Age? Pregnancy history?

Is this a young athlete (<12- prepuberty? Teen-post puberty? 18+ ? Never had a baby?)

• If they are young, or never had a baby- pelvic floor ‘weakness’ or ‘damage’ doesn’t really fit as the only source of leaks, so Kegels may not either. Instead, think about it like an overuse injury— you would identify triggers, look for patterns, and symptom behavior. When do the leaks while running occur and what factors contribute to them is crucial.
• If they have a pregnancy or delivery in their history, we need to consider other variables. Vaginal or C-section? Number of pregnancies? Time between pregnancies? Were the symptoms present prior to pregnancy (see previous paragraph)? Started during pregnancy? Or new postpartum? Think about this as someone with an acute “injury or multiple injuries to the same area” who never rehabilitated and went straight back to their previous fitness or sport (over and over again). We need to promote resilience in those tissues, and positive adaptive strategies to rebuild and prepare them to take on the forces and demands of the activity. They need a graduated progressive overload plan.

Timing of Leaks While Running?

We learn a lot about running related pain symptoms based on when in the activity they occur- we need to ask that same questions about leaks while running.

• Leaks occur Immediately or early run? Poor impact absorption, pelvic floor overwhelm (may not be weakness-check out this blog for more depth on this concept) and/or trunk stiffness could be factors.
• Mid-to-late run leaks?  Think fatigue- not just pelvic floor fatigue- think whole body fatigue and fatigue related form changes (poor proximal hip control, respiratory endurance, heavier foot contact).

Leak Pattern?

Again, we can take the same clinical reasoning approach we do for pain during running or any physical activity, and look patterns. Are the leaks while running more common on…

• Certain surfaces (trail, track, or concrete)?
• With specific inclines (downhill or uphill)?
• Do speed changes make a difference-sustained speed changes or quick accelerations?

Identifying these triggers helps you plan a graded exposure program to address those specific challenges.

Comorbidities? 

Think whole person, whole presentation – what else is going on for that patient?

• Do hip or knee pain and leaks occur at the same time while running? Solve that trigger- Ex: poor proximal hip control and impact absorption may be build a plan that addresses those variables and you will have a win-win. Hint: There is a strong neuromuscular link between the glutes and pelvic floor!
• Are there sleep deficits? Do symptoms follow a hormonal pattern-worse certain times of the month? This may suggest modifications to training volume or intensity when sleep is less optimal or the part of the cycle that is more symptomatic to see if it would change symptom behavior.

There’s No Place Like Home

Click those ruby red heels together sports med pros- you’ve had the tools to understand and interpret an athlete’s leaks while running all along! Use your reasoning skills to dig deeper and address leaks as a part of the your care plan. Don’t get results? Refer, co-treat, learn more (see below)! 

Wanna learn more about integrating sports medicine and pelvic health? Check out our sports medicine online courses: Treating and Training the Female Runner (or Any Female Athlete, Sports Medicine Bundle, Persistent Pelvic Pain in Athletes: A Biopsychosocial Approach. 2024 Black Friday Sale is coming soon! 

Don’t wanna miss a post? Want updates on events and discounts on online course products ? Join my newsletter here. Find me on the socials: Instagram, Facebook, Twitter/X, and YouTube.

The post An Athlete Tells You They Have Leaks While Running-Now What? appeared first on Julie Wiebe PT.

See domains and definitions below from Moore et al, 2022.

This is such big news….folks are front loading future research with imperatives from the tippy top of athleticism. It will take time, but it gives us all rallying points to be sure we are on the same page- moving the conversation forward with collective intention.

Meet Me at the Rallying Point

In 2020, I began a collaboration with Chris Napier PT, PhD at the SFU Run Lab, with the intention of filling large gaps in the literature on some of these female athlete health domains (D-PR, D-PO, D-PF, and D-ME). While some of our results challenged my own biases, some of the results were novel! Offering new information to help fine tune our thought processes on how sport and female athlete health domains interact.

One of the strengths of our study was that we recruited for a running study first, then offered pelvic health surveys second. This limited participant selection bias, meaning folks chose to join the study as a runner, not as someone who runs AND has pelvic health challenges. The goal was to get a broader sampling of runners and get a clearer picture of prevalence of a variety of pelvic health needs in the recreational female runner population. In addition, we surveyed for a spectrum of pelvic health need across the lifespan not just urinary incontinence. That’s where some of the novel magic happened!

Check out study details below, followed by links to our published abstracts in open access journals. We looked at associations in the data between the above noted health domains, demographics, running history and volume, and kinematic and kinetic variables in a convenience sample of recreational female runners.

Take a Peek: Methods

Eighty-eight healthy recreational female runners (biologic female sex at birth) free of musculoskeletal pain who ran at least 1x/week for > 3 months were recruited from the local community for an instrumented biomechanical treadmill study. After data collection, they were invited to complete a series of surveys and screened for additional criteria. Runners <18 years-old, currently pregnant or <12 months from a delivery, breastfeeding, with an acute urinary tract, bladder, or vaginal infection, diabetes or neurological disease, or using diuretics were excluded. Sixty- six participants met additional criteria and volunteered to completed surveys.

