Returning to Running Postpartum

exercise postpartum fourth trimester postpartum return to running running postpartum Apr 10, 2023

Melissa Dessaulles, BScPT, BScKin, Pelvic Health and Gráinne Donnelly, Advanced Physiotherapist in Pelvic Health and clinical researcher, discuss the 2019 returning to running postnatal guidelines for health, medical and fitness professionals managing this population.



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[00:00:00] This episode is a collaboration between Melissa Dessaulles of Mommy Berries Physiotherapy and the Pelvic Floor Project.


[00:00:56] Melissa Dessaulles: How many of you love to run? I get it. It's [00:01:00] free. You can do it right from your doorstep. You can tune out and listen to music. Or my podcast. You can go slow, you can go fast, you can go several kilometers, or you could just go a few. But you've also heard messages like it's not good to run after having a baby. Running damages your pelvic floor. Running causes prolapse. I work with some clients who are very fearful of running and others that feel shame that they are running and just can't help themselves. What if I told you that running is a great postpartum goal, if you love to run? But running's just hard. So there are steps to consider when working your way back up.

[00:01:42] My guest today is Gráinne Donnelly, a clinical researcher and fellow pelvic health physiotherapist all the way from Ireland. She's not only a skilled and experienced therapist, but has helped to create a world renowned guideline that helps women return to running successfully after having a [00:02:00] baby. And she has the most amazing accent. Gráinne 2019, Grania, along with other physiotherapists called Emma Brockwell and Tom Goom, created a guideline called Return to Running Postnatal: Guidelines for Medical Health and Fitness Professionals managing this population. I actually refer my clients to these guidelines all the time for a few reasons. They help women understand the changes their body has gone through during pregnancy and birth, and all the literature to back that up is included. How to work back up to running and how this process can be started early on in the postpartum period. Now I'm excited to break down these guidelines with Gráinne for all of you today. Now, whether you are a healthcare provider that works with perinatal women or a new mom, chomping at the bit to feel the wind blowing through your hair, let's get running with this episode.

[00:02:58] All right, Gráinne. I'm really [00:03:00] looking forward to this topic because I think it'll help so many people. This is like getting back to running after having a baby is something that many women strive to do, right? And so I was kind of joking with you before I hit record that when I was thinking about who should I ask to talk about this? I thought, well, I'm gonna, I'm just gonna go straight to some of these people that have created guidelines recently, and I'm just gonna ask, they'll probably say no cuz they're so busy. But I'm just gonna ask, and you said yes!

[00:03:25] Gráinne Donnelly: So thank you. But I'm absolutely honored to be asked. Sorry. I am, and apologies for anyone who's heard me before. I lost my voice and I'm gonna blame it. I was on annual leave with the kids last week, and any of you moms out there will know a house full of kids are very busy. And I think this is just all catching up. I need a holiday after the holiday.

[00:03:42] Melissa Dessaulles: Absolutely. Totally. So. I want you to actually just maybe tell the listeners a little bit about yourself. So I'll tell you first how, tell everybody first how I heard about you. I mean, obviously the pelvic health community is fairly small in a lot of ways that we're all part of the same groups. You hear people talk and I [00:04:00] just hear your name come up often as it is associated not only with diastasis, but also with return to running and some guidelines that you and some other physios created a couple years ago. And I think that. If you don't mind really quickly talking about a little bit about yourself and just how did these guidelines come to be?

[00:04:19] Gráinne Donnelly: Yeah, thank you. Well, I'm a physiotherapist specialized in pelvic health. I'm based in Northern Ireland, which is actually part of the UK. People always think I'm Ireland, but I'm on the island Ireland, but it's the part of the UK and up until this year I worked as the clinical lead for pelvic health in my local health trust.

[00:04:39] But I recently left that post because I've just, I've started to dip my toe into research and I'm still doing my own private practice, so I just didn't have enough time to spin all plates. So the guidelines really came about when myself and a musculoskeletal physiotherapist called Tom Gumm, who is from England in the UK [00:05:00] and a fellow pelvic health physio called Emma Brockwell, came together because we realized there was very little guidance out there to inform both professionals and the public about how women should navigate a return to running after having a baby. And it almost seems that for all too long, this has been a neglected area. It's such an important milestone in someone's life, and yet there's very little to guide them afterwards. So realizing there was very little research, we decided to come together and do a scoping review of the literature and see if we could formulate the beginning of recommendations that may be evidence informed in order to guide people back to running in a safe and future-proofing manner.

[00:05:47] Melissa Dessaulles: Absolutely. I think it's really helped, as a pelvic health physio, I feel like it really helps almost give me a bit of a framework too. I mean, we know a lot of this stuff, when you think about it, you're like, oh, I know all of this. This is all stuff I apply, but [00:06:00] sometimes you feel like you need something to fall back on. Do you know what I mean? That, that you can refer to or that you can say listen, they've looked at the research and it just, it gives you a bit of backing, doesn't it?

[00:06:11] Gráinne Donnelly: Yeah. I think what you've said's really important because. When we have an absence of guidance, there's kind of an open playing field for anyone to take any approach that they want. So there's so many conflicting messages out there, which is very confusing to, if I was a mom after having a baby and I went and searched Google, I'd be very confused.

