Return to Running Post PregnancyEducation
The following guidelines are taken from a fantastic piece of work from Tom Goom, Grainne Donelly and Emma Brockwell.
Common postnatal pelvic health issues such as urinary incontinence are understood to create a barrier to exercise (Nygaard et al. 2005). Engagement in regular physical activity is a public health priority due to the established health benefits that it provides.
After having a baby, the pelvic floor is weak and injured in most women and may need instruction and supervision to be able to perform a correct pelvic floor muscle contraction, especially in those women who did not train these muscles before birth (Bø et al. 2017).
High-impact activity, such as running, is associated with a sudden rise in intra-abdominal pressure (Leitner et al. 2016). It has also been reported that ground reaction forces of between 1.6 and 2.5 times bodyweight can occur when running at a moderate speed of 11 Kilometers/hour (Gottschall and Kram 2005). Presently, it is unknown if or how much of this is absorbed through the lower limb on impact and therefore it is assumed that some, if not all, of those forces are also transmitted to the pelvic floor. This highlights the importance of strength and speed of contraction in the pelvic floor muscles in order to carry out their role in pelvic organ support and continence during high impact activities (Leitner et al. 2016). It also helps reason why weak, less co-ordinated muscles in postnatal women may not achieve the level of function needed to maintain these roles and highlights the importance and indication for adequate rehabilitation. The evidence supporting individualised pelvic floor rehabilitation for the management of urinary incontinence (Bø, 2003; Dumoulin et al. 2018; Price et al. 2010), POP (Hagen et al. 2013), sexual dysfunction (Brækken et al. 2015) and the prevention of POP (Hagen et al. 2016) is well established.
Running is a high impact sport placing a lot of demand on the body. In a recent systematic review investigating urinary incontinence in female athletes (De Mattos Lorenco et al. 2018), high impact exercise was found to have a 4.59 fold increased risk of pelvic floor dysfunction compared to low impact exercise. Postnatal women need adequate time to heal and regain strength, particularly in the abdominal and pelvic floor muscles after pregnancy and delivery. It is understood that the levator hiatus area widens during pregnancy and increases significantly after vaginal delivery. In most women following vaginal delivery, it is thought to return to a similar area by 12-months postnatal as to that seen immediately after caesarean delivery. However it is does not return to prenatal size (Stær-Jensen et al. 2015). Recovery of the levator ani muscle and associated connective tissue and nerves is generally maximized by 4-6 months postnatal and is considered to be a reflection of levator hiatus area recovery (Shek et al. 2010, Stær-Jensen et al. 2015).
Bladder neck mobility increases after vaginal delivery and, while the support to the bladder neck can improve postnatal, mobility remains higher than when measured at 37 weeks gestation (Toozs-Hobson et al. 2008, Stær-Jensen et al. 2015).
Following caesarean section delivery, consideration should also be given to the healing and remodeling of the uterine scar. It has been shown by ultrasound investigations that the uterine scar thickness is still increased at 6-weeks postnatal suggesting that the process of scar remodeling after caesarean delivery extends beyond the traditionally accepted period (Hamer et al. 2007). This is further supported by the understanding that abdominal fascia has only regained 51%-59% of its original tensile strength by 6-weeks post caesearean section and 73%-93% of its original tensile strength at 6-7 months postnatal. (Ceydeli et al. 2005).
We therefore recommend that a low impact exercise timeline is followed within the first 3 months of the postnatal period, followed by a return to running between 36 months postnatal, at the earliest.
Table 1: Key signs/symptoms of pelvic floor and/or abdominal wall dysfunction
• Urinary and/or faecal incontinence
• Urinary and/or faecal urgency that is difficult to defer
• Heaviness/pressure/bulge/dragging in the pelvic area
• Pain with intercourse
• Obstructive defecation
• Pendular abdomen, separated abdominal muscles and/or decreased abdominal strength and function
• Musculoskeletal lumbopelvic pain
Table 2: Risk factors for potential issues returning to running
• Less than 3 months postnatal
• Pre-existing hypermobility conditions (e.g. Ehlers-Danlos)
• Pre-existing pelvic floor dysfunction or lumbopelvic dysfunction
• Psychological issues which may predispose a postnatal mother to inappropriate intensity and/or duration of running as a coping strategy
• Caesarian Section or perineal scarring
• Relative Energy Deficiency in Sport (Red-S)
Load and impact management assessment
In order to successfully complete a return to exercise, the postnatal mother needs to achieve the following without pain, heaviness, dragging or incontinence:
⁃ Walking 30 minutes
⁃ Single leg balance 10 seconds
⁃ Single leg squat 10 repetitions each side
⁃ Jog on the spot 1 minute
⁃ Forward bounds 10 repetitions
⁃ Hop in place 10 repetitions each leg
⁃ Single leg ‘running man’: opposite arm and hip flexion/extension (bent knee) 10 repetitions each side
In order to ensure key muscle groups are prepared for running, each of the following movements should be performed with the number of repetitions counted to fatigue. Aim for 20 repetitions of each test.