Participants were provided a standardized shoe with insole-embedded inertial measurement units capturing peak resultant acceleration at initial contact (PRA-IC) as they ran on a treadmill at three speeds (2.5, 3.0, 3.5 m/s). Afterward, participants self-reported running mileage and experience, obstetrical history, hormonal status, and pelvic health symptomatology via a modified Epidemiology of Prolapse and Incontinence Questionnaire and the Queensland Pelvic Floor Questionnaire.

In addition, we asked questions regarding symptom behavior during running in the same 4 pelvic health domains captured by the Queensland (Urinary, Bowel, Prolapse, and Sexual Health). Currently, there are no validated measures specific to pelvic health in athletic populations, however the IOC consensus statement specifically suggested the Queensland because it asked questions in multiple pelvic health domains (Moore et al, 2022).

Take a Peek: Results

Now onto some of our results! See below links to 4 published abstracts of our 7 peer reviewed platform and poster presentations shared at state, national, and international conferences! Go Team (they are amazing*)! For now, I am sharing abstract links (you will need to scroll within the article to the Abstract# or page# indicated in the citation). Throw thoughts or questions below in the comments or send me an email!

Abstracts can only capture preliminary findings and snapshots of components of the study. Manuscripts are in process with the hope of creating a fuller picture of the data and contribute to filling gaps in the literature! I will be following up with more blogs, videos, and social media posts more specifically on our results soon! Stay tuned!

The Abstracts

Wiebe JW, Nguyen A, Huang MH, LaCross J, Fridman L, Tran N, Napier C. Prevalence of Pelvic Health Dysfunction and Help-Seeking Behavior Among Recreational Female Runners. [Abstract 41246]. In: Academy of Pelvic Health Physical Therapy. 2024 Combined Sections Meeting Platforms and Posters. J Womens Pelvic Health Phys Ther. 2024;48(1):47-71.

Wiebe J, Huang M, LaCross J, Nguyen A, Fridman L, Tran N, Napier C. Dyspareunia in recreational female runners: investigating obstetrical and running habit characteristics [Abstract page 3] In: Lamvu G. Abstracts from the International Pelvic Pain Society (IPPS) annual scientific meeting on pelvic pain 2023. Pain Rep. 2024;9(3):e1150. Published 2024 May 15.

Wiebe J,LaCross J, Huang M, Nguyen A, Fridman L, Tran N, Napier C. Prevalence of Pelvic Health Symptoms Associated with Pelvic Floor Overactivity in Recreational Female Runners [Abstract 093]. In: American Academy of Sports Physical Therapy Poster Presentation Abstracts. JOSPT Open 2024;2(4):CSM31-CSM79.

Wiebe J, Huang M, LaCross J, Nguyen A, Fridman L, Tran N, Napier C. Dyspareunia Associated with Peak Resultant Acceleration in Recreational Female Runners. [Abstract 084]. In: American Academy of Sports Physical Therapy Poster Presentation Abstracts. JOSPT Open 2024;2(4):CSM31-CSM79.

The Team

*The Team: Jennifer LaCross, PT, DPT, PhD, WCS, ATC; Min Huang, PT, PhD; Anna Nguyen, PT, DPT; Lauren Fridman; Nicolas Tran; Chris Napier, PT, PhD.

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References

Moore IS, Crossley KM, Bo K, et al. Female athlete health domains: a supplement to the International Olympic Committee consensus statement on methods for recording and reporting epidemiological data on injury and illness in sport. Br J Sports Med. 2023;57(18):1164-1174. doi:10.1136/bjsports-2022-106620

The post Female Athlete Health Domains are Research Priorities appeared first on Julie Wiebe PT.

What do we know? 

Research at the cross-section of sports medicine and pelvic health IS growing. However, we still have a long way to go to understand how best to advise and guide folks who want to engage in fitness and sport. This is particularly true with activities that involve higher impact forces. Previously we discussed having significantly more research on incontinence and athleticism. Lourenco et al. (2017) noted that as sport specific impact forces increase, rates of incontinence increase (higher impact, higher rates of incontinence). In addition it is noteworthy, that female recreational runners with the highest peak braking forces were 8x more likely to have a running related injury (Napier et al. 2018). 

But what about running and prolapse?  

What’s new…Highs and Lows?

In a 2016, 311 triathletes, ranging from Sprint to IronDistance, were recruited for a survey study. The authors found that 5% of the participants reported symptoms of POP (Yi et al. 2016). An additional survey of 1,379 runners and CrossFitters found that the Runners reported higher rates of POP symptoms than CrossFitters (12.7% vs 7.8%). (Forner et al. 2021). 

Considering the historical concerns about the relationship between high impact forces and the development or aggravation of POP, these prevalence rates are lower than expected. Interestingly, while the training of a triathlete and a runner seem to have more overlap, there was more similarity in the prevalence rate of POP in the Triathletes and CrossFitters (5% and 7.8% respectively). One takeaway may be that the triathletes and CrossFitters participate and train more movement variety than those that ONLY run. Running is a very repetitive impact activity. Exploring new movement patterns and activities might be a path for some to improve symptoms and build/rebuild resilience. 

