Birth as a Musculoskeletal Injury: The Role of Physiotherapy

Melissa Dessaulles, pelvic physiotherapist, shares with us her insider view into why we define birth as a musculoskeletal injury and what role physiotherapy can play in recovery.

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[00:00:50] Melissa Dessaulles: Birth is a miracle. Birth is beautiful. It's amazing what our body can do. It's no wonder some people feel uncomfortable when they hear that [00:01:00] birth is also maybe considered an injury. However, if you stop and think about what truly happens to mom's body during a C-section, which is a major abdominal surgery, or a vaginal birth, an extreme stretch to muscles, ligaments, vessels, and nerves, isn't that a tissue injury?

[00:01:18] if we don't acknowledge this, does that perhaps leave women feeling like something is wrong with them if they're left with symptoms that negatively affect their long-term quality of life? My name's Melissa Dessaulles. I call myself a physiotherapist for embarrassing things. My area of practice is primarily pelvic health and many of my clients are pregnant and postpartum women.

[00:01:41] I work with clients both in person and virtually. I'm based in Kelowna, BC, Canada and I myself host a podcast called The Pelvic Floor Project. I'm a strong advocate for proactive healthcare and collaboration with interdisciplinary care providers, so [00:02:00] I'm honoured to be part of this initiative. My goal for this episode today is to provide a bird's eye view of how physiotherapists can play a role in helping people prepare for and recover after the musculoskeletal injury that is birth.

[00:02:15] I've been a physiotherapist since 2006, a proud graduate of the University of Saskatchewan. The first 10 years of my career, I worked in the hospital setting. So in, for example, an orthopedic word as physiotherapists, we see people after they've had hip surgery, knee surgery, like joint replacements, broken bones, and we'd be consulted to see people the day after their surgery most often. And we'd look at their chart, we'd see what the doctor ordered. And then our job would be to go assess that person in front of us, help them mobilize, get them out of the bed maybe the first time, find out what kind of equipment they need, how are they gonna negotiate the stairs if they have at home, are they in a wheelchair? Are they a high level athlete? [00:03:00] But our job is to look at the person in front of us, help them get going, and then start working with them to progress the motion of their knee, eventually progress the strength of their knee, and then set them up with a plan to move forward. I also spent many years working in the intensive care unit. There, we would be involved with some of the sickest clients, where we'd work with the nurses to help get people up out of bed with multiple tubes attached to them. We knew the benefits of early mobilization for clients. I worked with people that were preparing for open heart surgery. We would see them as physiotherapists before their surgery to give them an idea of what to expect, how to get outta bed with the least amount of pain, how they're gonna hug a pillow supporting their chest or their breast bone to help protect the area that they had their operation. And also just give them a plan for afterwards what they could expect from us from a physiotherapy point of. And at the end of the day, we know [00:04:00] that preparation helps people feel less anxious and nervous, and feel like that they can put a plan in motion. Why do we do all of this as physiotherapists in the hospital setting?

[00:04:10] Evidence shows the benefits of being prepared not only for something, but early mobilization helps decrease length of hospital stay, less hospital readmissions, better long-term outcomes, but we don't do this for people preparing for birth and recovering after birth. I had my first baby nine years ago. I was pretty active in my pregnancy. I remember taking time to rest and recover after I had my baby, but I also was just itching to get back to exercise. I felt like my body was nothing the same as it used to be. I felt like I didn't recognize it, and of course none of my clothes fit. And I just was so used to doing something almost every day for activity and I couldn't get, couldn't wait to get back to just feeling like myself again.

[00:04:58] And my typical activities were [00:05:00] going to the gym and lifting weights, running, HIIT style exercise, cycling. So I started doing all of that. I craved that. That was the stuff that I was normal for me, but I really had a lot of symptoms. I remember leaking, I remember horrendous pelvic pain. After I exercise, I remember I'd sit down and I'd go to stand up again and I couldn't even, I couldn't even take a step without wincing in pain. And I would say my body just felt broken. My husband's a physiotherapist too, and I remember always going to him with something new. My calf hurts. My shoulder hurts, my hip feels sore.