⁃ Single leg calf raise
⁃ Single leg bridge
⁃ Single leg sit to stand
⁃ Side lying abduction
Diastasis Rectus Abdominis (DRA)
There is a paucity of evidence for the impact of running with DRA. The relationship between DRA and pelvic floor dysfunction continues to be debated with no conclusive outcome from the limited research base, however, a recent systematic review confirmed that there is a weak correlation between DRA and pelvic organ prolapse (Benjamin et al. 2018).
The expert consensus from specialist pelvic health physiotherapists is that running prior to regaining functional control of the abdominal wall (in order to manage IAP and load transfer) may be counter-productive and result in overloading or compensatory strategies in the pelvic floor. Until such time that research informs us otherwise, the current authors suggest that DRA should be considered in terms of potential risk for pelvic floor dysfunction.
Failed load transfer can be indicated by abdominal doming/sinking at the midline, lateral shift of the trunk or significant rib flare during load transfer tests such as active SLR to 30 degrees, resisted trunk rotation or chin to chest.
The World Health Organisation (WHO) advises women to breastfeed for at least the first 6 months postnatal and up 2 years (WHO 2016). It is likely that women embarking on return to running are still breastfeeding. It is recognised that breastfeeding prolongs the presence of a hormonally altered environment in the postnatal mother with lower levels of oestrogen and the possibility for slightly raised levels of relaxin to continue. Theories that higher relaxin levels postnatal increase the risk of joint laxity and potential injury have not been proven (Marnach et al. 2003; Schauberger et al. 1996). It is not fully understood why some breastfeeding women may have increased joint laxity compared to baseline however it is recognised that the overall environment of hormones during this period of time and up to 3 months following weaning may influence joint laxity. This, in turn, may increase the mother’s risk of developing injury or dysfunction, including pelvic floor dysfunction or pelvic organ prolapse. It is important to establish whether any preexisting joint mobility existed prior to pregnancy and whether the environment that breastfeeding creates is significantly exacerbating this.
It is recommended that consideration of breastfeeding status is given to a postnatal mother throughout the process of her evaluation for return to running. Education should be provided about timing of feeds around running, to ensure that the breasts are not overly full or likely to become uncomfortably full during the run (ACOG, 2002). It is also important to consider hydration and the degree of exertion when a mother returns to running, in order to reduce potential impact upon the supply of milk. Women should be advised that moderate to vigorous exercise during lactation does not affect the quantity or composition of breast milk or impact infant growth (Cary and Quinn 2001; Davies et al. 2003; ACOG 2015). It is essential that postnatal mothers feel supported in their choice to continue feeding by offering solutions and advice to support continued breastfeeding while returning to running.
Women may benefit from wearing a personally fitted sports bra that offers support rather than compression (McGhee et al. 2013) as this provides significantly increased breast and bra comfort compared with a standard encapsulation sport bra during exercise (McGhee et al. 2010). High breast support has been suggested to be more beneficial in female runners and should be considered when fitting (Milligan et al. 2015). Personal fitting of sports bras is not common practice among female runners with most opting for off the shelf sizes however its merit is acknowledged for this population and health professionals are advised to increase awareness of the importance of getting professionally fitted (Brown et al. 2014).
Advice should be provided on the importance of supportive footwear. It should be noted that shoe size can alter permanently with pregnancy and footwear previously worn should not be presumed to be the correct fit.
Sportswear and clothing aimed at supporting the pelvic floor and lumbopelvic area is gaining increased awareness and understanding for the benefits that they may offer. Okayama et al. (2019) demonstrated that wearing supportive underwear was almost as effective as pelvic floor muscle training in reducing stress urinary incontinence in women at the end of a 6-week trial period. Ongoing high-quality studies are required to evaluate how each intervention compares beyond 6-weeks and also specifically in relation to high impact exercise, however, the outcome of this trial suggests that supportive underwear/sportswear may have a role alongside pelvic floor rehabilitation in the management of pelvic floor dysfunction and postnatal return to exercise.