But wait…..there’s more! 

In a 2024 study, runners were recruited for an instrumented treadmill study. Following data collection, they were offered the opportunity to opt into pelvic health surveys. Of the 66 that chose to participate and met inclusion criteria, 4.6% reported symptoms of prolapse while running. (Wiebe et al. 2024- ABSTRACT). This value was similar to the prevalence reported for triathletes and CrossFitters. So what gives?

A few things to note, Wiebe et al. (that’s me and my amazing team!) recruited athletes for a running study vs. recruiting for a study that explored pelvic health variables in those that run. This helped to reduce what is called the sampling bias, which is a strength of our study. A sampling bias is a fancy science term meaning folks with pelvic health issues are more likely to sign up for a study that is studying pelvic health, thus having the potential of artificially elevating the numbers in the results. Of course, the 66 that opted into the pelvic health survey were clearly-clued-into the purpose of the secondary study. However, the hope is that by sampling for runners first, our results MAY depict a more accurate reflection of the prolapse prevalence in the running population at large.

It is important to remember, as we discussed in the High Intensity and Pelvic Health blog earlier this month, up to 75% of folks self-select out of fitness due to POP symptoms. This may explain the lower prevalence found in our data. Conversely, there is a proposed thought process that physical activities can have a positive training effect on the pelvic floor (Bo and Nygaard, 2020; Leightner et al. 2018). Our findings MAY support this hypothesis, but we still have a LONG way to go to draw those conclusions.

So where do we go from here? 

Running and impact related activities have also been historical no-no’s to prevent or manage POP, so the lower than expected prevalence noted in these studies DOES support avoiding blanket edicts. However, please note POP is multifactorial, so this means we cannot suggest that the opposite blanket statement-that running is appropriate for everyone- is true.

Instead, our job is to distinguish and develop:

1. For whom is running appropriate? 
2. Individualized ways to coach or dose it in a way that improves folks tissue/symptom tolerance
3. Use strategies to rebuild and prepare folks for impact

Try these ideas to help with Running and Prolapse 

Here are some adaptations and strategies to help you make those decisions and develop programs to try to reduce aggravating forces and pressures on the prolapse and pelvic tissues in the trenches.

1. Ease your abs. Gripped abs while you run adds pressure/force from above downward towards your prolapse. A stiff trunk is not what you need when you are trying to absorb impact. Instead, we need to be springs with each step. This includes having a springy center.

2. Reduce pelvic floor rigidity. Folks often hold a Kegel while running thinking they are protecting their prolapse. But the pelvic floor MOVEs up and down while we are running in the same pattern as the glutes (lengthens to prep for foot contact, contracts up at foot contact). Learning to integrate that up and down movement in the pelvic floor with your glutes and abs helps reduce central stiffness (think SPRINGY), and helps absorb impact. 

3. Rotate. Emphasize rotation through your whole torso (not just your upper chest) while running to break up a tendency to grip at the tummy. This also helps to keep you propelling forward not bouncing up and down while you run (which increase impact forces). (More on that here)

4. Lean. Shift forward into the run like you are running up a gentle hill. Shifting your body mass over the lead leg reduces over-striding to the front, reducing impact forces. This also creates more stride behind you-kicking up your glutes (see#2), huge for absorbing impact! (More on that here)

5. Symptoms are Signals. Listen up, your body is giving you hints as to what you are ready for. A one size fits all approach to return to run, simply doesn’t work. YOUR signals are YOUR guide. Modify as needed. (More on that here)

Opportunities Abound!

While the lack of research is still glaring, recent efforts and attention on these needs are opening new doors, and, of course creating, lots of new questions! These are opportunities to keep digging deeper to keep moving the ball forward for the folks we care about!

Don’t wanna miss a post and enjoy subscriber only content and discounts- join my newsletter here. 

To Learn more, see courses below that can help you dig deeper: 

For Individuals 

For Pros interested in helping women return to run with prolapse (and other athletic activities) keeping pelvic health in mind

References

Lourenco TRDM, Matsuoka PK, Baracat EC, Haddad JM. Urinary incontinence in female athletes: A systematic review. IntUrogynecol J. 2018;29(12):1757-1763. doi:10.1007/s00192-018-3629-z.

Napier, C., C. L. Maclean, J. Maurer, J. E. Taunton, and M. A. Hunt. “Kinetic Risk Factors of Running-related Injuries in Female Recreational Runners.” Scandinavian Journal of Medicine & Science in Sports 28.10 (2018): 2164-172/

Yi J, Tenfelde S, Tell D, Brincat C, Fitzgerald C. Triathlete risk of pelvic floor disorders, pelvic girdle pain, and female athlete triad. Female Pelvic Med Reconstr Surg. 2016;22(5):373–6. https://doi. org/10.1097/SPV.0000000000000296.

