Lace up or Feet up? Running During Pregnancy

Running and exerciseJoanna Hess PT, DPT, PRC, WCS

Exercise in ever tightening spandex while making frequent public toilet stops, or binge on Netflix and cronuts? Pregnancy is a great equalizer. Not even Kate Middleton can escape the hormones that can cause pregnant women to suffer from mood swings, fatigue, nausea, and achiness. Those symptoms—and modern culture—frequently encourage pregnant women to decrease movement and everyday activities. However, there is resounding support in academic literature that recreational physical activity during pregnancy is beneficial to both mother and baby.

While the pregnant woman is best suited to monitor what is beneficial for her body and baby during pregnancy, adequate information to make that decision is not always readily available. Yet around 600 studies published between the mid-1980s and mid-1990s corroborate that exercise during pregnancy is not harmful by measure of fetal birth weight, mode of delivery, preterm delivery, Apgar scores, and acute fetal well-being (1-3). What’s more, the American College of Obstetricians and Gynecologists (4) removed the limitations for intense exercises back in 1985 (5) and a literature review showed that bed rest was not beneficial for pregnancy complications. Still, 95% of ob-gyns continue to prescribe activity restrictions to certain pregnant mothers (6).

Clearer guidelines are needed for how pregnant women can decrease injury while maintaining performance and the well-being of mother and baby. While running is only one mode of boosting fetal and maternal health, many women, especially here in New York, embrace it as a key part of their overall wellness. As a recreational runner myself, I was disappointed during my first pregnancy with the foggy information regarding how to run safely during pregnancy. I found myself as a self-case study, correlating the physiological and biomechanical pregnancy changes with a shift in running mechanics. At the third trimester, I had a suspicion that I should replace running with the elliptical and restorative yoga.

The scientific literature specific to running during pregnancy is extremely limited, and in its absence, I’ve used findings for “moderate to strenuous” physical activity, in addition to clinical knowledge of pregnancy related changes in the body and running patterns to develop the recommendations below. Recently, a group of researchers published a series of five papers and combined recent literature about higher level physical activity during pregnancy for application in appropriate populations (7-8).

Pregnancy and exercise:

Pregnancy may seem like a counter-intuitive time to start an exercise program. However, research shows that 150 minutes/week of moderate exercise (9) for inactive and relatively sedentary women, and moderate to strenuous exercise for active women, has strong health benefits for both fetus and mother. Moderate exercise is recognized as 5-6 on the Rate of Perceived Exertion (RPE), 40-59% HRR (Heart Rate Reserve = Heart rate max – Heart rate resting). Moderate to strenuous is described as 7-8 RPE, 60-84% HRR (1). So while growing a baby is not a good time to start a running program, it is a good time to increase an appropriate level of physical activity or continue an established running program. Some of the benefits of appropriately prescribed exercise are correlated to (10-16):

· Improved cardiovascular function

· Lower risk for gestational diabetes

· Improved strength and lean muscle mass

· Improved sense of wellbeing

· Improved sleep

· Decreased bone density loss

· Decreased physical discomfort – low back pain, pelvic girdle pain

· Healthier gestational weight gain, which protects against complications like cesarean delivery, hypertension, preeclampsia, and gestational diabetes

· Improved general healthy behaviors

· Improved psychological wellbeing – reduction in depression and anxiety, improved self-esteem, particularly for women who were previously inactive

· Improved ability of the placenta to deliver oxygen

· Increased amniotic fluid

· Healthier fetal birth weights that correlate to changes in leptin levels that continue to correlate with a healthier body fat and muscle ratio at the age of 5

· Increased gestational age

· Decreased rate of pregnancy complications, although one study showed higher use of physician assisted delivery (10)

· Faster delivery and decreased chance of Cesarean delivery in a setting that supports natural birth (11)

· Higher Apgar scores

· Lower fetal heart rate and increased fetal heart-rate variability

· Improved neonatal orientation

· Higher general intelligence and oral language skills at the age of 5

· Improved ability of baby to self-soothe after birth, (i.e. longer stretches of night sleep)

Precautions:

Strenuous activity is correlated to a higher rate of miscarriage during the implantation phase of pregnancy—about 20-23 days after the last menstrual cycle. Elevated body core temperature (above 103 degrees Fahrenheit), which can be caused by strenuous activities like marathon running or exercising in hot and humid weather, can increase the risk of fetal neural tube abnormalities during its development, 35-42 days after last menstrual period. Exercising for 60 minutes in a comfortable environment will not raise core temperature above 100 degrees Fahrenheit.

