Exercise Considerations for the

Postpartum Athlete Sarah Zahab BSc., R.Kin,

CSEP-CEP, NKT®

1

OVERVIEW

CSEP & ACOG Guidelines

Key muscles to address

DRA

Pelvic floor

Posture/Alignment

Breathing Mechanics

Movement mechanics/Considerations

Postnatal exercise prescription

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POSTNATAL GUIDELINESCANADIAN

Most types of exercise can be resumed in pp period

Some women may need to reduce intensity or time

Those with C-sections may slowly increase CV & ST, depending on discomfort and other factors (infection)

6 week postpartum evaluation excellent opportunity to work with health care providers to discuss

3

ACOG NEW GUIDELINESAPRIL 2018

Postpartum care an ongoing process (4th trimester)

All women meet with OB/HCP within 1st 3 weeks with anticipatory care beg in pregnancy & concluding with a visit no later than 12 weeks after birth

Follow up with ongoing care as needed to transition

Full assessment of: emotional well being, feeding & infant care, contraception/birth spacing, sleep & fatigue, physical recovery, chronic disease mang’t & health maintenance

Comprehensive visit is an app’t, not an ‘all-clear’. Does not remove the need for continued recovery & support through 6 wks & beyond

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ADDITIONAL GUIDELINES

Addition of strength training with focus on stability (hip, scapular & trunk stabilizers)

TvAs & Multifidus (connection, coordination, act)

Gradual progression of intensity, load, volume, time

Running & other impact activities 12-16 weeks postpartum if stable - assess running mechanics

Prep for run impact, load, endurance https://www.running-physio.com/postnatal-guide/

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You can’t fire a cannon from a canoe(Charles Poliquin)

Poor Stability = Poor results

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STABILITY

Ability to manage load effectively

Ability to maintain strict technique

Ability to maintain optimal alignment

Ability to avoid compensatory strategies

Ability to maintain connection with desired muscle throughout

Stability isn’t balance - remove unstable work

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MULTIFIDUS

1. Bilaterally: extends vertebral column

2. Unilaterally: Lateral flexion + Contralateral rotation

3. Provides stiffness, stability, and support to the spinal column

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TRANSVERSE ABDOMINUS

1. Supports abdominal wall

2. Aids in forced expiration & raising IAP

3. Provides thoracic & pelvic stability

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INTERNAL OBLIQUE

1. Rotates vertebral column (same side

2. Laterally flexes 3. Compresses

abdomen in forced expiration

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DRA EVIDENCE

DRA dysfunctions multi-dimensional and multi-factorial & requires tailored care (ROL, March 2019)

Women w. DRA lower trunk muscle rotation torque & lower sit-up test than those w/o (Hills et al 2018)

6-8 weeks ppm, only 52.4%, 12-14 weeks 53.6% & 6 months ppm, 39.3% + for DRA (Fernandes et al, 2014)

DRA assoc. w. low LA stiffness & distortion during semi-curl-up task; amount of distortion function of IRD and LA stiffness (Beamish, 2019)

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DRA EVIDENCE

IRD @ rest w. UI - 69% of those with DRA had doming/sagging/wrinkling (Lee & Hodges, 2016)

50% of those women could decrease doming/sagging/wrinkling by 20% with proper TVA activation during CU task

TvA pre-activation increases tension in LA (Lee & Hodges, 2016)

Many can CU w. EO/IO dominance & narrow IRD - not optimal

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AVOID DOMING

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OPTIMIZATION

Closure not necessary to restore function

Generating & increasing tension/integrity in LA key in helping correct DRA (tension/integrity > width)

Avoid doming & other DRA symp. Optimize function

Use a multi-faceted approach to restore optimal strategies for function & performance

Find primary driver - restore optimal strategies (breathing, alignment, muscle recruitment, timing etc.)

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OPTIMIZATION

Increase connection/coordination of TvAs & IAO

Limit/modify exercises that exacerbate symptoms

Proper movement mechanics, optimize breathing mechanics and alignment

Avoid exercises that create pressure on abdominal wall (eg. doming) & cause DRA symptoms

May require months of work to change postural habits, alignment, breathing mechanics, neural firing

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PELVIC FLOOR

May be weak or may be high tone or a combo of both

66% of women with DRA had a least one support related PF dysfunction (Spitznagle et al 2007)

Significant reduction in PF dysfn following 8 wk nutrition, exercise (PF & core focus) (Walton et al. 2019)

PF pressure (crunch vs walking @ 3.5km/hr, sit to stand hands @ chest/knees, crunch vs lying from stand

REFER - Pelvic Floor Physiotherapist

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ALIGNMENT

Maintain optimal alignment in standing, seated postures & movement

Plumb line: ear, shoulder, hips, knee, ankle

Key: Ribs over Hips (diaphragm over pelvic floor for optimal TVA activation) - Rib flare/hinge @ T/L junction not ideal

Pelvic shifts Thein-Nissenbaum et al. (2012) & Provenzano et al. (2019)

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BREATH

Chest or belly breathing not optimal (IAP)

Inhale: ribs expand laterally, PF descends, belly expands, 360°

Exhale: ribs return passively, PF lifts, belly returns (passive or active)

Practice & repetition for rewiring

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CONSIDERATIONS

Alignment & Breath

Symptoms

Unwanted movement?

Clean patterns

Compensatory strategies?

Firing & connection of desired muscle groups

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IF SYMPTOMATIC

Adjust mechanics

Perfect execution

Add in breath, core & pelvic floor activation (or relaxation)

Decrease load until symptoms subside if possible

Reduce intensity, time &/or volume & gradually increase as load can be managed

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PURPOSEFUL EXERCISE

Waiter bow (unilateral or bilateral)

Side lying multifidus activation/bird dog

Supine 90/90 breathing

SB T-spine extension

TvA supine press into ball w. alternating reach

Supported/unsupported marches

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