[00:06:33] So I think the idea of this framework, as you've mentioned, in order to even as a professional, so for any health and fitness professionals out there, even just to validate that, oh yeah, this is what I do. Good. This is what everybody else is doing too. So I think it's really important, and for anyone who was looking at the guideline and thinking, gosh, I don't consider this, or this isn't the approach I take, it's maybe getting them thinking about where maybe the evidence-based does take us. So I think it's really important [00:07:00] that across the world we're all having a common approach and women are accessing consistent evidence informed information.

[00:07:09] Melissa Dessaulles: Absolutely. And I think it's important to point out that maybe kind of what happened in the past, it still does happen. There's definitely changes, positive changes coming, but it used to be that, we have a baby, we, whether it be vaginal or cesarean birth, very little to no guidance in that in that early recovery phase, we go to see our healthcare provider, our appointments are based around our baby. Go to see our healthcare provider around that six week mark and generally, given that you know what you're okay to resume activities, and it leaves people on a spectrum anywhere from what are you sure like big things have happened and I'm supposed to do everything. Which can be scary to a lot of women and to other women are just like, yes, I can't wait to get out and run. I just wanna sweat and get away from the family and I just wanna feel like myself again. But I think that as, we can both agree too as physios, and I think a lot of [00:08:00] moms listening will be like, yeah, I mean, I definitely had problems with leaking or issues related to sexual function. My core felt off. A lot of people will describe, or I had heaviness and pressure, but lots of different symptoms that we see as postpartum women. And I think that when you, we start to kind of break down that, wow, like this is kind of another musculoskeletal injury that we go through. And we would never treat another injury like that, that we'd say rest for six weeks and pedal to the metal. Like we, we just wouldn't guide it that way. And I always say there's nothing wrong with running. Running's a great goal, but running's hard. Right? And so I think that, like you said, I think that this is an important activity to help women understand a little bit about what's, breakdown, what has happened with your body, but then also how are you going to get back to your goal?

[00:08:51] And I wonder what, how you feel about starting with, just really quickly talking about some of the things I talked about just now changes to our [00:09:00] body, because obviously that's something that you had to consider when putting together these guidelines. Look at, okay what does happen to the female body during pregnancy and during birth? Because that's, I'm sure, partially what you're basing these guidelines on.

[00:09:14] Gráinne Donnelly: Yeah. Such important points you've covered because. I think the traditional approach to women having babies has very much focused on the fact that it's a natural thing. We're made to have babies, which it is. But we can't just assume that it's a natural automatic recovery. And like you said, any other musculoskeletal injury, sports injury or change or repetitive strain or anything like that, that we come across in the rehabilitation world -we assess, we evaluate, we grade people back, we build them back up in a creative manner. And for some odd reason, women having babies just fell into this void of. You just get back, you have a baby back to the porridge on Monday, and if we think of the population we're talking about here, I'm a mom. [00:10:00] You're a mom. Many people listening to this will relate to the fact that you might have a baby and already have other toddlers at home, so it's very hard to go home and not do anything. We all know that once you're back, mom, you're called upon, you're gonna be asked to lift toddlers, you're going to be doing laundry because someone else isn't doing it quick enough. And so there's just so much expectation on mom. So we, I'm really passionate about making sure that women are fit for purpose.

[00:10:27] Now, what I do wanna highlight is that we are made for this and our bodies are very resilient, but we need to give them the care and appreciation of the changes that have unfolded. So let's consider pregnancy first of. Before we even take childbirth into consideration, the body is going through biomechanical changes, physiological changes, psychological changes as a result of pregnancy, center of gravity changes. So we do alter how we walk, and that's just natural and it evolves so gradually because the bump grows [00:11:00] gradually that we don't even really notice it. And no matter how fit we are during pregnancy, so even if you're a mom out there who exercised the whole way to delivery, There will be a degree of deconditioning because you won't be able to perform to the same level as you would have pre-pregnancy.

[00:11:18] So if we think of sports, even in the absence of injury, if we have a sport and then there's an off-season period, and then we're back to pre-season training, we all know that those performance athletes, or just recreational sporting people, have a period of reconditioning because that first three and in session back is usually whoa, I can't do this. I'm so unfit. So we need to start looking with that sort of approach to pregnancy, and that's before we consider potential trauma, whether we have vaginal delivery or abdominal delivery. You don't know what sort of trauma that each individual woman will be subjected to, and it is an individual [00:12:00] case, so some people do have a relatively straightforward delivery. Feel great. Don't notice any difference, are raring to get back. Other women know that they've had and experienced significant trauma, feel quite apprehensive and cautious about it, but don't know what to do in order to get back to running, and one of the things I like to highlight is, I'm gonna get a bit technical, but not too technical, but down below, if we think about our pelvic floor, everyone will have heard of pelvic floor, but there's an area called our levator hiatus. And what that basically means it's just the general area of our perineal body and our vaginal opening in that general area. And it actually lengthens and increases in size during pregnancy, so everybody's levator hiatus changes. Now women who undergo a vaginal delivery will have much more significant degree of increased size of levator hiatus, and this is one of the risk factors for developing issues like urinary incontinence or pelvic organ [00:13:00] prolapse afterwards. Does that make sense?

[00:13:02] Melissa Dessaulles: Totally, yes. Basically, like that undercarriage, goes through like lengthening process during pregnancy or so when you have a vaginal birth.

