How Physical Therapy Can Help Speed Your Recovery
There’s a reason they call it labor. Any mom-to-be knows her body will go through a workout to bring her new beloved into the world. It’s a small price to pay, of course. And any resulting physical problems usually go away.
ormal>Unfortunately, some new mothers end up paying an inflated price: lasting muscle and joint pain, incontinence (urine leakage) and pain during intercourse.
ormal>Fortunately, there’s good news: You don’t have to live with these “souvenirs” of pregnancy. They’re not normal, they are treatable – and you don’t need drugs or surgery.
ormal>The treatment of choice, according to women’s health experts and clinical studies? Physical therapy (PT), which directly addresses the anatomical causes of these postpartum problems.
ormal>The first step is to see your doctor to rule out non–childbirth-related causes of your pain or incontinence. Raquel Perlis, R.P.T., is a physical therapist specializing in women’s health, a frequent lecturer to gynecologists and sex therapists, and a member of the American Physical Therapy Association (APTA) Section on Women’s Health. She advises postpartum women not to be afraid to communicate with their doctors.
ormal>“If you have incontinence or painful sex, some doctors say, ‘What do you expect? You just had a baby!’ ‘It will get better with time’ or ‘You just need to relax,’” Perlis notes. But she urges that “if you don’t get the right answers, look elsewhere. Untreated problems can get worse.”
ormal>Here’s a lesson in postpartum anatomy – and how physical therapy can help these three common postpartum ailments:
Postpartum Vaginal Pain
Symptoms – After childbirth, the No. 1 vaginal complaint is pain upon penetration (dyspareunia) and touch. One study found that 45 percent of new mothers have vaginal pain.
Causes – The most common cause of this pain is episiotomy scarring. Others include:
• vaginal tearing;
• soft-tissue trauma from a forceps or vacuum delivery;
• prolonged lying in stirrups, which can strain lower-body muscles;
• stretching of, and pressure on, the pudendal and levator ani nerves (which run into the pelvis) as the baby passes through the birth canal (more likely with longer deliveries);
• abstaining from sex toward the end of pregnancy and after childbirth;
• vaginal tightening and “protective” guarding in response to pain; and
• “rock-bottom estrogen levels during breastfeeding,” according to Elizabeth G. Stewart, M.D., amember of the National Vulvodynia Association Medical Advisory Board and author of The V Book.
Despite all these strikes against a new mother’s body, “the vulva and vagina usually heal beautifully,” says Dr. Stewart. “They have an excellent blood supply and they’re rather forgiving. Many women heal by their six-week checkup. If not, they need to have a conversation with their doctor.”
However, Stewart cautions, pudendal nerve stretching can take up to six months to resolve, and sometimes it doesn’t recover fully.
She adds that, for unclear reasons, pregnancy can occasionally trigger chronic vestibulitis. Women with this condition report that any pressure on the vulvar vestibule (the tissue around the vaginal opening) causes pain and/or burning.
“Vestibulitis is often missed and instead blamed on the episiotomy, the pelvic muscles or the vague observation that ‘things are different after childbirth,’” Stewart says.
Treatment – Because each woman’s treatment plan will depend on her individual circumstances, your physical therapist will devote your first visit to an evaluation. Then she’ll likely use a combination of several of the following:
• Hands-on techniques – These may include scar-tissue mobilization, myofascial manipulation (of muscle and deep connective tissue), connective tissue manipulation (of skin and superficial tissue), trigger-point release (to relax tense “knots”), vaginal stretching, and neural mobilization and stretching. Your physical therapist may work either inside or outside the vagina, depending on your problem and your pain sensitivity. She may also teach you and your partner how to do some manual techniques at home.
• Ultrasound – Physical therapists can apply ultrasound’s deep, penetrating heat to episiotomy scars to help soothe and heal the tissue.
• Kegel exercises – These vaginal relax-and-contract exercises promote blood flow to damaged tissue; help relax tense, guarded muscles; and help increase vaginal elasticity. (Of course, they’re also famous for helping women regain vaginal muscle tone after childbirth.)
Studies show that 49 percent of women use the wrong muscles – stomach and thigh muscles versus pelvic muscles – to do Kegels. That’s why many physical therapists enlist biofeedback machines to monitor and display muscle function. Either you can insert a tampon-size probe into the vagina or, if this is too painful, the therapist can place sensors on your skin. Daily Kegels are vital.
Physical therapist Rhonda Kotarinos, M.S., P.T., a past president of the APTA Section on Women’s Health and a past board member of the International Pelvic Pain Society, often postpones Kegels until the new mother has responded to hands-on techniques. If the patient has shortened pelvic muscles, Kotarinos explains, they must first be “lengthened, then strengthened.”
• Dilators – Your physical therapist may recommend that you use increasingly larger dilators at home to stretch and desensitize the vagina.
• Referrals – Your therapist may send you to your gynecologist for injections of a local anesthetic; a prescription for a topical anesthetic; or, if you’re nursing, a prescription for topical estrogen cream. “For some reason, the word isn’t out about estrogen cream,” says Stewart. “If you’re breastfeeding, making it part of treatment is important.”
Typically, PT visits are weekly, and the longer you’ve been in pain, the longer you’ll be in treatment. Perlis says that most postpartum vaginal-pain patients see her for 10 to 20 visits. She and Kotarinos both say that the vast majority of their patients are significantly improved or cured.
