• Scar Mobilization and Massage
• Electrical Stimulation

Individualized evaluation and care are successful to rehab constipation developed during pregnancy.

Pelvic floor rehabilitation is up to 80% effective in the treatment of constipation [source].

Citation:

Rao, S. S., & Patcharatrakul, T. (2016). Diagnosis and Treatment of Dyssynergic Defecation. Journal of neurogastroenterology and motility, 22(3), 423–435. DOI: 10.5056/jnm16060

Tailbone (Coccyx) Pain

TAIL BONE (COCCYX) PAIN

Tail bone pain, otherwise known as coccyx dysfunction or coccydynia, often stems from a childbirth injury.

When left untreated it causes chronic lower back and pelvic pain. This pain is difficult to resolve with traditional physical therapy because the muscles are best accessed via the pelvic floor. A key symptom of coccyx dysfunction is pain and intolerance of sitting.

There are many structures that attach onto the small surface area on the coccyx. The coccyx also provides support to important organs, such as the rectum and anus.

Click image to open a larger version.

The position of the coccyx will affect everything that attaches to it, which is why pelvic floor therapists are uniquely qualified to treat coccydynia. In fact, medical research cites therapy to be 90% effective in treating coccydynia [source].

Therapeutic treatment modalities can include:

• Manual Techniques
• Joint Mobilization
• Pelvic Floor Muscle Training
• Biofeedback
• Transcutaneous Electrical Nerve Stimulation
• Cryotherapy/Thermotherapy

The goal for each patient with tail bone pain is to be pain free.

Tail bone pain is best treated in the postpartum period, but can be addressed years and even decades following delivery. 

Citation:

Lirette, L. S., Chaiban, G., Tolba, R., & Eissa, H. (2014). Coccydynia: an overview of the anatomy, etiology, and treatment of coccyx pain. The Ochsner Journal, 14(1), 84–87.

Shoulder and Neck Pain

POSTPARTUM SHOULDER AND NECK PAIN

Treatment for the shoulder and neck pain some new moms experience should be holistic, looking at total body biomechanics as well as the responsibilities of the new mom.

As a new mom, looking down at baby for extended periods of time puts incredible pressure on the shoulders and neck. Couple this with the likelihood that a new mom has weakened core stabilizer muscles to support her upper body (abdominal and pelvic floor muscles), and it becomes clear why nearly 75% of new moms experience shoulder and neck pain [source].

Preventing postpartum shoulder and neck pain via ergonomic education and postpartum pelvic floor therapy is the best plan of action. However, shoulder and neck pain can be treated at any time. The goal for each patient is to be pain free while caring for their infant.

New moms are often back to work and unable to take time to find comfortable positions. Therapy for postpartum upper back and shoulder pain can include:

• Biomechanical Evaluation
• Manual Techniques
• Joint Mobilization
• Ultrasound
• Taping
• Positioning
• Adaptive Techniques
• Core Stabilization
• Cryotherapy/Thermotherapy

Citation:

Koyasu, K., Kinkawa, M., Ueyama, N., Tanikawa, Y., Adachi, K., & Matsuo, H. (2015). The prevalence of primary neck and shoulder pain, and its related factors in Japanese postpartum women. Clinical and Experimental Obstetrics & Gynecology, 42(1), 5–10.

Decreased Sexual Satisfaction or Pain

DECREASED SEXUAL SATISFACTION OR PAIN

It’s estimated only 19% of women seek care for the sexual issues they experience during the postpartum period [source]. Don’t let this be your story!

Pregnancy and both vaginal and cesarean delivery changes things. The transition into parenthood should not be at the cost of a woman’s sexual satisfaction. However, it is estimated that 83% of women experience a sexual health issue at three months postpartum and 62% at six months [source]. When these issues go untreated, they can have lifetime consequences to a woman’s quality of life. 

Common postpartum sexual health symptoms include:

• Vaginal Dryness
• Painful Penetration
• Clitoral or Vaginal Pain
• Delayed or Diminished Orgasm
• Pain with Orgasm
• Vaginal Tightness
• Vaginal Looseness
• Bleeding or Irritation
• Decreased Desire

There are many reasons women can experience decreased sexual satisfaction or pain.