Forner LB, Beckman EM, Smith MD. Do women runners report more pelvic floor symptoms than women in CrossFit®? A cross- sectional survey. Int Urogynecol J. 2021;32(2):295–302. https:// doi.org/10.1007/s00192-020-04531-x.

Wiebe JW, LaCross J, Huang M, Nguyen A, Fridman L, Tran N, Napier C. Prevalence of Pelvic Health Symptoms Associated with Pelvic Floor Overactivity in Recreational Female Runners. Poster Presentation. American Academy of Sports Physical Therapy-American Physical Therapy Association. Combined Sections Meeting. Boston, MA. February 2024

Bø K, Nygaard IE. Is physical activity good or bad for the female pelvic floor? A narrative review. Sports Med. 2020;50(3):471–84. https://doi.org/10.1007/s40279-019-01243-1.

Leightner, Monika. “Evaluation of Pelvic Floor Kinematics in Continent and Incontinent Women during Running: An Exploratory Study.” Neurology and Urodynamics (2018); 37: 609-818. DOI: 10.1002/nau.23340

The post What’s New? Running and Prolapse appeared first on Julie Wiebe PT.

My How We’ve Grown!

In a scoping review by Giagio et al (2020), the authors noted a sharp increase in the number of studies on pelvic health in female athlete populations. Their search revealed 6 studies from 1990-1999, and 71 studies 2010-March 2020. However, a majority of that research (62/83 studies) explored urinary incontinence (UI), while only ONE was dedicated only to high intensity exercise and prolapse (POP). A recent narrative review by Bo et al (2023) searched databases from 1946-2022, and found only 8 studies that addressed POP (along with other pelvic health dysfunction) in relationship to physical activity. All 8 were found between 2016-2021. Again, it is good news that these questions are finally being asked! But clearly we are just getting started trying to understand this for our athletic and fit populations.

What’s New? Highs and Lows

The studies reviewed by Bo et al. (2023) looked at a variety of athletic and high-intensity exercise endeavors (running, CrossFit, Judo, triathlon, cheerleading, volleyball, and more). A history of pregnancy was a consistent risk factor for the development of POP symptoms in most of the studies. 

The highest prevalence of POP symptoms were noted amongst Olympic and Powerlifters at 23% (Skaug et al. 2022). However, most of the included studies found a much lower prevalence of POP symptoms reported by those that weight trained. Almeida et al.(2016) found that only 2.3% of amateur athletes who weight trained reported POP symptoms, while High et al. (2020) noted POP symptoms in only 3.2% of female CrossFitters. 

Wait, there’s more…

In addition, a large study found that only 14.4% of the 3934 participants, who reported a variety of activity levels, experienced prolapse symptoms (Forner et al. 2020). An important insight from this study was that symptoms were more prevalent among inactive women or those lifting lighter weights (<15 Kg), then those participants that lifted heavy (>50 Kg). The authors noted that vaginal deliveries and inactivity had the strongest associations with POP symptoms. Hello, this is huge. 

While these low numbers defy our historical understanding and expectations for POP symptoms and prevalence in those that regularly engage in weight training activities, we cannot take a victory lap just yet.

It is important to note that females with POP symptoms often remove themselves from these activities. Cook et al (2021) noted that 75% of those surveyed stopped or modified their fitness due to POP symptoms. Conversely, it has been proposed that global physical activities have a positive impact on the health of the pelvic floor (Bo and Nygaard, 2020, Leightner et al 2018). Forner’s 2020 results may support this idea, however, we still have a long way to go. 

So where do we go from here?

Our takeaways, or at least mine, are that these results, from Bo to Forner to Cook, continue to support that POP is multifactorial. Weight training and high-intensity exercise alone aren’t the bad guy, or the only bad guy. Often, our literature and clinical pathways seem to be asking either/or questions. Should we or shouldn’t we? Is weight training or physical activity a friend or foe of pelvic health?

However, the reality in the trenches is much more nuanced than that. More complex questions may help us start to tease out solutions that address that multifactorial, biopsychosocial nature of the relationship between high-intensity exercise and pelvic organ prolapse: 

• Forner’s 2020 study suggests that inactivity and lighter weights may have a more detrimental impact on pelvic health, and begs the question: have we unintentionally under-loaded folks in an effort to protect them from POP or other pelvic health dysfunction? (more on that here)
• Why does physical activity promote pelvic health for some, while it propels dysfunction for others? 
• Rather than focus only on the symptomatic folks, what can we learn from the large percentages of folks in these studies that had no symptoms of prolapse- it is HOW they are doing the exercises? Is it volume, speed, type? Is it genetics (fascia/collagen content? Levator hiatus width?).
• Could these protective efforts toward “safe” exercise added fears and kinesiophobia that impacted the decision making of those surveyed in Cook’s 2021 study to discontinue participation in their fitness of choice? (Some ideas of how to adapt vs abandon exercise)
• How does the lack of available guidance on a return to exercise after pregnancy impact these numbers? Would guidance have turned the tide for Cook’s survey participants? (Here is some guidance!)
• How does our lack of education of medical, rehabilitation, and fitness providers on the basics of pregnancy recovery and return to fitness impact their comfort with these topics, to improve their ability to engage athletes on these topics provide this guidance? (Some ideas here! Let’s coach this! 
• How can we improve our educational processes to change that professional trajectory?   