The pregnant woman’s heart rate should not exceed 90% of her maximal heart rate. Because of physiological changes, the pregnant runner will underestimate her heart rate based on the typical rate of perceived exertion or talk test. For this reason, the pregnant runner should modify the run intensity knowing that her heart is working harder than she perceives or wear a heart rate monitor using the HRmax = 220-age, unless she has access to laboratory equipment that can calculate HRmax without full exhaustion.

The American College of Obstetrics and Gynecology, (ACOG) has set absolute and relative contraindications to aerobic exercise during pregnancy (4).

Absolute contraindications:

· Hemodynamically significant heart disease

· Restrictive lung disease

· Incompetent cervix or cerclage

· Multiple gestation at risk of premature labor

· Persistent second or third trimester bleeding

· Placenta previa after 26 weeks of gestation

· Premature labor during the current pregnancy

· Ruptured membranes

· Preeclampsia or pregnancy-induced hypertension

· Severe anemia (different than mild anemia)

Relative contraindications:

· Anemia

· Unevaluated maternal cardiac arrhythmia

· Chronic bronchitis

· Poorly controlled type 1 diabetes

· Extreme morbid obesity

· Extreme underweight (BMI <12)

· History of extremely sedentary lifestyle

· Intrauterine growth restriction in current pregnancy

· Poorly controlled hypertension

· Orthopedic limitations

· Poorly controlled seizure disorder

· Poorly controlled hyperthyroidism

· Heavy smoker

Warning signs:

Low back and pelvic girdle pain/instability, knee/hip pain, pelvic heaviness, sharp pains in the pelvic floor, urinary leakage, and regular ankle sprains are all signs that it may be time to modify running as exercise. In the clinic, I am often asked about pelvic floor symptoms, particularly urinary leakage during pregnancy, and specifically with running.

I like to think of these warning signs as a force transfer problem—something in the system is not working well. For stress incontinence and pelvic heaviness, it’s the inability of the pelvic floor to generate enough force to keep things up against the up-chain forces of running (2.5x while accepting weight after the flight phase) and down-chain forces of steadily increasing body weight + baby’s weight (around 20% of pre-pregnancy weight). But post-partum is not as simple as the forces that are generated from running or the ability to do a Kegel. Elite athletes and non-exercisers have about the same rate of post-partum incontinence. However, postpartum symptoms are more likely if exercise also caused urinary leakage during pregnancy (16).

The pregnant body is a little more complicated:

It needs to taken into account, that the 10-fold increase of relaxin and progesterone that might be responsible for more instability as forces from the ground traveling up into the falling arches of the feet, adduction of the knee, internal rotation of the hip, through the pelvic floor and gapping of the sacroiliac joint. As the fetus and breasts grow, the body’s center of gravity shifts forward, the ribs flare, and the pelvis tilts forward. While the gluteus maximus and calf muscles are getting stronger to propel the pregnant body forward, the front of the body gains significantly more mass. When this happens, the front of the diaphragm and the front of the pelvic floor are positioned so more forces are going through the front of the pelvic floor than the back. This requires more support of the bladder through the pelvic floor. As the pelvis widens, foot step width increases in walking (17), but decreases in running during the single stance phase, requiring more pelvic control. In other words, the pregnant runner’s leg strength, particularly the hip stabilizing muscles, gluteus medius and minimus, need to be exponentially stronger than in the non-pregnant runner to account for additional weight, forward weight shift, and ligamentous laxity. I primarily talk about the deficit of the gluteus group because of what I see clinically, but depending on when the woman is experiencing pain or pelvic floor instability symptoms, other muscles may also need attention.