[00:13:11] Gráinne Donnelly: Yeah, and that increases your risk factors. So there has to be an appreciation for the healing process, and there has to be guidance so that women can ensure that their body heals as it's supposed to, recovers as it's supposed to, builds up tolerance to load again as it's supposed to, rather than feeling great after delivery, feeling so good they want to hit the streets running, but they end up overloading those tissues, which then predisposes them to issues. So we don't want moms to go back to run and be okay initially. And then find the developed problems, which become a barrier to running. We wanna get women back running at the right time so that they can maintain it long term. And running is a great sport for moms. I myself can totally appreciate this because it's a type of sport that, an exercise that doesn't really tie [00:14:00] you to a time or a location, so it's very adaptable to moms, especially with young kids when life's unpredictable. Let's be real.

[00:14:07] Melissa Dessaulles: Totally. Yeah, it's free. It's out your door. You can do it from anywhere. You don't really need any equipment besides shoes. You get to turn your brain off. Absolutely. I get the appeal for sure. What about, so you talked a little bit about the changes to the, like kind of the pelvic floor itself. I always tell people to picture it like a trampoline and that it needs to have a lot of recoil and a lot of action, right, when we do anything on it, if that makes sense. But also too, like you talk about some of the changes in the bony structure itself of the pelvis, right.

[00:14:39] Gráinne Donnelly: Yeah, so biomechanical changes, absolutely. Like we know that like women change, the whole center of gravity changes. So we do get larger lumbar lordosis. We do tend to lean back and do you know what? That's the type of thing that doesn't always just automatically resume prenatal form. Now, I'm not one that [00:15:00] thinks that there's any one way to stand or one way to be aligned, and we're not perfectly symmetrical. We never were, but I do notice that even when it comes to running, sometimes women have what I would call a postnatal running form. And it's usually when we run more up and down because we're so used to that center of gravity being back the ways. So rather than leaning into a run and having a forward sort of center of gravity, sometimes when we're postnatal, we tend to do an up down kind of movement. So I think that's really relevant and something worth knowing about. Worth knowing how to rehabilitate appropriately, et cetera.

[00:15:36] Melissa Dessaulles: It's just different, right? Your body's gone through something so big. It's hard for, like you said, to go back to the same. And then also too, I mean, you talk a lot about the abdominal wall and just what changes like from pregnancy just like all the stretching that happens to the muscles. And I think a lot of people don't connect the front of our belly is connected with our pelvic floor too. Like it's all connected and you've gone through this huge stretch at the [00:16:00] front of your abdomen that just isn't gonna necessarily transferring load, or transferring strength through it the same, right. It all just, like you said, takes time to rehabilitate. So I think just like you said, just recognizing what our body goes through to help people understand why they would progress a certain way after

[00:16:20] Gráinne Donnelly: Absolutely., and the abdominal wall stretching, there's, yeah, we have to be aware that especially towards the end of the pregnancy. We can't, that's why women can't do that sit up action outta bed. We lose an element of rectus range, like a rectus abdominal, that six pack muscle. It's our muscle that makes us sit up outta bed and with any muscle when we're not performing the same activities, we will have muscle wasting. We will have weakness in that muscle and that needs retraining in the same way as the pelvic floor needs retraining after childbirth and delivery. And that's regardless of delivery mode, by the way. So anyone who has even a cesarean section delivery, you still need to think about the [00:17:00] pelvic floor after having a baby too. So because of all those changes I've already mentioned during pregnancy.

[00:17:05] Melissa Dessaulles: Absolutely. And I think that I would love for you to talk a little bit now, cause I know in the, as part of the guidelines, you mentioned the quality of research to support pelvic floor physiotherapy. And I wonder, and I guess I want to tie in just a little bit about kinda what the evidence shows about the benefits of rehab, I think, and then maybe we'll get into just the guidelines themselves and how suggest people work through. So, speak a little bit about the evidence to support, physiotherapy for some of the symptoms that, that women experience after, because we're gonna be tying in physio into the guidelines.

[00:17:42] Gráinne Donnelly: Yeah. Well, this is the exciting part because actually physiotherapy. Pelvic Health Physiotherapy, in terms of pelvic floor rehab is one of the few areas of rehabilitation that has really high quality evidence. We have level one, and what that means is that high quality, well [00:18:00] charted studies time and time again, are showing the benefits of pelvic floor muscle rehabilitation, and they're actually demonstrating that isolated or focused pelvic floor muscle training has a place. So yes, while as human beings, we don't function as one muscle group at any given time, our body works as a whole system, so to speak. But there is merit in after pregnancy and delivery because of the changes to that specific region. There is a need to have concentrated application of rehabilitation to the pelvic floor region. So we know that pelvic floor muscle training has a role in the prevention and management of pelvic organ prolapse. We have high quality studies demonstrating that. We know that it has a role in the management of urinary incontinence, and we know that it has a role in the management of sexual function. And these are all issues that women have risk factors for after having a baby. So, if we have such high level evidence out there, [00:19:00] it would be amiss of us not to be letting women know about this and creating more of a preventative approach to childbirth and recovery rather than waiting until women get symptoms and reacting with them. Women need to know this information, know it's importance even in the absence of symptoms so that they can maintain good pelvic health and function.

