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SPEAKER_01:It's not just for pelvic health physios to be responsible for screening issues in the same way as a musculoskeletal physio screens for neurological signs, rheumatological signs, red flags. I think it's really important that you screen for pelvic floor dysfunction and it actually could be the limiting factor in your musculoskeletal rehab with a woman. If you're trying to progress her rehab and she's either not complying, it could be that there's pelvic health symptoms holding back her getting into that exertion or complying with symptoms.
SPEAKER_00:Getting the postpartum journey can be quite complex. So today we had Granier Donnelly. She's the founder of Absolute Physio, which is pelvic health focused physiotherapy. She also has a wonderful podcast called At Your Cervix, pardon the pun. Now, Granier really explored a lot of topics here. So the timelines around the postpartum journey, return to exercise, but also just really highlighting and grounding for us exactly what has gone on in the woman's body and how we need to honor that process just as much as we honour any other rehab process. Please enjoy this episode. My name is Michael Risk and this is Physio Explained. Rania, welcome and thank you for joining us.
SPEAKER_01:Oh, thanks for having me.
SPEAKER_00:You've done a masterclass for us on all things exercise, prenatal and postnatal and returning to exercise postpartum. So we're going to dig a little deeper into that. We were going to start at the start with timeframes and generic timeframes that we see out there in the physio world. Could you tee us up with what you're seeing are the current accepted timeframes and then we'll go deeper on that?
SPEAKER_01:Yeah, so it's a very good question. Currently, the healing timeframes after having a baby seem to centre around the six-week postpartum GP check. And what that means is that there's almost this presumption that at the six-week timeframe, women wake up and they're automatically fully recovered. And that's just simply not the case. If we actually delve into healing timeframes and what we understand, if we think of pelvic floor trauma, abdominal wall trauma, if someone has a cesarean section delivery, we actually understand that the healing timeframes go well beyond that. So for pelvic floor trauma, it really depends on the degree trauma experience, but that can go anywhere from a matter of six weeks to actually some levator in a so part of the pelvic floor and muscles. Some of those take up to one year for recovery, which a lot of people don't realize. And then abdominal wall surgery, major surgery. I think we can appreciate that that can span anything from four to seven months.
SPEAKER_00:Where did the six weeks come from? How did we get there?
SPEAKER_01:I think that came from that six-week postpartum check. So it is a good timescale to go and have a check with your primary care physician. But maybe back in previous times, maybe the GP check had more involvement for women. Maybe there was more time given. And just the way healthcare services have evolved over the last few decades, GPs are under serious pressure. And really, it's very much an informal chat. So to assume that everything has been taken care of and everything's been screened at that check is just... it's not appropriate and we need to do better to serve the women that we're dealing with.
SPEAKER_00:A lot of women are just getting that six-week check and no follow-up care after that. Is that what you're still seeing?
SPEAKER_01:No follow-up care. And also they may not be asked the questions to highlight issues that are common postpartum. So if we think about things like urinary incontinence or pelvic organ prolapse or any other sort of pelvic floor dysfunction symptoms, they're not easiest thing to bring up and a lot of women actually assume that they're normal after having a baby that this is just the way it is they're not likely to volunteer it so unless you're specifically probed and ask those questions you're unlikely to raise it and how many women are getting screened with questions at that six-week postpartum check specifically about pelvic floor function
SPEAKER_00:and we were we were having a bit of banter off air about the comparisons to the trauma of giving birth and potentially the muscle damage and surgery if there has been one and the idea that a six-week check would be enough as compared to other injuries like an ACL tear and all the research and you need 12 months of physio. Can you talk more to that?
SPEAKER_01:Yeah, so I basically think that recovery post-childbirth is completely underestimated. It is very much a normal process. Women give birth every day. Therefore, it's can be very much normalised in that it's assumed that healing is just natural and there's no rehabilitation or advice or guidance required. Like you've mentioned, a sports person can have a microscopic SEL surgery and have a protocol of rehab spanning months, whereas women can go and have what's considered a normal delivery on paper. And it's just considered that they're back to normal on Monday, that they're back looking after other kids in the house doing normal duties. And really, when we consider that they're They have sustained load on both their pelvic floor and abdominal wall for months. And then they're likely to have tissue trauma during childbirth. We really need to start considering tissue healing more appropriately and supporting them the same way as we support sports injuries.
SPEAKER_00:That's a wonderful comparison. And I would love for you to take me through and maybe my naivety in the space and being a male physio. Talk to me about some of the damage that actually goes on. So muscle strains, muscle tears, even if a surgery occurs. And that might really ground, particularly for young physiotherapists, how they could compare it in their minds to an ACL tear.