[00:05:37] There was always something and it actually took me, I couldn't see it in myself but it, and it took me a while to recognize I did too much too soon. There's nothing wrong with getting back to running or jumping or cycling, but my body just wasn't quite ready for that. Similarly, I would never tell someone after a knee surgery that my guidance [00:06:00] is, to rest and elevate your leg and then just get back to jumping and running first. That person would stare at me and think I was crazy, but we just don't apply those same principles of gradual progression to a postpartum woman. The second time around when I had my next baby, three years later, I felt like I had learned so much in the process, so I was able to adopt this slow, steady progression and start with the components, gently rehab my body and then start to progress it. And I was able to return to things like jumping and running much more successfully. And then some people will say, I was fine. I didn't do any rehab. I didn't see a physio after I had my baby and my grandma sure didn't see a pelvic health physiotherapist. And to that I say absolutely. Our body is resilient and it has the ability to heal. With rest, nourishment, support, and gradual return, often our body will sort it out. Back when our moms or grandmas were having kids, I think times were a bit [00:07:00] different. Many women were younger, we're having our kids a little bit later in life. We often had more support around us. Maybe we lived with family or there closer by, so it was just a given that we had more time to rest. Many moms stayed home with their kids and had less pressure to return to work. Life was a bit simpler. Less activities to organize. Not so much time dedicated to this busy life that we have, and exercise was more about working around the house and walking places and playing with our kids, not necessarily the pressure to get back to the gym or lose weight fast.

[00:07:38] I see many pregnant and postpartum women, and if I could share some of the trends that I see over and over again. One, so back when I had my first baby nine years ago, there was no social media. There was no Instagram, Facebook, I don't remember using it that much. I didn't really go to Google as much as I went to the library or I asked people that I knew [00:08:00] and there were no podcasts. So I was fairly oblivious. Now, the pendulum is definitely swinging and there is this effort to provide more information. Social media is full of advice and so much of it is inaccurate, but the result quite often is overwhelmed and along with a busy life, many women are choosing to stop being physically active throughout pregnancy.

[00:08:29] I think most often if I ask people in pregnancy, tell me are you being, what kinds of things are you doing for physical activity? And so many women say nothing and I think sometimes it's, I get that you're not feeling well. Sometimes people are like, I'm just absolutely exhausted because they're busy, right? And they're pregnant. But also they'll say I don't know what to do. There's so much information, so I'm just not doing anything. Cause I'm worried something will go wrong. But then if you think about it, lack of physical activity also means deconditioning. Anytime we stop doing physical activity, [00:09:00] our whole body will decondition.

[00:09:04] Postpartum, a trend that I quite often see is like new moms finding themselves on two different ends of a spectrum. On one end there's a fear of damage or doing something wrong, so they avoid moving their body as much as possible. They've heard that if you twist, you're gonna split your abs apart.

[00:09:24] If you bend down, you're gonna prolapse. If you, if you lift something too heavy, you're gonna wreck your pelvic floor, and that's scary information, which makes people stop moving. The other end of the spectrum, I see moms who feel absolutely elated. Like superheroes and just like me, my first pregnancy, they crave getting back to their old activities. I just can't wait to run again. Oh my gosh. Like I, oh, I feel so flabby. I just wanna fit in my clothes and I can't wait to get back to the gym where my friends are hanging out. So they get back to those activities that [00:10:00] are just a little bit too much, too soon. And again, there's nothing wrong with those being a goal. But if you think about the whole change that has happened not only during birth but to your whole body throughout pregnancy we have a different body postpartum and it takes a while to build back up to more intense activity.

[00:10:23] Another thing I see just, in general is most guidance postpartum is geared towards the baby. So it's no wonder that women are finding it hard to find guidance for themselves. How do we support these moms? Enter physiotherapists. This is our bread and butter. Our education is based around understanding the body as a whole and looking at the person in front of us. Remember how I said when I'm consulted in the hospital to see someone after a hip or knee surgery? What I would first do if I was given a requisition to go see someone in the hospital, the first thing I would do is I would look at their chart and I would see [00:11:00] a little bit about this person. How old are they? What does their life look like? Do they live at home with other people? What do they do for work?