What’s Next?

Lots to consider as we move forward. But the good news is that we are moving forward. While the low prevalence of POP in these studies is encouraging, we need to absorb them broadly as we continue to gather more information. However, I do think that they support re-evaluation of the blanket premise that weight training leads to POP. Instead it moves us toward the consideration of more variables and asking deeper, more complex questions! Thus providing us with more entry points to make changes for our patients and clients, and can help us offer more hope! 

#educatedhope

Don’t wanna miss a post and enjoy subscriber only content and discounts- join my newsletter here. 

To Learn more, see courses below that can help you dig deeper: 

For Individuals 

For Pros interested in helping women return to run with prolapse (and other athletic activities) keeping pelvic health in mind

References

Giagio S, Salvioli S, Pillastrini P, Innocenti T. Sport and pelvic floor dysfunction in male and female athletes: A scoping review. Neurourology and urodynamics. 2021;40(1):55-64. doi:10.1002/nau.24564

Bø, K., Anglès-Acedo, S., Batra, A. et al. Strenuous physical activity, exercise, and pelvic organ prolapse: a narrative scoping review. Int Urogynecol J 34, 1153–1164 (2023). https://doi.org/10.1007/s00192-023-05450-3

Skaug KL, Engh ME, Frawley H, Bø K. Prevalence of pelvic floor dysfunction, bother, and risk factors and knowledge of the pelvic floor muscles in Norwegian male and female pow- erlifters and Olympic weightlifters. J Strength Cond Res. 2022;36(10):2800–7. https://doi.org/10.1519/JSC.0000000000 003919.

Almeida MBA, Barra AA, Saltiel F, Silva-Filho AL, Fonseca AMRM, Figueiredo EM. Urinary incontinence and other pelvic floor dysfunctions in female athletes in Brazil: A cross-sectional study. Scandinavian journal of medicine & science in sports. 2016;26(9):1109-1116. doi:10.1111/sms.12546

High R, Thai K, Virani H, Kuehl T, Danford J. Prevalence of Pelvic Floor Disorders in Female CrossFit Athletes. Female Pelvic Medicine & Reconstructive Surgery. 2020; 26 (8): 498-502. doi: 10.1097/SPV.0000000000000776

Forner LB, Beckman EM, Smith MD. Symptoms of pelvic organ prolapse in women who lift heavy weights for exercise: a cross-sectional survey. International Urogynecology Journal. 2019;31(8):1551-1558. doi:10.1007/s00192-019-04163-w

Cook J, Frawley H, Dakic J, Hay-Smith J, Lin KY. Pelvic floor disorders in exercising women: impact on participation, symptom disclosure and screening. Journal of science and medicine in sport. 2021;24:S56-S56. doi:10.1016/j.jsams.2021.09.142

Leightner, Monika. “Evaluation of Pelvic Floor Kinematics in Continent and Incontinent Women during Running: An Exploratory Study.” Neurology and Urodynamics (2018); 37: 609-818. DOI: 10.1002/nau.23340

The post What’s New? High-Intensity Exercise and Prolapse (POP) appeared first on Julie Wiebe PT.

Give it some thought.

To be clear, this proposed Diastasis classification system isn’t mine, but it is a starting point for all of us to consider. I actually appreciate that it is coming out of the Medical Doctor/Surgeon/Researcher space. They, the docs and NPs, are the starting place for so many on their pregnancy recovery journey, and they set the tone for patient beliefs and expectations around their Diastasis. As a clinician, I often find it hard to shift the perspective of a patient who has been told they need surgery for a DRA by their doctor. No matter the results we are achieving, their buy-in is trickier, and the work of conservative care seems pointless if surgery is the end result anyway. 

The German Hernia Society and International Endohernia Society published a paper in 2019 (Reinpold et al)  to suggested classifying a diastasis as Mild, Moderate, or Severe* based on an Inter-Recti Distance (IRD) width.

Mild (< 3 cm) 

Moderate (3-5 cm)

Severe (> 5 cm) 

While they were not specific as to the measurement point, they summarized multiple articles that used a variety of measurement points. These studies supported a consensus around a separation beyond 2 cm as a diastasis, including the 2009 study by Beer et al (Read more details about that here). 

That seems too simple…

While this diastasis classification system may seem over-simplified, and I know I have regularly seen much larger Diastasis measures in my own practice, it is a communication starting point. It changes the gravity of social media posts and marketing of programs on how someone healed their own 3 cm DRA. How different would it be if…

1. The same social media posts would now read-“find out how I healed my MILD Diastasis’
2. A doctor suggested to a patient that the DRA was measuring as MILD, and therefore they are a great candidate for conservative care before considering another approach
3. A new mama thinks- oh phew, my Diastasis is only MILD, I can do this!! 