[00:19:22] Melissa Dessaulles: Exactly, and I think where I was going with that is that, okay, so we've talked about the changes we know happened to the body during pregnancy, that happened during birth. We know that there's high quality evidence for physiotherapy guidance and assessment to help, address some of the issues that come from these changes in our body. But what tends to most often happen is that when women perhaps bring up their symptoms or like they wait that six weeks, generally they think that, do you know what all I'm supposed to do is just rest and recover and then I'm gonna get that go ahead at six weeks and then I'm gonna go see the physio, or I'm gonna start some of my physio exercises while [00:20:00] I run. That's what you kind of hear a lot of. Right. And I think, like you said, there's so benefit to just the understanding, the proactive approach so that you can say, okay, I get that all of these things are happening, and maybe instead of waiting until that six week mark when I get my all clear, I wonder if there are, am I all clear to run, I wonder if there are things that we could do to work up to that six week mark where then when your care provider says you can do more, your body's ready for that. Right? Your mind, Absolutely, and your body are ready for that. And so I think that, putting all these pieces together, I think that some of our, some of us physios are kind of like shouting from the rooftops saying start early or don't wait till six weeks. Cuz when they come in to see us at six weeks, I find that they're like, Melissa, I don't want to think of the dumb breathing exercises right now. I wanna run. Do you know what I mean? Or are you serious? I have to think about pelvic floor in my breath. Couldn't I have done this [00:21:00] before? Yes. Yeah. So I think that's what I wanna talk about now, because I know that your guidelines, they set the stage for this is what's happening. This is what the research says. Now what does this look like in an ideal world? And so, Let's start at the very beginning, kind of with, you've set the stage for what are some of the things that you would suggest for someone at the very beginning, in the first couple of weeks?

[00:21:23] Gráinne Donnelly: Yeah, that's a really good point. And yes, we are all passionate about empowering women to be able to do something. It's not a case of do nothing. So that's not what our guidelines are saying. They're saying this is what you need to do to prep. Now as soon as you have your baby, as soon as you feel any way inclined to, you can start pelvic floor muscle exercises and should do. Now if you have a Cesearean section and you have a catheter or you the catheter in for any other reason, we advise waiting until the catheter's out. But once you don't have a catheter in, it's really important to get that area coordinated and blood flow into the area [00:22:00] and getting things moving again. I totally understand for anyone who's just had a baby, if you're thinking, oh, I don't wanna be doing physio floor exercises now, I hear you. It can be quite scary when you've just had a vaginal delivery in particular to think about anything to do with that area. It can be quite off-putting and scary, but our body's resilient and what you have to remember. That area is already under load, straight away after delivery because we go and we empty our bowels, we cough, we sneeze, even movement, transparent from lying to sit and sitting to standing, it's getting used. So if you can start to get it recruited so that muscle's actually starting to get stronger and rehabilitate, that's advantageous. But even in the early days, you're gonna be up walking, building up, walking, little and often. And you can, as soon as you start to feel ready to, and that will depend on your delivery experience. You can start doing what I would call low level core, re core rehab. So I tend to think they tend to be like pilates style exercises, but I'm not, it's not [00:23:00] limited to that. But you can start to as, as long as you feel okay to do it, you can start to do low level exercises, get the core muscles going in the pelvic floor and lower abdominals, and start to really feel like you're starting to move again and reconnect with an area that has been limited in function for the last number of weeks.

[00:23:19] Melissa Dessaulles: Totally. Just connect the dots again, right? Like we just talked about how everything's changing so much and that baby comes out. I remember the feeling of like deflated balloon, like just like it was squishy. Nothing was connected. And I remember, I actually remember had a vaginal birth and it was fairly traumatic. And I remember actually the nurses coming in and kind of like making faces when they looked like I, I knew it looked bad just by their face. And I, yeah, it was traumatic and I, but I do remember I had, I was so thankful I had the knowledge, you know what, I understand it's swollen. I'm sure it looks bad. It definitely feels a bit sore, but I know just based on I, what I would tell someone if they had a swollen wrist or a swollen ankle, let's [00:24:00] just get it moving. Let's just get some of the swelling out of there. Let's take away some of the fear that you have, Melissa, and just start working on like just, I remember coordinating inhale. I feel a little bit relaxed down there. Exhale. I feel a little bit tight. No, actually I don't feel it, but I'm just gonna imagine it. And day by day I, oh, I can move it better. It feels easier. Peeing and pooping is getting easier. Like just. Helping those muscles do their day-to-day. And I think there is still unfortunately a lot of messaging saying no pelvic floor movement after your birth. Like women get that information.

[00:24:33] Gráinne Donnelly: Wow. Cause I was gonna say in the UK we're so pro getting personal exercises as soon as possible.

[00:24:39] Melissa Dessaulles: No, I feel like that's something that women here are not hearing necessarily from their care providers. They're starting to hear, go see a physio. And so I think they're leaving it up to us, but I think sometimes they're not, well, they're not getting that necessarily from the nurses or for, from their doctors in the hospital, but, yeah. Okay. So great. In the early stages, just think about it. [00:25:00] Always within comfort. I say gentle movement, just starting to think about connecting the dots.

[00:25:05] Gráinne Donnelly: Yes, absolutely. And then progressing. Yeah, progressing as you feel fit. So as the weeks go on, then, like basically, let's be realistic. We've talked about the role of moms and the expectations. Once you're back home, you're back home and you're probably squatting anywhere. You're squatting off a toilet, but you're probably squatting down to toddlers in the floor or a baby, or to a laundry basket. So, gentle squats are okay. You know what I mean? Let's translate that. Let's make you fit. Let's do it in terms where you can control. And even things like lunges and closed chain sort of exercises, which aren't putting too much pressure anywhere, but if it feels like too much pressure, scale it back. So it's very individual. What works for you at two or three weeks might not work for me at two or three weeks.

