by Yvonne McKenny & Caitlin Stannard
How long do you wait? How do you best prepare for this return to activity? What does the road back to running look like for you?
The team at Evoker physiotherapy have kindly written us this exclusive two-part article on a well-debated topic: running in pregnancy and postpartum. Here is part 2: returning to running postpartum. If you didn't catch Part 1: running in pregnancy, you can read it here.
RETURN TO RUNNING POSTPARTUM
So you’ve had your baby and you’re busting to return to running and jumping or whichever high impact exercise of your choosing. How long do you wait? How do you best prepare for this return to activity? What does the road back to activity look like for you?
Well the reality is we are still somewhat lacking the hard hitting evidence from a research perspective. In the absence of such, we have an excellent clinical guideline written by Tom Goom, Grainne Donnelly and Emma Brockwell in March 2019 which compiles the best available evidence alongside experienced clinical opinion from physiotherapists across the profession.
The good news: It is general consensus that waiting for your 6 week postnatal check before commencing any activity is too long to wait for postnatal women looking to return to low impact exercise. This could include gentle walking, pelvic floor activation and abdominal exercises. Its an excellent time to take it down a notch and nurture your body!
For return to certain activities, patience, time and preparation are key. However, with regards to abdominal separation, the evidence actually suggests that the sooner you get started, the greater the chances you have of improving and reducing it. Abdominal separation is common during pregnancy as the rectus abdominus muscle needs to stretch and separate in order to make way for the growing baby.
In fact it is the connective tissue that adjoins the two sides of the abdominal wall, called the the linea alba, (not the muscle) that becomes soft and malleable and allows this stretch to occur. After birth, this linea alba remains softened and continues to be so for up to 3-6 months postpartum. Therefore, we can utilise this malleability in the early post partum phase, with exercises that you may be able to start from a few days after birth. These exercises are best prescribed under physio guidance and need to be individualised and updated regularly but include a series of simple abdominal strengthening and activation exercises. Eventually this linea alba will return to its preconception state and stiffen once again, at which point it is much harder to make changes.
(** In fact, for those of you who have an old separation and still looking to have children again in future, it is in your post natal phase next time while the linea alba is soft again that you may be able to make some greater changes here)
Now, with regards to high impact activity, including running, the advice is quite clear and non negotiable on a recommended minimum of three months postpartum. And this is not including women with any extra dysfunction, pain or added considerations, which will inevitably extend that timeline out a little further. But before you roll your eyes and discredit this as another unnecessarily conservative approach, let’s unpack why this is the case.
Even in uncomplicated normal vaginal deliveries, the pelvic floor has undergone significant trauma as it stretches and makes way for childbirth - stretching up to 250% of it’s normal length. Regaining the ability to correctly perform a pelvic floor muscle contraction is the first challenge.
Developing endurance, speed of contraction and coordination of these muscles in order to support the pelvic organs through exercise is far more involved and not something that reflexively returns postnatally.
Not to mention the natural healing time (+/- 12 weeks postpartum) required for the levator hiatus (space where the baby comes through) and the bladder neck mobility (say what!?) to improve postnatally ).
Does that mean that I’m in the clear if I’ve had a c-section? Unfortunately not, uterine scar formation may only have developed approx. 50% of its original tensile strength by six weeks post Caesarean section and 73-93% by 6-7 months postnatal.
High impact activity, including running, increases intra-abdominal pressure and there are significant increases in ground reaction forces that are not necessarily absorbed by the legs. Therefore it has been suggested that many of these forces are being transmitted to the pelvic floor. So you can see how the pelvic floor needs to be on it’s a -game before dealing with running and high impact activity.
But what is at risk? High impact has a 4.59 fold increased risk on PF dysfunction compared to low impact. So it's really important that you’re weighing up the risks when deciding how to work out. Is it worth it long term, to push harder and faster? Or could giving yourself an extra few months to adequately recover, focus on other areas of strength and fitness before taking on the big guns be a smarter move for you?
So what do I mean by pelvic floor dysfunction? This could entail;
So, you’ve been working on your pelvic floor strength, all appears to be well in your pelvic function and you’ve hit that 3 month mark, rearing and ready to go. Do you just lace up and head on out the door?
The reality is that even in the absence of symptoms, there are still things to consider.
The pelvic floor consists of fascia and muscle. It acts as a hammock of support for your pelvic organs and your whole upper body and torso. Muscle is contractile tissue, that is, you can consciously activate it and tighten it. Fascia is passive and non contractile thus outside of your conscious control. This means that damage to fascia will not be improved by pelvic floor muscles exercises. The fascia and the muscle work together to create support and without each other, may lead to dysfunction. If you have sustained some pelvic floor damage, unbeknownst to you, without added support, it may become further exacerbated down the track.
Therefore simply being able to achieve a pelvic floor muscle contraction, may not be enough to give you the green light and confidence to get back out to your high impact exercise without risk of prolapse or incontinence.
This is where a pelvic floor assessment by a women's health trained physiotherapist can help ascertain the function and strength of your pelvic floor. Screening and strengths tests can be utilised to get a better understanding and best help you on your return to activity. Guidelines and recommendations have their limitations. Ultimately there will also be parts of the population that sit outside of these rules, so if you want a more clear, personalised recommendation of when is a safer time for you to resume running, there really is no substitute to getting assessed.
I write this information not to instil fear. The reality is that not every sign or symptom is enough to take you away from returning to the exercise you love and some symptoms are more concerning to people than others. But lacking transparency on the risks and considerations, can leave you uninformed when navigating your choices. Ultimately we are moving further and further into an age of movement optimism but let's do it in a safe way and assess each person on a case by case scenario.
Images with kind permission and thanks to Phoebe Chester who you can find at @buggyrunningwithmarlowe