Helping to encourage folks to know their Diastasis baseline is also something I have written about before. The hill doesn’t seem so far to climb if you have a 3 or 4 cm IRD, and you know you started with a 2 cm naturally occurring separation pre-pregnancy. But if you think you started at zero, that takes your mindset to a very different place as you consider the information you are receiving. 

But what about the fascia?! 

I know what you are thinking- but what about the fascia?! We have moved forward to understanding more about the transmission of forces via the fascia, and the role it has in recovery challenges (no longer just looking at IRD). I AM ALL IN on that thought process and understanding it better. However, we still do not have a clinically accessible, and uniform way of describing and classifying fascia either. Real time ultrasound is awesome, but most clinicians are priced out. 

After palpating A LOT of linea alba’s over the years, I know what density I’d like to feel, but my min/mod/max may not be the same as yours. And heads-up, you do not get an 8-12 cm IRD without some very thinned, low density fascia. They are part of the same clinical picture. 

The reality is we need to be studying and quantifying the FUNCTION of the whole abdominal wall, and how to restore that. We are still sorting out the clinical meaning of a DRA at any width and fascial quality/density. So we have a long way to go. (Read more on one of my fave studies on abdominal wall function with and without DRA here). 

In other words, IRD and fascial quality and density, still don’t paint the full clinical picture. Considering abdominal wall function, quality of life, and patient beliefs are more pieces of the puzzle we need to explore. So are genetics, but y’all….we can’t get it all into one blog! (I did put some other thoughts here)

Let’s reframe step-one.

The Reinhold study gives us a place to start. A Diastasis classification system to clarify our communication between providers, patients, and the public. I am not suggesting we move backward in our thought process (conflating IRD with DRA), however, meausring the IRD is objective, cost-effective, and still a primary tool used across specialties. It is also still the primary focus of the public. It may create an opportunity to use the classifications to advocate for patients who are not interested in surgery and can’t convince their doctors to write them a PT prescription. The Beer et al study suggestion of an IRD that is >2 cm at  3 cm above the navel has been utilized in a lot of research to distinguish what is and what is not a DRA. We can add this specific measurement location to the full scope of our intake paradigms. This can help to solidify that we are talking about the same thing when we talk across specialties about DRA.

The Reinpold article (free full text) also offered other classifications that do speak to fascia/connective tissue and other parameters that would help our communication among specialties including:

• DRA length and location of IRD- Subxiphoidal, Epigastric, Umbilical, Infraumbilical, and Suprapubic. (see picture)

• Number of previous pregnancies

• Skin laxity

• Clinical bulge while standing and with a sit-up
• (Picture Source- Reinpold et al 2019)

We have more work to do! Reframing step-one may be a really wise way to get us all heading in the same direction. Let me know what you think!

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References:

Reinpold W, Köckerling F, Bittner R, Conze J, Fortelny R, Koch A, Kukleta J, Kuthe A, Lorenz R and Stechemesser B (2019) Classification of Rectus Diastasis—A Proposal by the German Hernia Society (DHG) and the International Endohernia Society (IEHS). Front. Surg. 6:1. doi: 10.3389/fsurg.2019.00001.

*based on previous work- Ranney B. Diastasis recti and umbilical hernia causes, recognition and repair. SDJ Med. (1990) 43:5–8.

The Normal Width of the Linea Alba in Nulliparous Women. Beer GM, Schuster A, Seifert B, Manestar M, Mihic-Probst D, Weber SA. Clin. Anat. 22:706–711, 2009.

The post A Diastasis Classification System appeared first on Julie Wiebe PT.

Female Athlete for the Win

The conference pulled together the collective wisdom of athletes, coaches, sports med physicians, physiotherapists, athletic trainers, kinesiologist, nutritionists, researchers, etc. There was even an adolescent sports gynecologist….what?!! I didn’t even know that was a thing. In addition, we got sneak peaks at upcoming female athlete expert consensus statements on Concussions, REDS, Menstrual Cycles and performance, and Postpartum care. Moreover, open forums about athlete mental health, gender, race, and disability inequalities, challenges in professional sport, coaching abuses, and athlete identity did not disappoint. (Check out resources here: USCenterforSafeSport.org and VoiceinSportFoundation.org)

Takeaways

I am still digesting all the content and the experience, but thought I would share a few of my major takeaways.

1. Huge research leaders in female athlete medicine, all from different areas of care, collectively indicated that we have low to moderate quality evidence as it relates to the female athlete. For example, one statistic shared was that 6% of sport and exercise science research has been solely focused on females. While disheartening, it was somehow encouraging to know that the poor quality and QUANTITY of evidence in the athletic pregnancy, postpartum, and pelvic health arena wasn’t unique. Our little corner of the athlete world, we aren’t as far behind as I thought, and now there are financial resources to support the science to propel our care.
2. However, recognition of our little corner of the athlete world is growing! The push by pregnancy and postpartum female athletes to continue to participate has shifted the interest of sports medicine researchers along the life stage continuum. Hopefully, our silo-smudging sports medicine + pelvic health community can be there to guide the research questions, and athletes that are moving into this chapter of their careers.
3. The needs of a female athlete are multifactorial. The conversation is so much bigger than the strength of anyone muscle group, hormone fluctuations, or running forces. It takes a village, and thankfully the community of folks out there doing the work is growing and connecting.
4. Check out a summary of specific highlights from colleagues @theactivewomensclinic.
5. Consider checking out the virtual conference (it was all recorded) to glean your own takeaways! It is available until July 21. Stop by my e-poster on the early results of my research into the pelvic health clinical features and running biomechanics! More results are on the way!