The usual period of pain experienced by pregnant runner’s initial strike to single stance, corresponds with the biomechanical gapping of the sacroiliac joint. Alleviating such issues will require force absorption and muscle activation through the quadriceps, medial hamstrings, calf muscles, tibialis anterior, TFL, adductor magnus, iliopsoas, and gluteus medius/minimus. Symptoms of lower extremity and lumbopelvic pain, pelvic heaviness, or sharp pains in the pelvic floor have similar biomechanical and physiological causes as urinary leakage. They should be treated in a similar manner whether controlling the upward and downward loads by:

· decreasing speed of running – correlated to double flight phase, which increases upward pressures

· decreasing vertical displacement

· landing with a midfoot strike to increase shock absorption (18)

· increasing arm swing/thoracic movement – dispersing upward forces and facilitating the respiratory and pelvic floor piston

· decreasing daily physical exertion that causes increased abdominal pressure

· increasing external support with (sacroiliac joint) SIJ belts or foot orthotics – decreasing the body’s instability

· improving glute strength in functional positions – tandem lunges, close chained glute isometrics

· improving dynamic single leg pelvic stability – star excursion

· maintaining hip flexor mobility – controlling forward pelvic tilt, movement throughout the day out of sitting posture, hip flexor stretches, shifting weight back through heels, diaphragmatic vs. back breathing

An orthopedic physical therapist specializing in pelvic floor dysfunction and in prenatal and postpartum care will be able to give more specific recommendations, since each woman’s symptoms are a little different.

Expected running changes in pregnancy:

For previous recreational to elite runners, about 70% will continue to run at some point in the pregnancy with only 1/3 continuing into the third trimester. They usually cut the running volume and intensity by 50% compared to non-pregnancy training. For those who stopped running during pregnancy, over half elected to do so because of self-monitoring symptoms of wellness, about one quarter stopped due to physician’s advice, and the remainder stopped for fear of a miscarriage. Whether choosing to continue or stop running during pregnancy, most women had returned to running by 2 months postpartum, and without negative impact on breastfeeding (19).

Speed will decline as instability increases, so that the body has less time with both feet off the ground. Ankle sprains may happen intermittently because of changes in foot position, possible increased swelling, and laxity in the ankle ligaments. Resting heart rate increases 15-20%. Breathing might be more labored during running because of increased sensitivity to carbon dioxide (particularly in early pregnancy) and decreased lung capacity/rib excursion (in late pregnancy). Pregnancy-related mild anemia, which decreases available blood oxygen, affects more than 40% of pregnant women and may show up as accelerated fatigue and increased respiratory rate during running. Be sure that fatigue is not related to severe anemia or hypothyroidism, particularly in persistent symptoms. The pregnant body will improve its ability to thermoregulate with increased sweating to dissipate more heat.

Clothes won’t fit like they once did, especially the spandex. Find some appropriately fitting, breathable, loose exercise clothing that does not excessively compress around the stomach. Urinary urgency and frequency are common limitations in running as the pregnancy progresses, which requires some planning and increased water intake.

Running during pregnancy presents an opportunity to do something overwhelmingly beneficial for both mother and baby, with the added incentive of tuning into the body’s remarkable capacities. While physical activity, running or otherwise, will look different during pregnancy, the goals are similar for a healthy lifestyle. Be kind to yourself—body, mind, and spirit. You and your baby will be thankful. Happy trails. Please leave any comments or questions here!

Joanna is currently taking new patients at our downtown office.

Irene &amp; Joanna treatment 4
Joanna keeping fit with personal trainer, Irene Donahue at our Downtown location

Phone: (212)- 267- 0240

 

 

1. Szymanski LM, Satin AJ. Exercise during pregnancy: fetal responses to current public health guidelines. Obstetrics and gynecology. 2012 Mar;119(3):603.

2. Physical Activity Guidelines Advisory Committee. Physical Guidelines Advisory Committee Report, 2008. Wasington, DC: U.S. Department of Health and Human Services: 2008.

3. Barakat R, Stirling JR, Lucia A. Does exercise training during pregnancy affect gestational age? A randomised controlled trial. British Journal of Sports Medicine. 2008 Aug 1;42(8):674-8.

4. American College of Obstetricians and Gynecologists. Physical activity and exercise during pregnancy and the postpartum period. Committee Opinion No. 650. Obstet Gynecol. 2015;126(6):e135-142.

5. Artal R, O’toole M. Guidelines of the American College of Obstetricians and Gynecologists for exercise during pregnancy and the postpartum period. British journal of sports medicine. 2003 Feb 1;37(1):6-12.

6. Bigelow C, Stone J. Bed rest in pregnancy. Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine. 2011 Mar 1;78(2):291-302.