[00:25:46] And so there's no prescriptive or protocol, you must do this at this weeks. It's very much down to the woman, her birth experience, how she's psychologically feeling. Because if you are very anxious to move, don't push yourself into things that are [00:26:00] making you feel apprehensive. Take it at your pace and your comfort and go with yourself. If you're raring to get back to running.

[00:26:06] As I said in our guidelines, we on average recommend most women will probably be in and around the 12 week mark before we return into running, because that's based on what we understand from the evidence about tissue healing. And we know that there's still signs of recovery in around the four to six months mark for the pelvic floor, for people who've had a vaginal birth, and for people who've had abdominal surgery, even at six to seven months, there's signs for recovery. So taking those principles into consideration, we figured that 12 weeks is a more realistic expectation. Now, for many months, listening to that, who started running it two to four weeks, you're probably horrified to hear that, and that's okay for some women. They will be ready to run sooner. But what I want everyone to understand is that if you return to running and you're having any signs or symptoms such as leaking, peeing down below a feeling of a bulge or heaviness, [00:27:00] just even any discomfort in the lumbo-pelvic region, that's a sign that you need to get checked out because if you were doing any other sport and your calf started to niggle, or your hamstring felt like it was gonna pull, what would you do? You'd scale it back cuz you'd be afraid of causing any further injury or harm.

[00:27:18] And I want women to start to think about their pelvic floor and pelvic health with the same consideration because. I want a future for moms. I want them to feel like they can still run at 60 and 70 if they want, and not to find that they just about got through their mom years by patting up or putting up with symptoms of a prolapse. And then once they hit perimenopause, symptoms got so bad they couldn't participate in exercise. Because physical activity is so important for us at all life stages, for all aspects of health and wellbeing. So we need to empower women to ensure that they can maintain this.

[00:27:57] Melissa Dessaulles: Absolutely. And I like how you point out the calf [00:28:00] because I think there's a lot of belief around damage when it comes to postpartum recovery. A lot of do you think I'm damaging or am I splitting apart my diastasis more? Am I damaging my pelvic floor? You hear a lot of that. I'm scared to damage things, and I think you wouldn't necessarily have that same view with your calf. You should be like, oh, okay. I've overdone it. It's not like my calf's gonna blow off. But I think that there, unfortunately, we seem to think that with the pelvic health symptoms, so I think it's important to point out all it is just your body saying hold up, pump the brakes a little bit. Let's figure out like, what's my issue here? Is it, is it a musculoskeletal problem? Maybe it's my glutes, may, what's part of the puzzle? Do you need to kind of focus a bit on? Right.

[00:28:39] Gráinne Donnelly: Maybe it's not even that you need to pull back from running completely. Maybe it's that you need to shorten your running volume because you're fine until you get to a certain volume, then the muscles fatigue and you just need to. Hold it at a certain volume until you rehab up and then you know, there's so many variables. It is similar in its approach to sports medicine. So we just need to think about it like any [00:29:00] other injury or niggle. Get it checked out, evaluate it, find out what the issue is, address that.

[00:29:05] And the other thing is that a lot of people don't consider. Moms have so many multifactorial things feeding into this because what mom's getting a full night's sleep? I'm still not so many years later. So you have to think that we know in the sports world that if athletes don't get good sleep quality, it increases their injury risk. So same thing can go on. Like maybe if you've had a period where you've had a week of bad sleep, maybe going for that really long run isn't the most sensible thing for you. Or maybe you need to scale back the intensity of it. We just need to figure out what the reason is and figure all those factors feeding into it, like sleep quality and even your nutrition. Because moms are actually a population who are at risk of being in an energy deficit. And what that means is the amount of energy they're putting out or the demands from their daily life, [00:30:00] being a mom, looking after kids, maybe trying to work and have a career, maybe trying to exercise and keep up health and fitness, all that is draining the battery. And if you're not filling the battery up with good nutrition, good sleep, good psychological wellbeing. You stand to have an energy deficit. And when we have an energy deficit that leads to other bodily systems being compromised. So let's consider that and not drain the battery. So that's another thing. It may be appropriate for some moms out there to think, do you know what? I've had a rough two weeks. I'm not really feeling at my best. I'll go for a light jog. I'll not go for my usual level of run. And that's okay..

[00:30:38] Melissa Dessaulles: Totally. And I think it's such a good thing to point out because it's so hard. It's our nature as women to kind of be like, okay, I'm doing so crappy at sleep. I'm doing so crappy at my nutrition. Gosh, I'm not doing this right. That's why I can't run. But instead kind of maybe approaching and no wonder I'm not doing awesome here. I'm not hitting my personal best. Do you know what I mean? Give myself a little bit of grace here, because I think it's hard when you're in the middle of it to see [00:31:00] that. But I mean, I, my baby's five now and I, I have enough insight now and I can ab, I'm able to look back on that period now and just be like, oh, no wonder I didn't, wasn't, running my best then, or but I think in the middle of that time, it's hard to understand why you don't feel like yourself when you run. Absolutely. Can I go back really quickly to when we were talking about some of those earlier weeks and how you're, you progress the pelvic floor and some of the core muscles to just day to day movement, and it just reminded me of some clients I've had lately that I think this is the benefit of us educating women during pregnancy a about what these muscles even look like and how they behave. Because how many times do we have clients that come in and say, oh, I just engage those all day. Aren't I supposed to engage those all day because they, they've, a baby's come out of them and now they're weak and they're loose, and I need to tighten them so that when I run they're tight. But I think, again, just understanding that as, after your birth, understanding those muscles just don't work at their prime. They're not simply loose, [00:32:00] they're not simply tight, but they just need to learn how to move through their range of motion and move with the rest of the body again. And I think just understanding that with the quality of movement, right, when you're doing your squats or when you're doing your lunges to understand that those muscles just need to be free to move again, right? Because, yeah. Isn't that what you.