SPEAKER_01:Yeah. And I think firstly, if we think of a cesarean section delivery, which are very common, we can appreciate that that is major abdominal surgery. So skin, muscle tissue, fascia, even the uterus lining is cut open. So we have to appreciate that there is going to be a healing process required there. Sometimes it's assumed that with vaginal delivery, that this is normal and straightforward. But in fact, there can be surgical delivery there too. Women can have episiotomies or they can tear themselves and that can be quite significant. And they may actually require repair of that tear in theater. And the consequences of that, like anything to do with the pelvic floor means that bladder control, bowel control, pelvic organ support down below can all be impacted and pain can be a significant feature. And given that we have to empty our bladder and bowel and it's a function that we require on a daily basis, it's something that really needs considered. Even before we think about that, during pregnancy, because of the changes going on with our body in terms of muscle lengthening at both the pelvic floor and abdominal wall, And also considering that there's going to be a degree of deconditioning to that person. So even a woman who is active throughout her whole pregnancy will experience some degree of deconditioning because she'll be moving differently and less free and she'll be heavier and more sluggish towards the end. And to liken that to sports medicine again, if we consider any sport and they're off season, We know that coming back to pre-season training is all as a bit of a struggle. There's reconditioning required. And therefore, I think we need to think about pregnancy in the same sort of way. And we need to honour women with that facilitation back into getting that muscle conditioning back up.
SPEAKER_00:I love that comparison. I love what you say about honouring women. It's really grounding when you list off the things that happen. And... It puts it into perspective. It really does. And I love seeing your response when you talk about that too. So yeah, it's exciting. You're a general physio, right? So you're not a women's health physio. So this is, I'm speaking to physios out there. How would you advise them to improve their consult and ask some of these maybe more difficult questions and go beyond what you said before is this could be a normal delivery, but still have all of those things you mentioned?
SPEAKER_01:Yeah, so the first time a woman with any sort of issues postpartum might be attending a clinic, it most likely is going to be a general musculoskeletal clinic because they may not have discussed some of the pelvic health symptoms they're having, but they may be having barriers getting back to sports and exercise. And it's not just for pelvic health physios to be responsible for screening issues in the same way as a musculoskeletal physio screens for neurological signs, rheumatological signs, red flags. I think it's really important that you screen for pelvic floor dysfunction and it actually could be the limiting factor in your musculoskeletal rehab with a woman. If you're trying to progress her rehab and she's either not complying, It could be that there's pelvic health symptoms holding back or getting into that exertion or complying with symptoms. So I think it's really useful to ask questions such as, OK, I've realized you just had a baby recently. Do you know that it's very common for women to leak urine after having a baby, but it's not something that you have to put up with? It just tells us that there's some training needed. Would that be an issue? I think opening up with, do you know that this is quite common, makes it a safe question and a safe place for them to go, actually, I do, rather than feeling that they have to deny it. Bunny, we have a clinical commentary coming out in the special edition of Women's Health, the Journal of Women's Health Physical Therapy in January. And it's really aimed at general physios because we go through a step-by-step process about all the factors to consider. Because if we think we're all biopsychosocial clinicians here, and it's not just even pelvic health central, we want to think about all the other factors that are feeding into someone's recovery. So let's face it, what postpartum woman is getting lots of sleep? I'm still not getting sleep. My youngest is too. And I just think that that's, we know that that's a factor in recovery timescales after injuries. And yet we need to apply it to this population. And other factors could be the risk of postpartum depression, could even be exercise behaviors. They may either not be motivated for exercise or they may use exercise as a coping strategy and excessively look to get back. So you're trying to pick up on factors like that, which may influence your assessment and evaluation and what management they require. One of the ones that I think is often overlooked is relative energy deficiency in sport. I think it's really common for postpartum women to enter this energy deficit just because they're likely to be sleep deprived. They might be eating on the go or feeding everyone else in the house and grazing themselves. And they may just have a very, very busy and demanding lifestyle. And then if we throw exercise into the mix and they're trying to get back to running, what's that doing to their energy reserves? So we know that that can have negative implications for bone health and their menstrual health. So it's really, really important to flag that as well. I
SPEAKER_00:feel like a wonderful way to help all women is potentially upskill and include some of those questions for all physiotherapists, especially males, especially new grads, because they might just be coming, women might just be coming with plantar fascia or knee pain but there is a hangover effect three, six, even 12 months down the track. Is that something you see?
