Set Up: Stand with one foot on the platform and one foot on the carriage, keeping your feet parallel. Find a squat position with knees over ankles, extended, neutral spine, and core engaged.
Execution: Transfer weight to the platform leg and press carriage away with the carriage leg. Maintain the squat position while extending and bending the carriage leg keeping the pelvis level.
Focus: Stabilize standing leg. Do not let the pelvis or the knee on the standing leg move. Standing glute and hamstring should be the main focus here.
Importance: Form is huge in executing this one properly. Keep your hips back, knee over ankle, level pelvis, neutral spine.
Modifications: For less intensity use lighter springs. For more of a challenge and abductor strengthening, use heavier springs. This can also be done with the stabilizing leg on the carriage opposed to the platform.
Check out Julia’s experiencing Pilates to help her weight lifting program here
If you follow anything in the physical therapy world, you probably have heard about myofascial release, or MFR if your hip to our abbreviations. It has been a darling of the manual therapist’s tool kit for some time. But did you know their many different camps of physical therapy and these different camps prefer different tools? I love coming from a field that can produce multiple solutions to any given problem. I feel it maximizes every unique individuals’ chances of finding meaningful relief through treatment, but it’s definitely fair to say that MFR does have some detractors in the physical therapy field. In this blog, I will be discussing why MFR is a wonderful tool for treatment of pain conditions and functional issues. MFR doesn’t always get the love it deserves and it is my hope, that by the end of this blog you will understand how MFR is thought to work and why it can be so helpful.
What the heck is the myofascial system?
As the name would imply, the myofascial system is the combination of the muscular system (myo) and the fascial system (fascial). Most of us have a pretty good concept of the muscular system but the concept of fascia is slightly more elusive. Fascia is the covering and connection of just about everything in the body. It wraps around organs, nerves, and muscles and allows these parts to retain their shape and function well. The composition of fascia is fascinating, even if you aren’t a total nerd, like me. We may encounter fascia when removing that filmy substance from a chicken breast while preparing it. When you see that film it looks pretty simple, but on a microscopic level that “stuff” is actually teaming with diverse and different cells all doing different things. Within fascia we have adipocytes, (fat cell makers), fibroblasts, which make collagen and elastin…. AND ARE CONTRACTILE! Yes I put this in all caps because it is amazing and it can be easy to overlook when you are thinking about fascia. Fascia also has mast cells (which make histamine) and histocytes (are part of the immune system). It’s honestly a cell party inside that stuff. Keeping with the metaphor of cell party, the house those cells are chilling in is made up of collagen (which provides support), elastin (which provides strength and flexibility), and ground substance (which is the cushioning).
All this stuff together helps fascia to accomplish some pretty cool tasks. Like I said before, fascia covers everything in the body and helps it keep its form. It also allows organs and muscles to slide and glide over each other, which is obviously very important when we are thinking of muscles. But what’s most interesting, in my opinion, is that fascia acts as a sense organ. It is innervated with type III and IV sense receptors and responds to light touch. It can contract and when fascia is stimulated it has an effect on the autonomic nervous system (think flight or fight). You probably could guess that issues within the myofascial system could wreak havoc on the rest of the body.
What goes wrong with the myofascial system and why does it get messed up?
The concept of fascia and its dysfunction contributing to pain is not necessarily a new one. People were thinking about myofascial pain although they had different words for it as early as the late 1600’s with the first description of trigger points in 1816. Trigger points have been called many different things from “nodular tumors” in the 1800’s to “muskelshweile” meaning muscle calluses, which is my personal favorite.
So where do these “muscle calluses” and trigger points come from? The reasons are myriad. Fascia can become restricted with discrete injuries (what I term, “the Oh Poo moment”, where you know you have injured yourself) or they may build quietly over time due to poor posture and other types of repetitive strain or chronic muscle holding.
Fascial restrictions and trigger points can cause a whole host of symptoms. It should seem obvious that restrictions in the fascia of a certain area of the body will restrict the movement in in that area. But fascial restrictions can present in less obvious ways.