Symptoms – The most common type of incontinence after (and before) childbirth is stress incontinence: the leaking of urine when coughing, sneezing, crying, lifting and exercising, all of which put pressure on the bladder.
Causes – “Think of a bucket. Each time you pour something into it, it comes closer to overflowing. It’s the same with incontinence: As you add predisposing factors, you’re more likely to end up with a problem,” explains Jerome Weiss, M.D., director of the Pacific Center for Pelvic Pain and Dysfunction in San Francisco and president of the International Pelvic Pain Society. Among the risk factors for incontinence:
Diastasis recti, or separation of the abdominal muscles – In this common “side effect” of pregnancy, the growing fetus stretches the mother’s abdominal wall until it separates down the middle. “In 60 percent of new mothers, the separation heals on its own,” says Kotarinos. If not, this sagging support may lead to incontinence, low back pain and prolapsed (fallen) pelvic organs – in days or even decades to come.
A damaged pudendal or levator ani nerve – This can weaken the pelvic muscles that the nerve “feeds.” Nerves typically have trouble healing.
Stretching, weakening and tearing of pelvic muscles during pregnancy and childbirth – In general, muscles heal better than nerves.
Add these together, and you’ve got the perfect recipe for incontinence, Dr. Weiss explains: “To control urination, you use the muscles around your bladder and urethra. When they weaken for any reason, you have less control. Even if you seem fine right now, hormonal changes during menopause can cause thinning and weakening of the urethra. Add in pre-existing muscle weakness from childbirth, and you can develop incontinence.”
Treatment – Again, your physical therapist will evaluate you and choose techniques suited to your circumstances. Her bag of therapeutic tricks includes:
• Abdominal exercises – Diastasis recti calls for specialized exercises; traditional sit-ups will not help, Kotarinos explains. As your abdominal muscles heal, your physical therapist will introduce more-standard strengthening exercises.
• Hands-on techniques – Examples include trigger-point release, myofascial manipulation and connective tissue manipulation. The goal, explains Weiss, is to “eliminate any trigger points and normalize muscle functioning before introducing strengthening exercises.” Women with healthier muscles may not need manual manipulation, according to Kotarinos.
• Kegel exercises – Among their many perks, Kegels strengthen “pelvic floor” muscles, the support structure for the bladder and other organs. Many physical therapists add biofeedback to help patients isolate the muscles that control urination. Again, daily practice is critical.
soNormal>If you have trouble recruiting the correct muscles, perhaps because of extreme weakness or nerve damage, Perlis says your therapist may “jump-start” your muscles with electrical stimulation – a safe, controllable, therapeutic current.
soNormal>• Vaginal cones – Vaginally insert a weighted “cone,” then try to keep it in place – automatically, you contract and strengthen your pelvic muscles. Your therapist may give you a set of graded (lighter to heavier) cones for gradual strengthening at home.
soNormal>Incontinence PT typically involves fewer, and less frequent, visits than vaginal-pain PT. Kotarinos and Perlis both say that, after four to six weeks, patients leak substantially less or go “dry.”
soNormal>Confirming their success, several clinical studies show that Kegels plus biofeedback reduces leaking episodes by 80 percent. (Drugs had about 10 percent less success – and more side effects.)
soNormal>Other treatment options include medication and surgery, but “you really need to go through conservative measures before surgery,” says Weiss. “Even after surgery, you’ll need Kegels to prevent further problems.”
Postpartum Joint Pain
No one has to tell a mother-to-be that pregnancy can take its toll on muscles and joints. It’s not just the physical stress of carrying a child; it’s also the pregnancy hormone relaxin, which relaxes the ligaments attached to the pubic bone – and all other ligaments. That’s not even counting delivery, which can sprain or sometimes break the coccyx (tailbone). In addition, epidural anesthesia – blessing though it may be – blocks helpful pain signals that say, “This position hurts my back. I need to shift.”
soNormal>Not surprisingly, physical therapist Raquel Perlis sees many new mothers with neck, back, hip and even carpel tunnel (wrist) pain. She turns to many of the same treatments that help non-moms: stretching and strengthening exercises, posture retraining, hands-on techniques, ultrasound, electrical stimulation, heat and ice.
soNormal>Of course, there are a few twists: exercises must be modified for a postpartum body, and posture retraining also focuses on ergonomic nursing, burping and baby holding.
“After six to 12 visits for postpartum joint pain, most women get better,” Perlis says, unless they have a pre-existing condition such as arthritis or fibromyalgia.
Where to Find Help
First, a word of financial reassurance: Most insurance plans cover physical therapy for postpartum conditions. For verification and specifics, contact your insurance company.
The Right Physical Therapist
Not all physical therapists treat postpartum problems. Women’s health PT is a specialty requiring extra training. For help locating a qualified therapist, contact:
American Physical Therapy Association Section on Women’s Health – click on “Locate a Therapist”; 800-999-APTA (999-2782).
The Right Doctor
According to physical therapist Rhonda Kotarinos, “Doctors are more sophisticated about the role of physical therapy in musculoskeletal pain and incontinence. But for vaginal and pelvic pain, they’re less so.” To locate a knowledgeable doctor, contact:
International Pelvic Pain Society – 800-624-9676 or 205-877-2950.
National Association for Continence – 843-377-0900.
National Vulvodynia Association – click on “Patient Services” and then “Physician Referral”; 301-299-0775. Vulvodynia is chronic vaginal pain that may or may not be related to childbirth; but any doctor who is versed in vulvodynia should be knowledgeable about postpartum vaginal pain.