We ALL Win

To sum it up…take care, and take heart. The seeds of all our hard work are starting to grow.

*Identified biological sex female at birth (ex: menstrual cycles, capacity for pregnancy, menopause).

Don’t wanna miss a post? Want updates on events and discounts on online course products ? Join my newsletter here. Find me on the socials: Instagram, Facebook, Twitter, and YouTube.

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You can watch the video at Original Strength‘s youtube page following this link.

Listen in and enjoy!

The post Pregnancy Recovery and Restoring Pelvic Health Podcast with Original Strength appeared first on Julie Wiebe PT.

A: Short Answer: Both/and, not either/or. Long Answer: Let’s move the conversation forward and ask new questions.

What’s the Issue?

To Kegel or not to Kegel is a hot topic these days. However, the controversy and conversation is not new. The concern is that the promotion of Kegels (a contraction and hold of the pelvic floor, followed by relaxation) may not be appropriate for everyone. However, it remains the go-to suggestion for anything related to pelvic health. Kegels are intended to strengthen. If someone’s pelvic health issues might be irritated by strengthening or if a strength deficit isn’t the problem, then symptoms may worsen or not resolve (Not to Kegel).

This can add to frustrations and potentially really challenge recovery. It can also make folks doubt the availability of a solution. However, the use of them to raise awareness of and strengthen the pelvic floor, still has merit for those who need that type of help (To Kegel).

So how do we decide?

Part of the issue and the confusion is the nature of the Kegel itself. It is important to understand the thought process that has led to Kegels being the primary activity offered. When we unpack this history, and take a look at our evolving understanding of care for pelvic health needs, we can move beyond this either/or quandary. Then the question isn’t to Kegel or not to Kegel, it’s can we change the focus of our conversations? Let’s consider a shift.

Where We’ve Been

Kegels have been the only option for pelvic floor exercise for decades. Kegel-type activities have been the universally offered exercise for anything related to pregnancy, postpartum, or pelvic health needs. This idea has been embedded in medical, physiotherapy, fitness, and pop culture.

The good news is we have evolved a lot in those decades. A one-size-fits-all, or one-muscle-solves-all approach is not reflective of best practices in any area of clinical care or physical training. The idea that one exercise and one muscle group would solve the complexity of pregnancy, postpartum, and pelvic health needs must be reconsidered.

Where We Are Headed

• Let’s expand our language, and start discussing pelvic health, not pelvic floors. A focus on a muscle group, well, keeps the conversation on the muscle group. This limits how folks interpret needs that involve the pelvic floor- incontinence, pelvic pain, prolapse, pain with sex. Then the pelvic floor is considered both the only source, and the solution to these needs. A shift in language fosters a shift in thought. When we understand the range of direct and indirect factors that play into these issues, we broaden our investigation of other contributing considerations AND our options to bring change.

• To clarify, this isn’t an anti-Kegel or an anti-treating the pelvic floor post. It’s not. Instead, it’s an understand the whole picture post. Yes, the capacity and quality of pelvic floor engagement has a contributing role in pelvic health challenges. By all means, bring awareness to the pelvic floor and learn to engage or relax it through an activity like a Kegel. However, the quicker we look for why the pelvic floor is being overwhelmed or overused, the sooner we will know how to use or not use a Kegel.
• It also moves us beyond only considering only the characteristics and behavior of the pelvic floor as our solution. We can consider:
  • pressure systems
  • muscular relationships
  • exercise habits 
  • lack of exercise
  • social supports and influences
  • sleep
  • stress 
  • And more

Let’s Shift- Pros

• In clinical care, we learn to ALWAYS look above and below the joint and musculature that is experiencing symptoms. For example, for a knee, we always consider the hip and the ankle/foot. Use that same understanding here, consider above and below the pelvic floor/pelvis:
  • ABOVE: What’s happening in the trunk musculature? Intra-abdominal pressure? Rib cage?
  • BELOW: What’s up with the hip? How is their closed chain control? How is their impact control? Can they generate power out of the legs to lift, to assist the trunk/pelvic muscles?
• If we look at it this way, then pelvic floor weakness/underuse (To Kegel) or over-strengthened/over-recruited (Not to Kegel), becomes a less pressing question. Instead, we have so many more questions we can ask! We start to get at the WHY the pelvic floor issues and pelvic health needs may be a part of our clients whole picture.
• If we look ABOVE, we can appreciate that the pelvic floor may be plenty strong. However, it is being overwhelmed by high Intra-abdominal pressure from above contributing to leaks or prolapse symptoms. Therefore, strengthening the pelvic floor may not solve the issue, but managing intra-abdominal pressure is critical.
• If we look BELOW, we can understand that the pelvic floor may be over-recruited due to a lack of support from the hip musculature in their exercise patterns. This may result in painful sex, or pelvic pain. Thus, efforts to get the pelvic floor to relax will be challenged (even a Not to Kegel strategy), if the hips and leg power continue to be lacking while they exercise.
• To be clear I am not suggesting an either/or scenario: pelvic floor OR hip strength; pelvic floor OR pressure control. I am suggesting, both/and here too. Integrate them in a balanced way within function and fitness activities.

