Wednesday, 14 November 2018

Rectus Diastasis Treatment Update

Rectus Diastasis Update
Research in physiotherapy is continuously on-going. What we once thought was true, can shift as new perspectives along with new information become available. This is true for the ab separation. There is an abundance of popular media, fitness news, as well as social media information on the internet that can make it very challenging for therapists, never mind clients to figure out what is true.
There is some exciting new research soon to be published on rectus diastasis. A panel of the top Canadian educators and clinicians in physiotherapy came together to try and reach some consensus on the assessment and treatment of ab separation. I want to high-light a few points that I learned, that may be helpful to you as a consumer. The information presented is a summary of points presented by Dr. Sinead Dufour at the 2018 Healing Birth Summit.
In my previous blogs about rectus diastasis, I mentioned that the size of the gap was less important in comparison to the function and the ability to tense through the connective tissue which holds the two rectus abdominal muscles. If you haven’t read my previous blogs, you can go back anytime to read them.
The panel of Canadian experts did reach consensus that the gap is not really helpful as it only tells you what the gap is, but not why. I always thought it was the rectus abdominis muscles that were the problem and that if you pull those muscles closer together and work them out, the problem would be solved. Clinicians are still treating rectus diastasis with an exercise that pulls those muscles together with a mini crunch. However, from the new research, it turns out this isn’t the best exercise and I’ll explain why.
The problem with rectus diastasis is not the muscles, but rather the fascia connecting them. We call the fascia between the two recti muscles the linea alba. The function and ability of the linea alba is to draw tension with the rest of the core and in response to activity, is what is the focus should be on.
The fibers of the linea alba are intertwined with the transverse abdominis (TA) muscle and the TA muscle co-contracts with the rest of the core muscles, which includes the pelvic floor, diaphragm and multifidus.

What we need to actually assess is not just the gap, but whether or not the linea alba tensions when you perform a voluntary pelvic floor or deep abdominal muscle contraction. How well can you contract your core individually and as a team? This will help us understand why, the abs remain separated. We also need to assess how your core responds to activity and exercise.
Treatment will be dependent on what is specifically needed and what part of the system is not working well for you.
I received this question a couple times from my pregnant soon-to-be moms:  “Is there anything I can do during pregnancy to avoid or reduce my risks of ab separation?” So firstly, by the third trimester all women will have a separation. Yup! This is normal and what our tissue is suppose to do to make room for baby. There are a few things you can do to reduce the amount of pressure on your tummy however. You can have your core assessed and the physiotherapist can teach you how to activate all the muscles of core individually and then together. A stronger core during pregnancy has the benefit of a better recovery postpartum.
The second thing you can do is avoid repetitive increases in abdominal pressure during pregnancy. Examples would include avoiding straining on the toilet or to avoid activities that make your abdomen bulge. There are several benefits to doing a pre-natal session with a trained pelvic floor physiotherapist. Seeing a physiotherapist has the benefits of them teaching you various strategies for reducing abdominal pressure and modifying activities.
So let’s talk about a few things postpartum. We were taught in our training to assess for an ab separation between 6-8 weeks postpartum. It turns out that it is normal to have a separation for the first 13 weeks postpartum. This is known as the fourth trimester and it is the healing trimester which includes the ab separation. Yes it can improve on its own and this is dependent on how well your core is healing and activating. A 6-8 week postpartum assessment certainly can help you with recovery by giving you the right types of exercise to promote your core healing.
If there is a separation present after 13 weeks, it can become problematic and we need to really investigate why that is. Every good treatment for rectus diastasis should have an offensive plan, which includes exercises to optimize the function of the core and defensive strategies such as education on reducing intra-abdominal pressure and how to perform activities that puts the least amount of stress on the tissues.
Another question I get asked a lot is about specific core exercises. Ladies will come in after researching on the internet what exercises are “good” and which ones to avoid. While it is true that certain exercises “tend” to be more challenging for the core, it is not true for everyone. For example, you may read that planks are “not good” for an ab separation. While that may be true for some, it may also be a fantastic strengthening exercise for another. It’s best to see a therapist who can assess what your core can handle. Rather than avoiding these activities, get tested and learn what to look for that might indicate a problem.
I found these points from the Healing Birth Summit very educational and helpful in giving me guidance on how to best serve clients. Hopefully this blog gives you some more information to ask questions or seek out help from a trained professional.

The Pelvic Health Lady

Friday, 2 November 2018

The reality of sexual experiences after a baby

I see many women post partum who express a variety of different feelings regarding sex after childbirth. Some women resume with no problems, while others experience pain, dissatisfaction or very low desire. For the women who experience issues with sex postpartum, they often feel they are the only ones. These women express frustration because they aren’t provided any clear guidelines as to what is common, why they have the problem or what they can do about it.