[00:32:19] Gráinne Donnelly: They need to basically be like, and I think that's another misconception that is out there. It's that idea of having to consciously recruit them all the time because really how much did you think about your pelvic floor before having a baby? You didn't. It just was there and it did its job subconsciously. So it's an area of muscle that responds naturally to load. We don't even really feel it. And how I know about this as a clinician, I actually use ultrasound imaging in my, my type of practice, which a lot of physios do. And what it means is that we actually use it as a biofeedback tool for women coming into my clinic so women can see and get that mind body connection with their pelvic floor.

[00:32:57] But what we also know with that is [00:33:00] that sometimes women don't even really feel like they're contracting their pelvic floor. And then when they see it on the screen, they can. It is hap. It is recruiting. It is there. So it's really important what you said because women don't understand their pelvic floor, how it's such a taboo issue for so many years that women felt they couldn't even talk about it. And this is an issue because if you don't really understand or know or visualize what your pellet floor is or what it should do, how do we expect women to know how to rehabilitate it from reading a sheet of paper after they've had the really and really. I always give this example, but in MSK, if you're treating someone for a shoulder or something, we all know that everybody knows what the shoulder is, how you move it, what you know. We understand its function, and yet if we have someone in rehab and we demonstrate an exercise in front of them, whatever it may be, nine times outta 10, someone will repeat it back wrong initially, and you'll maybe have to cue them. And that's with them seeing me demonstrate it, knowing [00:34:00] what that area is. Mind body awareness and perception can be quite skewed. And yet women don't even know what their pelvic floor looks like. And they've probably Googled and found a Google image of a slinger muscle from front to back, which doesn't really represent the pelvic floor. Where the pelvic floor is more like a bowl.

[00:34:15] It's a bowl of lots of different muscles which forms the base of the pelvis, and it basically responds to pressure or changes in pressure or changes in load, and we shouldn't have to consciously draw it in all day. Now, yes, I talked about doing focused peripheral muscle training or kegs after having a baby, or if you're having any symptoms, even if you haven't had a baby. But when it comes to things like increasing your exercise, you should just simply do your squats, do your lunges, grade it back into running, and not think about recruiting your pelvic floor because you're hoping that it will just respond to those load changes because it's supposed to be, you mentioned a pelvic trampoline earlier. I like that analogy because a trampoline responds to with the appropriate resistance to load as it should do, [00:35:00] and that should be the scene as a pelvic floor. So just go and do it. And if you're having symptoms, that means that outside of that running training, outside of that squats lunges, you need to be doing focus pelvic floor muscle training where you're just simply drawn in your keels.

[00:35:13] And something I'm really passionate about getting across to women out there is that too many women I see come in and say, oh, I've been doing the kegels. They're not working. And for those that have been actually cuing the pelvic floor correctly, they've been doing them just a little few reflex and it's very easy and they can talk and chat and tell you how they're doing it. Now, with the principles of strength and condition in any other area of the body, if we wanted to tree in muscle up so that it builds strength, you have to challenge it. You have to push it into its fence of fatigue, and that means that you have to draw in the pelvic floor at a max capacity, relax, draw it in max. Relax, and that means that when it comes to reps 7, 8, 9, 10, you should be ready for that break. It shouldn't be like yet a 10 quick fix. No bother. It could have went on to 20. You're probably [00:36:00] not doing them right and you're probably doing them too easy. So if you're not sure how to do them, definitely access a pelvic health physiotherapist because that's why our profession exists. It's because most women do not know how to do it right. And actually, over 50% of the women who come into our clinics who say they know how to do pelvic floor are not doing them right. And they're maybe clenching their bum cheeks or squeezing their legs together and they're not, they're missing out on that conscious recruitment of that area.

[00:36:28] Melissa Dessaulles: Totally. So I think, yeah, I mean you've kind of painted a picture of kind of just get those muscles coordinating again, connect them with your brain, start to focus on them a little bit just because that's the kind of one of the areas that's gone through the most. But then start to progress it into the body.

[00:36:42] It works as a unit with the rest of the body. And then what about, cuz again we've got this 12 ish week mark where women are kinda like, okay, that's when I get to start putting it all together. But what else, what other things, cuz obviously. It's kind of specificity, right? We need to kind of look at, well, what does running actually look like? [00:37:00] It's different than swimming, it's different than pitching a ball. And so running looks like a lot of balance on one leg. The ability to hop, the ability to leave the ground, the ability to absorb impact. So I like how in the guidelines you start to go through, okay, well then now let's break down the movement and can you put- component. Can you do the components? Because if you can't do the components, I don't know how successful the big picture will be. Right. So I wonder if you wanna talk about that a little bit, about what kinds of things you suggest that women are doing to work up to the main event.