Let’s Shift- Individuals

• If you feel caught in the middle and are unsure what to do, here is a shift. If you are practicing Kegels, change them from a one-size-fits-all, contract/relax activity that isolates the pelvic floor, to integrating the pelvic floor in a controlled way into movements and fitness you enjoy. As a result, this will strengthen the pelvic floor(To Kegel), but because the focus is on control, it will reduce the possibility of overusing it (Not to Kegel).
• A cue I use to help folks learn to coordinate the pelvic floor without overuse is asking patients to predict the amount of pelvic floor lift they need for a particular activity, e.g. “Are you lifting a couch or a pencil? How much pelvic floor do you need for the pencil vs the couch?”.
• If it is an athlete who is lifting heavy weights, I ask “What would the lift feel if you were doing 50% of your max? 30%? 80%?”.
• Control driven work is less likely to become an over-recruiting activity. Accordingly, this helps folks distinguish their need for added oomph for a challenge at the gym vs simply air squatting to pick up an abandoned pacifier (or pencil). The strategy for how you use your pelvic floor must meet the demands placed on it.

Moving Forward

All things considered, these shifts will go a long way toward moving us beyond an either/or choice and a debate that really isn’t new. Our understanding has evolved, we can impact pelvic health without a solo focus on the pelvic floor. Research is now exploring these new ideas and asking new questions! We are moving forward.

Finally, many are now joining in the conversation, and want to understand this piece of the puzzle in their care and training. This is awesome, we need you! So if you are new here….let’s start here. With a deeper, more robust appreciation for how the pelvic floor fits into our clinical and fitness puzzles versus as a stand alone entity. Tell your friend, it’s both/and.

Don’t wanna miss a post? Want updates on events and discounts on online course products ? Join my newsletter here. Find me on the socials: Instagram, Facebook, Twitter, and YouTube.

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In addition, I will be joining a great line-up of speakers at the online EIM Elevate Pelvic Health Symposium on January 28, 2023. Don’t miss out! Use code WIEBE5 for 5% off registration.

My topic for the Symposium: Graded Exposure: Prepare the Path for Return to Athletic Performance

Whether your patient’s max effort is lifting a baby or a barbell, chasing a toddler or crossing a finish line, the strategies to help them accomplish it pelvic health symptom-free are similar. Break down the task, then build it back up. Learn how to create graded exposure strategies to prepare a path for your patient to return to functional and fitness challenges. 

See you there!

Thanks again to Tim, Bryan, and EIM for having me on the podcast and including me in the Movers and Mentors project.

The post Practice Leadership Podcast-Julie Wiebe, PT appeared first on Julie Wiebe PT.

One Size Does Not Fit All (Activities)

Many female runners have tried Kegels without success. Here’s the deal, a one muscle solution will not meet the complex needs of an activity like running. Instead, we must address leaks with a multifaceted approach. All the variables that play into continence control during sport must be considered to build a tailored program to help you.

We would not ignore pain in an athlete, or encourage them to ignore it. Instead we would explore what variables are contributing to the pain, and see what we could modify. We need to have the same approach for incontinence.

Identify the Triggers

To build a program specific to the needs of a runner, gathering information about the behavior of the leaks will help identify the why. If we understand the triggers, then we can tailor our programs to solve for the why. The athlete, coach and physio/PT should ask:

When does the leak occur? Start, middle, or end of run? At the start, consider running mechanics. At the end, consider fatigue related form changes for the whole runner (not just fatigue of the pelvic floor).

If fatigue and form break down are associated with the start of leaks- in what way does the form break down? Proximal hip control changes? Sharper foot strike angles? Loss of reciprocation? Respiratory endurance changes breath patterns?

Do the leaks happen during the final sprint to the finish? Or on the downhill? Speed changes are a common culprit-reducing rotation and adding trunk stiffness. Downhill runs keep the foot well ahead of the center of mass, increasing the forces at each footfall.

Is the leak occurring frequently, throughout the run and with every run? This needs a longer look by the pro and athlete (and may need a referral to a pelvic health pro). Can they connect with their pelvic floor, are they running with a gripped abdomen, are they a really noisy runner (heavy footfalls).

Adapt the Training, Stop the Leaks with Running

These are all very different demands on both the continence and running systems. We must adapt their training to meet each of those challenges in order to stop leaks with running. Let’s keep runners moving and dry!*

Wanna learn more? Check out our online course: Treating and Training the Female Runner (or Any Female Athlete

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