7. Bø K, Artal R, Barakat R, Brown W, Davies GA, Dooley M, Evenson KR, Haakstad LA, Henriksson-Larsen K, Kayser B, Kinnunen TI. Exercise and pregnancy in recreational and elite athletes: 2016 evidence summary from the IOC expert group meeting, Lausanne. Part 1—exercise in women planning pregnancy and those who are pregnant. Br J Sports Med. 2016 May 1;50(10):571-89.

8. Bø K, Artal R, Barakat R, Brown W, Dooley M, Evenson KR, Haakstad LA, Larsen K, Kayser B, Kinnunen TI, Mottola MF. Exercise and pregnancy in recreational and elite athletes: 2016 evidence summary from the IOC expert group meeting, Lausanne. Part 2—the effect of exercise on the fetus, labour and birth. Br J Sports Med. 2016 Sep 22:bjsports-2016.

9. US Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans. Department of Health and Human Services. Washington, DC: 2008.

10. Kuhrt K, Harmon M, Hezelgrave NL, Seed PT, Shennan AH. Is recreational running associated with earlier delivery and lower birth weight in women who continue to run during pregnancy? An international retrospective cohort study of running habits of 1293 female runners during pregnancy. BMJ open sport & exercise medicine. 2018 Mar 1;4(1):e000296.

11. Erdelyi GJ. Gynecology survey of female atheletes. J Sports Med Phys Fitness. 1962;2:174-179.

12. Prather H, Spitznagle T, Hunt D. Benefits of exercise during pregnancy. PM&R. 2012 Nov 1;4(11):845-50.[Ine

13. Hoeg TB. Baby on Board: Long Distance Running During Pregnancy – iRunFar.com [Internet]. iRunFar.com. 2017 [cited 2018May7]. Available from: https://www.irunfar.com/2017/12/baby-on-board-long-distance-running-during-pregnancy.html

14. Clapp JH, Capeless E. The VO2max of recreational atheletes before and after pregnancy. Med Sci Sports Exerci. 1991;23:1128-33

15. Gjestland K, Bø K, Owe KM, Eberhard-Gran M. Do pregnant women follow exercise guidelines? Prevalence data among 3482 women, and prediction of low-back pain, pelvic girdle pain and depression. Br J Sports Med. 2012 Aug 1:bjsports-2012.

16. Bø K, Sundgot‐Borgen J. Are former female elite athletes more likely to experience urinary incontinence later in life than non‐athletes?. Scandinavian journal of medicine & science in sports. 2010 Feb 1;20(1):100-4.

17. Gilleard WL. Trunk motion and gait characteristics of pregnant women when walking: report of a longitudinal study with a control group. BMC pregnancy and childbirth. 2013 Dec;13(1):71.

18. Nicola TL, Jewison DJ. The anatomy and biomechanics of running. Clinics in sports medicine. 2012 Apr 1;31(2):187-201.

19. Tenforde AS, Toth KE, Langen E, Fredericson M, Sainani KL. Running habits of competitive runners during pregnancy and breastfeeding. Sports health. 2015 Mar;7(2):172-6.

Sacroiliac Joint Dysfunction

Pelvic 3

By: Kaitlyn Parrotte, PT, DPT, OCS, CFMT

What is the sacroiliac joint?

You’ve probably heard of SI pain, but what is the SIJ and what can we do if something goes wrong?

The sacroiliac joint (SIJ) connects the sacrum, the wedge-shaped bone at the bottom of the spine, to the ilium, which is one of three bones that make up each half of the pelvis. (1) The sacroiliac joint is designated as a diarthrodial joint, which means it is a moveable joint that is surrounded by connective tissue. (2,3) Each joint is supported mainly by ligaments that lie in front and behind it, that are made up of strong, threadlike types of connective tissue. Stability is also enhanced through ligaments that connect between the spine and the sacrum (sacrospinous ligament), and the sit bone and the sacrum (sacrotuberous ligament). (2)

The SIJ helps us to walk and change positions by being stable enough to move weight from the spine to the legs, while allowing for a small amount of movement between the spine and the pelvis. This small amount of movement between the spine and the pelvis is also important as it allows for the pelvis to expand to make childbirth easier. (2,4) These functions can occur due to the unique design of the SIJ.