The World Health Organization describes sexual health as, “a state of physical, emotional, mental and social well-being related to sexuality; it is not merely the absence of disease, dysfunction or infirmity” (1). The transition to parenthood comes with many changes that impacts sexuality and this blog will explore these changes and the impacts on sex.

Female sexual dysfunction affects approx 40% of women postpartum (2). Under the sexual dysfunction umbrella are sexual pain disorders, hypoactive sexual desire disorder and arousal and orgasmic disorders (1), which in layman’s terms means painful sex, lack of desire and difficulty becoming aroused or orgasming.

The most common reason for women to not return to intercourse at 6 weeks postpartum is pain. They may experience pain with penetration or an inability to penetrate due to muscle spasm. About 42% of women will experience pain immediately following delivery and will reduce to 22% at 8 weeks and 10% at 12 weeks. One study of 796 first time moms revealed that 62% experienced pain at 3 months, 31% at 6 months and 12% at 12 months.

Another study looked at the medical records of 626 first time moms and found that women with second degree tearing were 80% more likely to report painful intercourse than women with no or minimal tearing and that women with third or fourth degree tearing were 270% more likely to report pain at 3 months postpartum (1).

When it comes to tearing versus episiotomies, one study found women had more pain with episiotomies and assisted vaginal delivery versus tearing alone. FYI.. an assisted vaginal delivery may include forceps, suction, vacuum (2). Specifically, 30% of 438 women experienced pain at 8 weeks with assisted delivery versus 7% of women who gave birth naturally. Other studies have found similar results where women with assisted delivery report sexual pain at 8, 16 and 24 weeks post partum (1).

Low sexual desire is reported by about 53% of women at 3 months compared to 37% at 6 months post partum (1). Most studies find that desire improves over time and was mostly impacted by changes in body image, mother’s mental health and the status of the martial relationship (1). Many women report that the physical changes to their body following childbirth makes them feel less attractive (3) and that they were anxious about the looseness of their vagina (3).

Other factors reported by women are the changes in priorities. Whenever they get spare time, they just want to relax and read or sleep (3). The demands of the child often leave the mother fatigued and desiring alone, quiet time versus engaging in sex (3). When women were asked about their low desire, the most common reasons reported were, tiredness, breast-feeding, lack of time and concerns over vaginal damage from delivery (3).

Breast-feeding women versus non-breastfeeding women appear to return to sex much later. One study of 25 first time moms found decreases in the levels of testosterone and androstenedione, which are responsible for increased sex drive. This is supported by another study of 576 women who reported low or no arousal during the time of breastfeeding (1).

Another potential reason breast-feeding changes sexual activity is that the breasts are no longer viewed as a sexual or arousing area. Women find it difficult to associate breasts with sex when the focus now is on nourishing the child (3).

For those women who do engage in sex, many experience arousal and orgasmic changes. One study of 796 first time moms, 33% reported difficulty reaching orgasm at 3 months and 23% at 6 months postpartum. Orgasmic disorders were associated with perineal trauma, those who sustained more trauma had more difficulty with sex (1). Other factors impacting arousal and orgasm postpartum are the physical decrease in blood flow to the vaginal region, negative experiences such as pain with intercourse, distractions, sexual anxiety, tiredness and depression (1).

Some women admitted that they agreed to have sex with partners, while experiencing no desire to have sex. Some women would even pretend to be aroused and orgasm for the sake of their partner and relationship (3).

What I hope you gain from this blog is a better understanding of the factors that may be impacting your desire. I want you to know that you are not alone and that there is help if you are willing to talk about it and seek treatment. Pelvic floor physiotherapy is very helpful for addressing the pain aspect of intercourse, while a psychotherapist may help you work through all the thoughts and feelings you are having in this time of transition.

Your family doctor or a Naturopathic doctor may be able to provide you with other solutions centered on hormones, nutrition and getting rest. If you are reaching out to your healthcare provider and they don’t seem to be taking it seriously or offering solutions, then you need to find another healthcare provider for a second opinion.


The Pelvic Health Lady

1.       Abdool, Z et al. 2009. Postpartum female sexual function: A review. European Journal of Obstetrics & Gynecology and Reproductive Biology doi: 10.1016/j.ejogrb.2009.04.014.
2.       Yeniel, A. O and E Petri. 2014. Pregnancy, childbirth and sexual function: perceptions and facts. Int Urogynecol J 25: 5-14.
3.       Olsson, Ann et al. 2005. Women’s thoughts about sexual life after childbirth: focus group discussions with women after childbirth. Scand J Caring 19: 381-387.