 Treatment options can include:

• Scar Mobilization
• Manual Myofascial Techniques
• Visceral Manipulation
• Neuromuscular Reeducation
• Biofeedback
• Pelvic Floor Muscle Training

Each woman has a unique set of symptoms, which is why an individualized treatment plan is necessary to resolve postpartum sexual issues. Goals are specifically designed to address each individual woman’s preference of sexual satisfaction.

Citations:

1. Barrett, G., Pendry, E., Peacock, J., Victor, C., Thakar, R., & Manyonda, I. (2000). Women’s sexual health after childbirth. BJOG : An International Journal of Obstetrics and Gynaecology, 107(2), 186–195.

2. Barrett G, Pendry E, Peacock J, Victor C, Thakar R, Manyonda I. Women’s Sexuality After Childbirth: A Pilot Study. Archives of Sexual Behavior. 1999 Apr;28(2):179-91. doi: 10.1023/a:1018771906780. PMID: 10483509.

Postpartum Pelvic Pain

POSTPARTUM PELVIC PAIN

Pelvic floor therapy is a powerful tool to treat postpartum pelvic pain. 

Many women experience chronic pelvic pain after pregnancy. The pelvic floor muscles are intricately involved in pregnancy. They also support the internal organs, spine, and pelvic girdle.

When the pelvic floor muscles are unable to relax or tissues of the pelvis are scarred from laceration or microtears, it can produce imbalance in the pelvic area and result in chronic pelvic pain.

Illustration of the pelvis and pelvic floor muscles.

Nonrelaxing pelvic floor dysfunction is often unrecognized by providers and instead treated as low back pain or other common orthopedic impairments [source]. Many women suffer a lifetime of pelvic pain from pregnancy that did not get resolved in the postpartum period.

Another cause of pelvic pain after pregnancy is the changed position of the uterus. When the uterus descends or shifts after pregnancy, it can create painful tension on the uterine ligaments that attach to the pelvic bones.

Treatment for pelvic pain can include:

• Manual Techniques
• Joint Mobilization
• Pelvic Floor Muscle Training
• Biofeedback
• Transcutaneous Electrical Nerve Stimulation
• Cryotherapy/Thermotherapy
• Core Stabilization
• Recommendation for Pessary Placement

Our goal for each patient is to be pain free.

Citation:

Faubion, S. S., Shuster, L. T., & Bharucha, A. E. (2012). Recognition and management of nonrelaxing pelvic floor dysfunction. Mayo Clinic Proceedings, 87(2), 187–193. DOI: 10.1016/j.mayocp.2011.09.004

Preventing Pelvic Organ Prolapse

PREVENTING PELVIC ORGAN PROLAPSE

Pelvic organ prolapse is a significant health risk for postpartum women.

Pelvic organ prolapse is where the muscles and supporting structures of the pelvis become weak and loosened, allowing one or more of the pelvic organs to collapse or fall into the vagina. In severe cases, the pelvic organs will protrude outside of the vaginal entrance.

Pelvic organ prolapse is a significant health risk for postpartum women. Nearly 50% of women having prolapse six months after both vaginal and cesarean delivery [source]. Symptoms include a heavy pressure in the pelvis or feeling like something is falling out. Other symptoms may include bladder leakage, constipation, pain with sex, and/or lower back or pelvic pain.

Strengthening the pelvic floor muscles is effective to support and recede prolapse. In some cases, especially women who are high impact athletes, we will recommend being fit for pessary to provide additional support. Each prolapse is different and many are not detected unless being displaced by gravity in a standing position or impact with exercise.

Treatment for prolapse may include:

• Pelvic Floor Muscle Training
• Core Stabilization
• Education in Body Mechanics to Decrease the Load Onto the Pelvic Floor
• Biofeedback
• Adaptive Techniques to Decrease Symptoms

It is estimated that 1 in 5 women will have surgery to correct prolapse, which is why we highly recommend pelvic floor therapy for all postpartum women to manage and prevent pelvic organ prolapse [source]. Rehabilitation can begin almost immediately after delivery, if not contraindicated by tear.

Citations:

1. Hagen, S., & Stark, D. (2011). Conservative prevention and management of pelvic organ prolapse in women. The Cochrane Database of Systematic Reviews, (12), CD003882. DOI: 10.1002/14651858.CD003882.pub4

2. Hallock, J. L., & Handa, V. L. (2016). The Epidemiology of Pelvic Floor Disorders and Childbirth: An Update. Obstetrics and gynecology clinics of North America, 43(1), 1–13. DOI: 10.1016/j.ogc.2015.10.008