[00:11:07] What kind of surgery did they have? What guidelines have the surgeon has the surgeon put into place? When do they wanna follow up? I look through the nurse's notes to see what kind of issues this patient is having. Have they been outta bed yet? Is there pain managed? And so I can picture what's going on with this person before I even show up into their room.

[00:11:27] So that's what I'm thinking too when I work with a person during pregnancy or postpartum, is I think of that person as a whole. I don't just think of their pelvic floor or their abdominal incision, but what does this person's life look like? How are they coping right What do they need to get back to?

[00:11:42] That's our job as physiotherapists. Where are they now and where do they need to be and how are we gonna progress them? While being mindful of the stages of healing. I'm definitely also seeing a trend towards people coming to see me virtually or in person during pregnancy [00:12:00] and saying, I'm here, my friend or my midwife, or my doctor told me to come. And sometimes they don't know why. I always ask them like, oh, in what context are you here? What are you interested in? And quite often they'll say, geez. I don't know. I just was told that it was so valuable and that's why I always parallel something like the knee because either people have had a surgery themselves or they've seen a parent before, or they can conceptualize what happens. But it's very similar. And so I explain, let's say you knew that you were having a knee surgery in six weeks time and you're a pro, you have a proactive mindset and you wanted to know how do I go into my knee surgery with my best foot forward and how do I optimize my recovery?

[00:12:46] I would explain that we wanna optimize the movement of your knee and optimize the strength of your knee and going into the surgery. But then I would also want to give you an idea of what [00:13:00] to expect after. And so we would work with that patient to, help them feel confident going into their surgery. And then, as I mentioned earlier, we would show up the day often with a physiotherapy assistant, show up in the room the day after surgery. And the first thing I would do is I would look at that person and just see, are they in bed? Are they outta bed? And obviously, at the very early stages after something like a surgery, we want to prioritize rest. Rest is the most important thing for healing, so I would expect that person after the knee surgery is gonna spend most of their time in their bed or in their chair with their leg elevated. I would want to make sure that they have adequate pain management. So I would talk with the nurse and just, or talk with the patient like, how are you feeling? Cause I want you to have adequate pain management so that you can get around. And I would also want to see like how much movement. Now that you've just [00:14:00] had your surgery, let's start getting a little bit of movement in your knee. And I wouldn't expect much. It wouldn't be something that I would force to have full movement by any stretch of the imagination. But just let's start some early movement and let's get you outta bed. Let's see. How much help you need? Can you do it on your own or can we give you a hand? Give you some tips because sometimes it's hard to figure out how do I move now when my leg has to stay straight? Or how do I move when I have such a sore leg?

[00:14:25] So help problem solve things like without the bedrail in the hospital. How are you gonna get up? How are you gonna use these crutches? How are you gonna use this walker? Let's make sure that you can get around the hospital room. Let's talk about what your house looks like. Do we need to review how to do the stairs. Do you need to do anything special? Do you need to talk about how to get in and out of a car, anything like that? And then we would show up a couple times a day to get going on some very basic exercises at the beginning. Just very early motion and strength and that first six weeks is very critical for [00:15:00] rest, primarily. And then we'll slowly progress the exercise intensity or the the difficulty of the exercises. Eventually you'd be walking with a limp. Absolutely. Maybe you can't even put your foot down initially, but we'd be working towards you walking without a limp. And then eventually when you're working with someone out in the community, they start working on you starting to have, maybe moving with more strength, adding some bands, adding some resistance, adding some weight, starting to add some impact.

[00:15:30] Slowly progress the impact, eventually progress back to running and back to the activity or sport of your choice. This is when I usually say to the client, what do you think of that? Does that make sense? And most people are like, that makes complete sense like that. I understand that you would rest at the beginning.