Fascial restrictions can affect organs and dysfunction in the organs can affect fascia. This is because of the somatovisceral reflex and viscerosomatic reflex respectively. We see a lot of organ and myofascial interplay at Beyond Basics Physical Therapy. We commonly see increased trigger points in parts of the body that are innervated by similar nerve root fibers off of the spinal cord. Specifically, we may see someone who has endometriosis adhesions on their rectum experience pain and trigger points in their pelvic floor. Additionally trigger points in the pelvic floor can refer to other parts of the body and present as pain in the bladder or rectum, and other places.
Restrictions and trigger points in the fascia are linked to a whole host of symptoms. Treating the body at the level of the fascia is often very helpful at easing or resolving these symptoms. Below is a non exhaustive list of symptoms and conditions related to myofascial trigger points and dysfunction:
Fibromyalgia pain syndrome
Myofascial pain syndrome
Complex regional pain syndrome
Urinary and fecal incontinence
Sports and orthopedic injuries
How do we treat it?
Here is where it gets “controversial” in the health community. Fascia is strong. Really, really strong. Some would say as strong as steel. There are many in the community that claim myofascial release is impossible because there’s no clinician who is strong enough and applying enough force to break through and make a difference in the knots… I mean, I have a pretty solid deadlift but you won’t be finding me bending metal beams anytime soon. This argument misses the point and fails to recognize how complex fascia is. Think back to our cell party. We are not simply trying to break through fascia; we are providing a sensory stimulus and allowing the fascia to adapt or change in response. When true myofascial release is formed correctly, very little force is being used and it is usually an extremely gentle technique that can be tolerated by many patients who may not have been able to tolerate more aggressive techniques. When performing myofascial release, the clinician engages the barrier, meaning they apply enough force to feel the first inklings of resistance, and they hold their pressure there and slowly take up slack as the barrier melts underneath them. There is nothing forceful about it. In fact, when I first learned this technique from a mentor trained in Barnes myofascial release technique, she would always say, “If you think you are working too hard, you probably are”. There’s nothing steel beam bendy about MFR at all. Myofascial release allows the tissue to respond to the input the clinician is providing, rather than aggressively stretching, mashing, or pulling it. Although the exact mechanism of how MFR works is elusive, many theories recognize the individual players and cell types within the fascia, (remember our cell party), whether that be down regulation of the autonomic nervous system, (reduced fight or flight), activation of the central nervous system, and release of chemicals from the cells within the fascia.
The fact is with physical therapy, there are so many different tools that one can use. Usually clinicians tend to gravitate towards what they are good at and what tends to help the maximum number of their patients. At BBPT we value MFR as a helpful tool in our repertoire.
Ajimsha M.S., Al- Mudahka N. Effectiveness of myofascial release: Systemic review of randomized control trials. J Bodyw Mov Ther. 2015 Jan;19(1):102-12.
Horton R, “Mobilization of the myofascial layer: pelvis and lower extremity”. Raleigh, NC, USA. 9/22/2017- 9/ 24-2017. lecture.
Shah J, Thaker N, Heimur J, et al. Myofascial trigger points then and now: A historical and scientific prospective. PM R. 2015; 7(7): 746-61
Beyond Basics Physical Therapy has some exciting news. We are running the New York City Marathon for the third year in a row with Team Tisch MS. What makes it doubly exciting is that for the first time ever not one but two physical therapists will be running! Both Molly Caughlan and I will be running to raise $5,000 each, for a total of $10,000 dollars to directly support the work of Tisch MS Research Center of New York to help END multiple sclerosis.
Over the course of the next 7 or so months, you will see blogs documenting our progress towards our goal as well as blogs highlighting the work Molly will be doing with her amazing physical therapist, Tina Cardenia, and Myself, and my awesome physical therapist, Jessica Babich. Molly will soon introduce herself and say why she is working with our girl, Tina. But for now, let me explain why I am so excited to return to work with Coach Jess, ( yes, I am calling her coach Jess now, it’s a thing).
In 2017, together, Jessica and I managed to shave off 17 whole minutes from my last NYC Marathon. My dream of all dreams would be to seek out a BQ (Boston Qualifying time), which would require another time shave of about 13 minutes… and 2 seconds to be precise. Which… is a lot (like, a lot a lot). But shoot for the stars, as they say.