According to a well-known researcher named Andry Vleeming, the SIJ gains its stability in one of two ways: through form closure or force closure. Form closure refers to the stability provided by the bony surfaces of the sacrum and ilium, which fit together like a puzzle. You may use this type of stability, for instance, when you are lifting a heavy box, or pushing a very full cart of groceries; you want your SIJ to be as immobile as possible so your trunk can be stiff and rigid, allowing you to move a heavy load without overstressing any muscles in your back. Force closure describes stability occurring through the ligaments and muscles around the joint; this allows for more movement to occur. For this type of stability, think salsa dancing. In salsa dancing you need a great deal of hip and pelvic movement; however, you need those movements to be in control so you can move with precision along with the quick beat of the music. (5-7)

 

What is sacroiliac joint dysfunction?

Sacroiliac joint dysfunction (SIJD) is a common cause of low back pain, accounting for up to 40% of cases of nonspecific low back pain. (4,8) It can occur in any population: males and females; those with a sedentary lifestyle and those who are athletes. However, there seems to be a slightly greater occurrence in women, with the theory being that since the joint surface in women is smaller and less curved, the SIJ may become dislodged more easily. (2,4) SIJD can have a negative impact on quality of life, from being less active to having a financial impact. For instance, indirect health-care costs associated with low back pain range from $7-$28 billion per year, and individuals lose an estimated 5.2 hours of work time per week. (4)

The origin of SIJ pain is unknown; however, factors that may contribute include fractures, ligamentous injuries, or inflammation that occur with excessive stress to the SIJ. (8) Risk factors for developing SIJD include abnormal walking patterns, differences in leg length, scoliosis (abnormal curvature of the spine), heavy physical exertion, trauma, pregnancy, and back surgery. (8) Presentation of symptoms can vary quite a bit; however, individuals with SIJD often present with achy low back pain that can make it difficult to find a comfortable position. Pain may worsen with running, climbing stairs, or standing from a seated position. Also, if pain is truly coming from the SIJ, a person will not experience symptoms down into the leg, as is seen with sciatic nerve involvement. (4)

 

How is SIJD diagnosed?

SIJD can be very challenging to diagnose due to the complexity of the joint itself, as well as the variation in pain patterns that can be seen; thus, if you visit a healthcare provider, you may find he or she performs an array of components in an examination. Many individuals have tenderness with touch over the joint; this can help a healthcare provider rule in SIJD. (2,8). Also, various orthopedic tests can be performed that put stress on this joint, such as by putting a person’s trunk or leg in a certain position to see if it recreates symptoms. (2) Imaging can be performed in this area, but it rarely provides clear information that can help make a diagnosis; however, a doctor might recommend it if there is a concern for infection, inflammation, fracture, or other more serious conditions. (2) Injections into the SIJ itself can also be used to help diagnosis this condition, and are shown to be one of the single-most definitive diagnostic tools available. (2) Overall, effective diagnosis for dysfunction at the SIJ requires the use of multiple tools to help increase the accuracy of the condition being ruled in or out.

 

How can this impact function? Why does it matter?

It is hypothesized that SIJD can have such a significant impact on quality of life because it results in inadequate stability at the joint during movement. If the SIJ is unable to maintain an optimal level of stability, then excessive stresses will likely be placed on surrounding structures and tissues when each leg has body weight going through it. This can lead to other areas of pain, and potentially start the process of degeneration. (4) A recent research group looked at the impact of SIJD on a simple, but common functional task of rising from a chair. They found that in individuals with SIJD, there were significant differences in the amount of weight a person was putting through the leg on the painful side, as well as in the amount of bend at the hips when sitting. They also found that when individuals began to rise from a chair, muscles on the side of SIJ did not turn on right away, which means the muscles were not helping to keep the SIJ from moving too much. (4) Thus, this condition can make it challenging to use the body efficiently due to pain and weakness, which can negatively impact function throughout a given day.

 

What can physical therapy do?