[00:37:34] Gráinne Donnelly: Absolutely. And yes, so we call them load and impact tests, but they can be used as a rehab tool as well. So they're not just a test. But basically we have outlined a couple, a series of things that you can do, like you should be able to walk 30 minutes symptom free. That's a given, and most people will be no problem with that, but if you're getting symptoms while walking, you definitely need to access rehab. There's other things like hopping in one. Single leg squat. Forward [00:38:00] bounds is like jumping forward in two legs. And again, worth increasing impact with all these, and it's a nice test. And don't they sound easy? But actually I remember doing them after I had my fourth baby and I waited until the 12 week mark and I was being my own case study, so to speak, for the guidelines. And these tests are actually harder than you think. You start to really flag areas of strength and condition and needs that you need. And I was able to find out what areas I needed to work on. Now what we also highlighted was general strength and conditioning exercises that we recommend while you're building up. And that includes things like, single leg, half raises, single leg bridge, which is tough. We have 20 reps of that, and I couldn't do that 12 weeks, no, I don't know if I could do that now. I couldn't do the single leg sit to stand at 12 weeks. I couldn't do 20 of them. But it highlighted to me that even though I'm feeling good and in my head, I was taking all these boxes that I'm ready. I was like, Ooh, I actually have endurance issues when it comes to using all these muscles to do single sit to stand. So I [00:39:00] was able to employ those into my rehab, while I started a graded return to run. So I just think it's quite a nice way of identifying key muscle groups that need more strengthening that we otherwise don't really think about.

[00:39:11] Melissa Dessaulles: Totally. And I think that can that kind of gives an idea of how you would progress and work up to your goal at, like you said, the, an arbitrary, not an arbitrary date of 12 weeks, but again, everybody's an individual and I understand the guidelines can't be like everybody needs to do exactly this, but I think that. If you go, if you don't have these guidelines, and if you just said to someone, okay, you can start at 12 weeks after, if you had told a, an actual runner that you know, you'd get, oh my gosh. Like I don't wanna go see that physio. That is so depressing. Yeah. She's being so conservative. She doesn't understand me, she doesn't understand my mental health. Whereas if you take that same, same person, and you explain listen, I get your goal. That's a great goal. That makes sense that you wanna get there. However, I just want you to know that these are some of the things that have gone on in your body. This is going on right now, [00:40:00] but have you ever had any other injuries?

[00:40:02] And pretty well, every person has been like, yeah, I've had an injury. And do you kind of understand that process you worked through? Oh yeah. Well let's do the same thing and your goal is this and let's kind of. Reverse all of that and think about how you're gonna get there, break down the components and when you explain it to them, I'm like, thank you. I got that. And I look forward to my 12 weeks or whatever. But in the meantime, I have something to get there. And I think if you explain, cuz usually they've seen other postpartum women that have kind of done that progress crash. Progress crash. And they don't want that for their mental health either. I always say, look, we're looking for kind of slow and steady gains cuz. Rewarding is that, and I think that, again, it comes down to us educating. And so I, I've really appreciated these guidelines because again, I can talk about them with people, but I can also send them home with it to digest it. And then when they understand why, then they're just like, thank you. Because so many of them have had to spend a lot of time looking for [00:41:00] answers or trying to figure out why they, why their body has failed them, which they often feel right.

[00:41:07] Gráinne Donnelly: Yeah, and like the thing is for anyone who does wanna return much sooner than that, like I understand the need for running as a release, as an identity, as a psychological, or as a psychological health management. But if you say, went through the loading impact test and had no symptoms. Okay, start a grade return to run. That's pretty good. You could might by only four to six weeks, but if it falls straightforward, you've considered those and you understand the principles of what our body's been through and you know the signs and symptoms to look out for, then you know that the first sign of a niggle or any sort of sign a pelvic floor is dysfunction. You'd be like, okay, I need more work here. And it gives you, it gives women a bit more empower. They understand and they can take that and apply it to them as an individual. They're absolutely not saying, you must not start until 12 weeks, and if you do, no physio will support you. Oh, exactly. We'll support women to [00:42:00] do whatever they need to do, but the biggest thing that we're trying to say is, We want, like you've already mentioned, we wanna keep you running. We wanna keep you there. And that's our bigger goal.

[00:42:09] Melissa Dessaulles: Totally. And I think if you ask a lot of women, like there's this one client I have in mind who's marathon runner. And I remember her saying to me like, give me an idea, Mel. Like when can I think about running? And so we talked about all this. But then we talked, I also talked about it. I'm like, what is it that you'll miss the most? And she said, kinda like the burn or the sweat. And I'm like, well, what else could you do? Could you hike some hills? Could she's got a treadmill at home. Could you just walk on an incline? Could you hop on your bike trainer? And all of that stuff, which was like, yeah, that's giving me the burn because again, it's not that running's bad, but it does require a lot of impact and it's a very complex activity, whereas you can still get that cardiovascular burn or that sweat from other activities that don't require as much from the body. So again, I think that there's ways to kind of satisfy, like what is it about the running? Do you miss the socialization with a certain friend? Can you get that another way for now? [00:43:00] Or...