[00:15:46] I picture that if it was my dad having a knee surgery we would rally around him. He wouldn't have to worry about mowing the lawn, he wouldn't be at work for a while. And we'd be bringing him his lunch initially on the coach. But then after a while, he'd start doing it himself. [00:16:00] He'd start doing a little bit more. Maybe he can only do half the lawn, then he can do the whole lawn. People can picture that progression and it makes sense. It doesn't make sense for them to say okay, dad's going home and dad's gonna mow the lawn first day. Everybody knows that.

[00:16:15] So how do we apply this to pregnancy and postpartum? So if we go back to that client and I've said to them, why are you here? What interests you? I quite often draw this picture. I have a piece of paper and in the middle of the paper I write down pregnancy. And then I have all these lines coming off the word pregnancy. And I say to people, this is why some people come in during pregnancy and what they're interested in. One of the ideas is aches and pains. Some people have aches and pains in pregnancy. Some pelvic pain. Back pain. They're not able to get through their day without having aches and pains, and so that's something that I might work with them on. Sometimes it's exercise modification. As I mentioned, there's a lot of fear around exercise in pregnancy. But there's actually a lot of evidence to support that [00:17:00] exercise is very valuable for so many reasons in pregnancy. But the benefits far outweigh the risks unless there's obviously some different reasons that would be individual for a for a client. But I want people to feel as active as they can in their pregnancy. But obviously with things they want to do. So that's always an individual conversation. What are you doing right now and what do you want to do? Because I wanna help you understand how to modify and how to stay well-rounded in your exercise because postpartum requires you carry around a heavy weight a lot.

[00:17:34] Your baby is a lot of weight that you're carrying around repetitively in awkward positions. And to avoid aches and pains postpartum, I want you to feel strong. And so we'll talk a little bit about exercise if they're interested in. I also wanna dispel any fears. So I often say a lot of women during pregnancy have heard terms like diastasis or prolapse or pelvic floor damage, and I want you to [00:18:00] understand your body so that you don't have fear. This is the time to be excited and I want you to not fear, feel fear when it comes to your body. So is there anything here that you want to talk about? Lots of times people have heard about physiotherapy for birth preparation. And so that's something else that we do a lot of work with. And then another option would be that we can talk about postpartum recovery.

[00:18:21] And a lot of people are like actually, I'm interested in all of that. And we use those sessions to go through what they want to, and I have to say here that sometimes there's a misconception that you need to see a physio throughout your pregnancy every week or something like that. I very much tailor this to whatever the person in front of me wants. Some people say, you know what, Mel? I don't have benefits. And time is limited. So I wanna get the most bang for my buck, and I'm very much dedicated to doing things on my own at home. So for some people, I'll see them once and that's completely fine. For other people, they want much more guidance, and so I see them more often. [00:19:00] Everybody's different, and so there is not a set number of times that you need to see me in your pregnancy. I'll be diving deeper into all of those topics for pregnancy in later episodes, but just giving you a bit of a bird's eye view, big picture as to what we're able to provide education and support for in pregnancy.

[00:19:20] I always suggest to people if you're interested in having some guidance throughout your pregnancy and your postpartum recovery, if you can reach out to someone and find someone that you know, and trust in pregnancy, mainly because postpartum can feel like a very vulnerable time and you're less likely to reach out to a stranger at that time. I think sometimes there's a lot of fear around, I've gotta wait to see a physiotherapist until after six weeks postpartum. I couldn't disagree more. This comes back to what I saw all the time working in the hospital. If I wouldn't see any of those patients in the hospital for six weeks, I feel like we miss out on so much opportunity for long-term [00:20:00] benefit.