Once a person is diagnosed with SIJD, what can be done? Research has shown that non-surgical treatment, such as physical therapy, can be very beneficial for someone with SIJD. If you see a physical therapist, you will likely receive some variation of joint mobilization and exercise, which is shown to help achieve significant improvements in pain, function, alignment, and muscle control. Exercise programs that emphasized pelvic stability through core, pelvic floor, and gluteus (hip and buttock) exercises, as well as increasing the strength of hip rotator muscles, decreased pain and decreased reported disability after a range of 8-12 weeks. (8,9) In other studies, an exercise program that focused mostly on gluteus maximus strengthening was utilized, since this muscle is considered one of the primary stabilizers of the SIJ. The exercises in these programs included bridging, single leg bridging, hip extension on hands and knees, fire hydrants, deadlifts, and single-leg squatting. In these studies, participants reported less pain after the course of treatment, demonstrated increased muscle strength, and returned to normal daily activities. (10,11) While there is no set exercise protocol established at this point, a strengthening program, with or without a home program, is a mainstay for treating this condition, and results in improved function.

 

Are there other treatments?

In some cases, physical therapy alone is unable to resolve the issue. In these situations, a patient may be given an injection of corticosteroids to decrease inflammation, in or around the SIJ. Prolotherapy is also sometimes used in this population to help reconstruct or regenerate damaged or weakened connective tissue. While it is helpful to know what other options are out there, it is important to note that the research in these areas is continuing to develop, and there is no consensus on dosage or who is the optimal candidate. (2)

 

Conclusion

The sacroiliac joint is a complex joint between the back and the pelvis, that allows for minimal mobility, and is required to maintain stability between the trunk and the legs. It can become painful due to direct or indirect trauma, which can have a significant impact on function and quality of life. While diagnosis can be tricky due to the wide variety of symptoms, research is finding that conservative care through physical therapy can make a significant difference by promoting optimal alignment and stability. If you or someone you know is struggling with sacroiliac joint dysfunction, make an appointment with a physical therapist today to help improve function. Feel free to contact our office at 212-354-2622, or visit our website (www.beyondbasicsphysicaltherapy.com) for more information!

 

 

Sources:

1. Ullrich, Peter F. “Sacroiliac Joint Anatomy.” Spine-Health, www.spine-health.com/conditions/spine-anatomy/sacroiliac-joint-anatomy.

2. Peebles R, Jonas CE. Sacroiliac joint dysfunction in the athlete: diagnosis and management. Current Sports Medicine Reports, vol. 16, no. 5, 2017, pp. 336-342.

3. “Diarthrodial Joint.” Biology Online, www.biology-online.org/dictionary/Diarthrodial_ joint.

4. Capobianco RA, Feeney DF, Jeffers JR, et al. Sacroiliac joint dysfunction patients exhibit altered movement strategies when performing a sit-to-stand task. The Spine Journal, 2018, DOI: https://doiorg/10.1016/j.spinee.2018.03.008.

5. Vleeming A, Stoeckart R, Volkers AC, et al. Relation between form and function in the sacroiliac joint. Part I: Clinical anatomical aspects. Spine, vol 15, 1990, pp. 130-132.

6. Vleeming A, Volkers AC, Snijders CJ, et al. Relation between form and function in the sacroiliac jt. Part II: Biomechanical aspects. Spine, vol 15, 1990, pp. 133-136.

7. Vleeming A, Schuenke MD, Masi AT, et al. The sacroiliac joint: an overview of its anatomy, function, and potential clinical implications. J Anat, vol 221, 2012, pp. 537-567.

8. Al-Subahi M, Alayat M, Alshehri MA, et al. The effectiveness of physiotherapy interventions for the sacroiliac joint dysfunction: a systematic review. J Phys Ther Sci, vol 29, 2017, pp. 1689-1694.

9. Albright J, Allman R, Bonfiglio RP, et al. Philadelphia Panel Evidence-Based Clinical Practice Guidelines on Selected Rehabilitation Interventions for Low Back Pain, Physical Therapy, vol 81, n 10, 2001, pp. 1641–1674.

10. Added MAN, de Freitas DG, Kasawara KT, et al. Strengthening the gluteus maximus in subjects with sacroiliac dysfunction. International Journal of Sports Phys Ther, vol 13, n 1, 2018, pp. 114-120.

11. Yoo WG. Effect of the single-leg, lateral oblique, decline squat exercise on sacroiliac joint pain with knee pain. J Phys Ther Sci, vol 28, 2016, pp. 2688-2689.

The Special Care Needs of the LGBTQ+ Community

Happy Pride Month!!!!