Return to Running
It is sensible to start small, often with around 1 to 2 minutes of running at an easy pace. Setting short-term goals, such as reaching a target distance, can be helpful alongside long term goals such as competing in a race. These goals will influence training progression.
For run-training progression, building training volume (e.g. running distance/time) prior to increasing training intensity is recommended. Expert consensus of the present authors advises that a total weekly running distance/time should not be increased by more than around 10% per week. However, it should be noted that when starting with very low training volume (such as running just a few minutes) a 10% increase may be prohibitively slow. Consider the relative increase (i.e. in percentage) and the absolute increase (i.e. in distance/time). A higher relative increase may be manageable when the absolute increase is small. For example progressing from 1 minute to 2 minutes is a high relative increase of 100% but the absolute increase is small, only an additional minute.
Including walk breaks can be helpful to reduce fatigue initially and can be gradually reduced and removed. A ‘couch to 5km’ programme can be helpful as this usually includes walk breaks and builds gradually towards 5km of running within around 9 weeks. Programmes vary but the NHS ‘couch to 5km’ starts with 3 runs in week 1 beginning with a brisk 5 minute walk then alternating 1 minute of running with 90 seconds of walking for a total of 20 minutes
Heaviness, dragging, incontinence or moderate to severe pain may suggest excessive training distance or intensity. Mild musculoskeletal pain (0-3/10 on a pain scale) which settles quickly after a run with no pain lasting into the next day is often acceptable and has been used as a guide in management of tendinopathy and other conditions (Silbernagel et al. 2007).
Running with a buggy
The general advice given to women regarding buggy-running focuses on the baby’s health. It is advised that if considering running with a buggy that the buggy in one that is designed for this function i.e. that it has a five-point harness for the baby, fixed front wheels, hand-operated brakes, rear wheel suspension, pneumatic tyres, 3 wheels and a wrist strap. Buggy companies advise that buggy- running should not commence until baby is between 6-9 months old to protect the baby’s neck and spine. The research on the physical, physiological and biomechanical effects of running with a buggy on the postnatal mother is limited and variable. The studies are often small. According to Wall-Scheffer (2015), buggy running can be included in the list of ‘challenging human locomotor regimes’
O’Sullivan (2015) found that running with a buggy leads to minor changes in trunk, pelvis and hip kinematics with no significant changes at the knee and ankle. Due to these changes in kinematics the authors suggest that flexibility work for the spine, pelvis, hips and gluteal strengthening exercises may be recommended for the runner.
The authors of these guidelines recommend that women do not consider running with a buggy until their baby is at least 6-9 months old (as per manufacturers guidelines). Further, that when they do start buggy-running, the buggy is designed for running and the woman commences slowly, in a graded fashion, initially using the 2 handed technique. A strength and stretch program for spine, pelvis, and hips should also be advised.
Example of exercise progression for the early postnatal period (0-3 months)
Week 0 to 2 • Pelvic floor muscle exercises (once catheter removed) targeting strength and endurance functions. • Basic core exercises e.g. pelvic tilt, bent knee drop out, side lying abduction. • Walking (for cardiovascular exercise).
Week 2 to 4 • Progress walking/pelvic floor muscle/core rehab. • Consider introduction of squats, lunges and bridging, in line with the functional requirements of day-to-day life as a new mother.
Week 4 to 6 • Introduce low impact exercise e.g. static cycling or cross-trainer taking into account individual postnatal recovery, mode of delivery and perineal trauma. Recovery should be such that the new mother is comfortable sitting on a saddle.
Week 6 to 8 • scar mobilisation (for either c-section or perineal scar) • power walking • increased duration/intensity of low impact exercise • deadlift techniques beginning at light weights no more than the weight of the baby in a car seat (15kg) with gradual load progression e.g. barbell only with no weight. This aims to strengthen and restore strategies for carrying out the normal everyday tasks required when caring for a newborn and/or older siblings. • resistance work during core and lower limb rehab
Weeks 8 to 12 • Introduce swimming (if lochia has stopped and there are no issues with wound healing). • Spinning (if comfortable sitting on a spinning saddle).