[00:20:01] If we just left those people after a knee surgery and said ah, you know what? Just wing it for six weeks and then let's hope for the best. Versus someone that had guidance, which one would you prefer? And most people say, oh, I'd rather have some guidance. And I think this is where the misconception around physiotherapy often comes postpartum is I think physiotherapy and work hard, exercise more, is what people picture. Whereas in that first six weeks, I find my role to be more like, let me help you ease your mind about some of the things that you're feeling. Let me help you understand what's going on in your body. Let me give you some tips and tricks on how to move with more ease. Just like I'd be showing up in that hospital room to see the patient after their knee surgery, helping them move better. I wouldn't be like, let's run. Let's jump. And be like, let me just see if we can offload your knee. A bit like with the crutches or with a walker. For a postpartum body, I'd be looking at things like, okay, I understand, like again, I'm picturing you in your environment. [00:21:00] I understand that this is what you need to do. I'm thinking about who's gonna support you after. I know you need to lift your baby a lot. I know you need to be moving in all sorts of awkward positions. So let me give you some ideas on how you can do that with less pain or with less pressure, or making you feel like it's easier. And the focus postpartum would be on decreasing pain, giving you strategies to feel more comfortable, and also giving you some very basic things like early movement of your knee, early movement of your core in your pelvic floor.

[00:21:33] I wouldn't be forcing the knee to move. I'm not gonna force the core and pelvic floor to move, but we know the benefits of early mobilization and movement of muscles after an injury. So this is why I suggest to people, people say, when should I see you postpartum? I like to do my first, at least the first appointment with people online because then you don't have to leave your house. You can stay in your pukey PJs and your baby can be with you the whole time if you want. And I tell [00:22:00] people, reach out as soon as you're ready. I don't want you to be sitting at home with questions or feeling nervous. I've seen people as early as two days postpartum because maybe they've had a c-section they're not anticipating, or maybe they just, so many people just have a proactive mindset and they want to know that they're doing everything that they can. Again, our body has the potential to heal and it's sometimes we just need a little bit more support. Some people have questions, some people like more guidance, and I would say another one of the trends I see is just , you know, people saying, oh, I wish I would've known some things to do because I think I overdid it. I noticed that my C-section incision didn't heal as well, or, maybe people say, I popped to stitch down in my perineum and I realize I, I'll never forget one lady that said I was climbing up on the counter to get something. I felt like a million bucks and I was climbing up on the counter. I didn't even think that my body wasn't ready to do harder things. So again, I can't say enough. [00:23:00] Physiotherapy role in the first six weeks is definitely around helping you understand your body, supporting your body, and giving you a plan for gentle progression. Once people are starting to feel that their day-to-day activity is starting to feel a bit easier, we'll talk about walking progression, how walking progression might turn into hill walking and then running, and what return to running might look like. Maybe there's someone that likes strength training. So how can we start with just body weight movements that you can incorporate into your day? Maybe just two minutes. It doesn't need to look like the gym right away, but how can you get in some very early movement at the beginning to help your brain connect with those muscles again, help you feel confident in that, and how to slowly progress the amount of weight you're lifting.

[00:23:42] It's all about progressive loading and helping you get back to the, your, the activity of your choice. So if I could leave you with a couple take home messages. First, does everybody need to see a physiotherapist before and after birth? No, I can't tell you what to do. [00:24:00] If you're someone that loves guidance, you feel supported when you have more information and you think that it would enhance your pregnancy or postpartum recovery? Great. If you're someone that feels confident in the process, you understand the concept of a slow and steady progression after, and you feel like you'll sort it out as you go, that is great too. If you decide to work with someone, please know, no two physiotherapists are the same, and find someone that you know and trust. If you were to go to a restaurant and you had a good experience, you'd probably go back. If you didn't, you probably wouldn't go back. And the same applies for physiotherapy. If you find someone and it doesn't feel right, or you don't have that warm fuzzy feeling inside, you don't have to go back. There's no two physios the same. Find someone that helps you feel supported. And for that I suggest reaching out for ideas from friends, from mom groups, ask your doctor, ask your [00:25:00] midwife, and go with how it feels because you deserve to feel supported and work with someone that you feel like you click with.

[00:25:06] For providers out there, I hope this encourages you to reach out to physiotherapists in your area to make a connection, figure out what each one is about, and have that network of people around you because collaborative care really helps to support our clients in so many different ways. Stay tuned for future episodes where I'm gonna go into more detail on all these topics about how physiotherapy can support clients during pregnancy and postpartum.

[00:25:35] You can find more about me and my podcast, The Pelvic Floor Project at mommyberries.com.