We are reposting an old post broadly discussing the LGBTQ+ community, with special focus on transgender individuals. Please keep checking back as we continue to discuss specific issues relating to the care of the LGBTQ+ community.  

Amy Stein PT, DPT and Fiona McMahon PT, DPT

rainbow flag

Who are LGBTQ+ individuals?

At Beyond Basics Physical Therapy, we have been meeting and studying with experts about the LGBTQ + community. LGBTQ+ refers to individuals who do not identify as heterosexual or do not identify as cis- gendered (although these two categories are not mutually exclusive). Cis-gender means you identify with the genital anatomy you were born with. People who belong to the LGBTQ+ community can be cis-gendered (meaning they identify with the genital anatomy that they were born with) and be gay/lesbian/ bisexual/ questioning etc.  They can be trans-gender and heterosexual or some combination thereof. Basically LGBTQ+ is a term that includes people who are not both cis-gender and heterosexual. LGBTQ+ is an acronym for lesbian, gay, bisexual, transgender, queer/questioning, and other individuals.  

Never Assume. Listen, Ask.

We were excited to understand and learn more about how we can help, specifically with patients experiencing pain or weakness in the pelvic floor. We met with an LGBTQ + advocate and he recommended the following when it comes to treating patients both within and outside the LGBTQ+ community.  First rule of thumb:  with all patients, don’t assume and be open to any questions or discussion. Ask if your patient would like you to stay away from certain terms regarding their anatomy, as well as their preferred gender pronoun. Use language that they want us to use.

 As with all patients, we need to use a biopsychosocial approach. With any patient, Richard Green at Bellevue hospital says that we always want to know exactly what is going on with our patient. We must subjectively understand why they are visiting us.  Has there been trauma, surgery, complications, or anything that has worsened their symptoms? What hormones and medications are they on? Don’t single anyone out. These questions are important for every patient.  

We want to get the medical and surgical history during or prior to the visit. There is no standard one surgical procedure or hormonal protocol in trans care. Hormones, either testosterone, estrogen, lupron, puberty blocking, testosterone suppressing can be used in many patients, but are also used specifically to aid in transition in transgender patients. Many hormones have consequences or side effects and our patients need be educated on the various options.  There is research on hormones and bodily changes, however there is no good research on how the hormones affect the pelvic region. Anti-estrogen hormones may result in vaginal drying and atrophy, more tissue tearing, and pain with penetration.  Endometriosis can be worsened with testosterone hormones.  Hormones can be administered via injection, pellets, patches, creams, gels, and pill form.  It’s important to realize side effects and risks of hormones for each patient. Dosage depends on body type, weight, previous surgeries, etc.  Hormone therapy can be given by a primary care provider or endocrinologist; however, many are not familiar with a specific protocol but at the same time each person may have different goals.  Progression of hormones can be monitored for each patient and according to patients wants and needs.  

For those who opt for surgical transition, it can result in pelvic pain and or weakness as organs are moved and or removed. Like we mentioned before, there is no one surgical protocol and it will vary from surgeon to surgeon, from changes in hormones from the removal of certain organs.  Knowing what tissues have been removed or moved and or where scar tissue could have been formed, is important to addressing a patient’s complaints. Also, it’s important to ask if the patient was having these symptoms or pain prior to any of the surgeries or hormonal medications. Surgical transition can take a long time with various surgeries and various symptoms that arise throughout. Some issues that  can occur are fistulas or fissures and when dealing with nerve implants there could be nerve damage and restrictions.

 

How is care for the LGBTQ+ community funded and regulated?

Medical coverage for the LGBTQ + community is non-regulated and different in each state. The Affordable Care Act, (ACA) covers some therapies and surgeries. You can try to appeal with each insurance which have their own policies on gender affirming care.

How can physical therapy help?

At Beyond Basics Physical Therapy, we specialize in abdomino-pelvic disorders, including pain, weakness, bladder, bowel and sexual dysfunction.  We also specialize in orthopedics and functional manual therapy.  We treat the LGBTQ+ community and we welcome any questions at desk@beyondbasicspt.com or call 212-354-2622. We are happy to help and look forward to hearing from you!
Resources: Center of excellence for transgender health.

WPATH center for care Endocrine Society

  • speaks on hormone therapy (however some information may be out of date).

 Adolescent Health Center