[00:43:00] Gráinne Donnelly: Yeah I love that. And that's, you've hit the nail head because one of the things I'm really into is that exercise needs to be meaningful for the person. So it shouldn't be the type of exercise I think is good. It should be exactly what you're saying. What is it that you like and what do you wanna get back to and why? And then you can break it down. And even you've had really good examples there. And even for anyone who goes to a gym, the StairMaster, those stair treadmills are ideal cuz you can get your sweater on the cross trainer, you can get a nice sweat on, still feel like you're working out and incline, treadmill even to do if you're really rare and to run. Incline treadmill or uphill drills are lower impact on the pelvic floor region than running on a flat surface or running downhill. So even no one thinks that can be really beneficial.

[00:43:44] Melissa Dessaulles: Absolutely. I actually created a couple years ago because I was seeing so many women that were coming in around that six week mark when their care provider discharged them coming in saying, hey, I wanna be proactive. I wanna start. And I was I just trying to get across the message you could start earlier. You don't have [00:44:00] to, you start when you're ready, but a lot of people are ready to start some of those basics earlier. So created an online program that people could work through at their own pace to literally do everything that we just talked about. But I also think it's important and I included your guidelines and how to incorporate that because I think running's an activity that a lot of people are very interested in. However, I think there's a lot of, there's a lot of confusion around confusion because we've just talked a lot about how everyone's an individual. So I think sometimes people will say, well, cause there are a lot of online programs out there, and they used to get a lot of oh, how can an online program help?

[00:44:34] But I do think that this is an individual process for everybody, and I'm finding that people are coming in with so many questions that sometimes it's hard to go through all of that. And I think that if you're trying to figure out like, what am I supposed to do? Go see someone in person or work through this program online. I think you kind of, think about your learning style and think about how you tend to consume information. The program I created is not meant for be an all, be all and end all [00:45:00] cause I absolutely agree that we all have to be. It's beneficial to have an assessment with someone to look at you and consider your individual body and goals, however, There's a lot that you can consume at home in the early phase when you can't get out as a new mom. Right? Yeah. And I think that's such a barrier, and I think if you just kind of think, well, it's not necessarily gonna be the be all and end all, but then when I go into that appointment, I have practiced this stuff. I've put it all into practice, I've tried it all, and I need you to help. Tell me if I'm on the right track or I need to talk through my symptoms with the therapist.

[00:45:31] So I think that's where a lot of this online content comes into play. And I feel like a lot of people listening to this will be feeling confused about, do I see someone in person? Do I do? But I think that's kind of my take home with it.

[00:45:42] Gráinne Donnelly: Yeah. And the other thing is that not everyone, despite our call for everyone to get a pelvic health assessment, not all women will be able to access it. There may not be the service provision in their locality, or they may not be able to access it because it may not be freely accessible to them. And then if it's not freely [00:46:00] accessible, we're coming down to affordability and that's not an even playing field. And so we have to have. Opportunities where women can access stuff. And maybe more convenient cuz maybe it is a case that they have no childcare and they can't get out to appointments. So mom goes to the bottom of the list. But this is a way that it can fit into their life. So I totally agree with you. All forms of accessing quality information is welcome and everything compliments each other. So even women who went for a pelvic health evaluation then know how to apply that when they go to your online program and things. So I think that's good, but I just think that. One of the things I wanted to mention before I forget is that since doing the guidelines, we have the opportunity to connect with wonderful people, including Dr. Izzy Mure, who's a researcher, accord of Metropolitan University in England in Wales, and we actually carried out a study over lockdown, which we published in one of our journals in the UK recently. But one of the key findings of it, it was about returning to run in [00:47:00] postpartum and what factors affect a woman's ability to return to running postpartum. Fear of movement was a huge element. And that comes down to the conflicting messages. The lack of knowing what to do. Fear of movement was one, and the feeling of vaginal heaviness was another word. So people, when they felt that they didn't know what to do. So I think a lot of what we've touched on today will be really useful information for women in order to navigate postpartum and what happens when you have symptoms and what symptoms you should look out for.

[00:47:33] Melissa Dessaulles: Absolutely. I appreciate your time on this matter. I appreciate everything you do to help spread awareness, and I wonder if you can really quickly end with some of the other things that you provide because you not only have played a huge role in these return to running guidelines, but.

[00:47:48] I don't even know how you get done. All the things you do, you also play a huge role in diastasis education. And same type of messaging is this is not something to be feared. This is something that's pretty natural for us to go through everyone on a [00:48:00] different part of the spectrum, but that it doesn't need to be scary. And so I think I, I would not only want you to talk a little bit about where people can find you about that information. But you also have an amazing podcast that I love to listen to your episodes. I think that you guys cover really interesting topics, so speak to both of those really quickly before we wrap this up.

[00:48:19] Gráinne Donnelly: Okay, so podcast, just cause it's fresher is At Your Cervix, The Podcast. So it's a bit of a play in words cuz me and Emma all always finish it with this is Emma Grok at your cervix. So we cover topics relevant to pelvic health and it's both pitched at the general public and health and fitness professionals. So we try cater for all. So if you're any way interested, you can check that out. In terms of diastasis, I do a lot of content online, particularly on Instagram. My handle's at I'm also on Twitter at Abs Physio Abs, P H Y s ao, and my website's www dot absolute dot Physio, which I'm currently refreshing. It should be refreshed in the [00:49:00] next few weeks. Hopeful.

[00:49:03] Melissa Dessaulles: Awesome. I'll link all of that in the show notes. And again, thank you so much for your, Thank you.

[00:49:08] Gráinne Donnelly: I really appreciate it. Thank you.



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