SPEAKER_01:Absolutely. And I think that oftentimes women just need one person to ask them that important question and it doesn't even have to be too invasive. You know, you can just allude to the fact that oftentimes women have pelvic floor dysfunction after having a baby or they may experience leaking, prolapse or pain down below. And you can tell them that if that's an issue, I can signpost you to someone that can help with that. And it just could be the one opportunity they have to go, actually, yes, I'm having issues with that. And you could be the person who changes the course of their journey because Pelvic floor dysfunction is one of the biggest barriers to women getting back to and maintaining exercise after having a baby. And it's underestimated because most women won't say to a class they're going to or to a personal trainer that they're leaking and that's the reason they're stopping. They'll come up with childcare or any other excuse because it's so taboo. So if we can be more proactive at screening people and picking up on when they need further rehab, you could potentially change the lung longevity of that woman's ability to exercise and we know that exercise is so important for overall mental and physical well-being and You mentioned about upskilling musculoskeletal staff, general physios, everybody. And that's basically what our masterclass goes through. So Emma Brockwell, my colleague, took the pregnancy section of that and I went through the postpartum and we basically break it down and give you what questions you should be including in your subjective evaluation, what factors you need to consider and why. And so it's not just for pelvic health physios. This is actually targeted at the wider physiotherapy population. I
SPEAKER_00:love that. I think that really is a call to action. I would be frustrated if only female physios who were interested in women's health went through that. my personal connection and enjoyment with patients when you started asking those questions. And even though it wasn't me helping them with those things, the connection that we then had meant they trusted me more in the future as well for all other things. So it was a real turning point for me personally to include some of those questions in consult. So I think it's a wonderful thing you've brought that up. I wanted to get into... What's the reality of returning to exercise postpartum? What do you tend to see rather than the six-week checkup and even the 12-week timeline?
SPEAKER_01:So I basically see that it's very individual because it depends on the degree of trauma and the delivery pregnancy journey that they've experienced, but also all those additional factors that happen afterwards. So all those biopsychosocial considerations, basically. On average, when we consider healing timeframes and the majority of trauma experience during childbirth, I would see women more likely to be returning around the 12 week timescale and that being a timescale that they can then maintain exercise. Whereas oftentimes women women who return sooner. initially they have no symptoms and it's only then as they start to expose themselves to that higher load that symptoms come to light and they may persevere through this in the short term and then it becomes a bigger barrier so it's like a niggle in your calf if you start running and you might think it's fine initially but if it keeps building and you don't address it it's going to become a bigger issue and it's going to stop you continuing that sport so we just need to like pelvic floor and pelvic health is just basically musculoskeletal and sports medicine but for a focused area and I think we just need to consider it with the same lens and not just box it off as this area that only certain people deal with and that doesn't relate to anything else.
SPEAKER_00:And consider it for longer is the takeaway I'm getting from you. So you're seeing in clinic around 12 weeks is the start. What do you tend to run through around that 12 week period as their load increases? Are you still doing specific pelvic floor exercises or are you starting to go towards like plyometrics with pelvic floor? What does that look like?
SPEAKER_01:Well, that's a really good question. Yes. Initial days, we're going to honor the healing process and we're going to start with the key areas that are impacted, such as basic abdominal wall rehabilitation and pelvic floor rehabilitation. But postpartum rehab is about much more than just Kegels. It's about progressively restoring function. And like I mentioned earlier, all women, even those who are completely active during their pregnancy, have some reconditioning needs throughout their entire body. So it's all about getting functional. And for women, I'm particularly passionate about getting them strong for their daily demands, because there's no point us telling women that they can't do X, Y, or Z type of exercise, but then they're squatting and lunging with a kid on board and maybe a washing basket and who knows what else. So we have to look at their daily life and start to make their rehab like serve that and make them stronger for it. So as the weeks go on, we start to increase the likes of squats, lunges, so closed chain sort of loaded exercise and then gradually getting into impact. So by the 12 week timescale, there's actually load and impact tests that Emma and I put into the return to running guidelines alongside Tom Goom. And although we need a lot more research to validate whether these are the exact tests that should be used, these are a starting point. And that's certainly something I would run through with women. And if they can do those in clinic in front of me, symptom free I'm like, this is a good indication that you're ready to run. Whereas if within that clinic session, just going through a couple of those load and impact tests, they are finding that they're symptomatic. It tells us that there's more rehab to be done. There's more rehab needs and they're not managing that load.
SPEAKER_00:When you say symptomatic, what do you notice? Is that leaking or just general pains around pelvis, back?
SPEAKER_01:Both. So basically any aches or pains around the lumbar pelvic or even lower limbs. So a lot of women postpartum experience lower limbs, musculoskeletal pain, and we need to be flagging that and addressing it. And again, that could be part of the deconditioning experience towards the end of pregnancy. Also asking them specifically, are you having any leaking or are you having any heaviness or pressure in the pelvic area? And it could be leaking from the bladder or bowel. Don't just assume that it's just the bladder. But asking them specifically about that usually will invite them and they usually will be happy enough to say, you know, women, once you open the conversation and they realize it's a safe zone in conversation, they're fine. I
SPEAKER_00:think that's the key is opening that safe space and showing a bit of vulnerability. And that really makes those conversations happen.
SPEAKER_01:Yeah, totally agree.
SPEAKER_00:Grenier, thank you so much for your time. I've had a few takeaways from this myself. Those questions are key, honouring women and the timeline and just what they've been through with their body. I think highlighting that even six and 12 months and beyond after the delivery, we can still be asking these questions and the groundwork for general physios everywhere. We've got a masterclass that we're going to put in the show notes. You can try it for free and people can go deeper into that. But thank you so much for the masterclass. the class and your time today on the podcast.
SPEAKER_01:Thank you, Michael. I've really enjoyed it. Thanks very much.