So why did I chose Jess to help me with this lofty goal? Because she is a jack of all trades. In 2017 she was able to tie in visceral (organ based) approaches, with orthopedic and pelvic approaches. She is thorough from checking my sneakers to my head and neck control while running. Working with her two years ago, made me feel like I had a new body.
Working with Jess was a commitment, but one that I saw pay dividends in the end. I won’t lie there were definitely times I wished I could sleep in an extra hour rather than come into PT early, but the thing is, that extra physical therapy kept me injury free and helped me maximize my training. You can have the highest VO2max in the world (a measure of cardiovascular fitness) but if something is keeping you from running efficiently, you won’t be running at your top times. You just won’t. Jess has no tolerance for inefficiency and can spot it with a laser focus and then work her magic to correct it.
Jess has been nerding out lately about new ways to facilitate or wake up the core for efficiency. She’s almost always playing with new techniques when she has the time to do it. Literally, she is always in the clinic gym playing with techniques. This is a major reason I love working with Jess: for her, it’s not just work it’s a passion.
Stay tuned for more from Jessica, Tina, Molly, and Me as we work our way towards Marathon Sunday.
Click here to Donate to myself or Molly. We’re competing to see who can raise the most… so if you’re team me or team Molly, make your donation count
Any persistent pain or chronic back or pelvic pain can be tough. It is tough to have and often times it can be extremely isolating. Many of our patients have to go through a number of clinicians before they even get a diagnosis of pelvic floor dysfunction. If you are reading this blog, you probably have some questions about pelvic floor dysfunction and if physical therapy is right for you.
We are here to help. If you are living in the Greater New York Area and have some questions about orthopedic, sports or pelvic floor dysfunction and if physical therapy is right for you, I encourage you to call our office. For a limited period of time, we are offering free 15-minute phone consults with our licensed physical therapists to patients in the greater New York Area. For those of you living outside this area, a fee may apply to the consult but can be applied towards payment for a PT visit if you chose to visit us. Don’t miss this opportunity to learn more about your pelvic floor and what PT can do for you.
The Physical Therapists at Beyond Basics also treat orthopedic (sport and joint injuries), pediatric pelvic floor dysfunction and orthopedic injury, and much more. Give us a call to discuss how PT can help with any one of these issues!
As we creep closer and closer towards marathon weekend, our very own Tina Cardenia PT, DPT, CFMT and Victoria LaManna (Vicky) PT, DPT, CLT, PRPC were kind enough to share their stories about preparing for the 2018 New York City Marathon. Vicky will be running her first marathon on November 4th, 2018 in order to raise money for Multiple Sclerosis Research. Tina was gracious enough to volunteer her expertise in orthopedic physical therapy to help Vicky have the best run possible for a great cause. If you are interested in donating to support MS research, please donate here and read more about their stories below. If you are interested in hearing more about our orthopedic and sports program here at Beyond Basics Physical Therapy, give us a call at 212-354-2622.
From the Runner’s Perspective
Victoria LaManna (Vicky) PT, DPT, CLT, PRPC
This year I am participating in my first ever marathon in the NYC Marathon for Team TischMS. Truly, this is my first ever 5k, Half Marathon, or Full Marathon. I am traditionally an anaerobic, (short bursts energy) exerciser. I have played soccer, dabbled in Muay Thai kickboxing, yoga, and weight lifting for exercise. The mind-body challenge of running a marathon (and doing it all for a great cause!) appealed to me. But where to start?
Luckily, I am in a profession that specializes in exercise, injury screening, and prevention, as well as injury rehabilitation. One of my co-workers has also run a few marathons and pointed me in the right direction for a training schedule. To further help ensure success in my training process, I also started physical therapy and made sure I got on my co-worker Tina’s super busy schedule.
She first tested my core strength, checked hip mobility and strength, as well as spine and rib cage mobility. All areas that are important for efficient running. Tina found that I had poor core-first responses to outside forces, meaning that every time my foot hit the ground while running, my core was not firing to connect my lower extremities to my trunk. This could definitely be why I was experiencing right low back pain with running, and it could actually lead to further injury and result in not being able to RUN at all! Tina also found limitations in my breathing, rib cage, and thoracic mobility. Other than back pain, my first main complaint a few weeks into training was that I could not breathe. While you could chalk that up to poor conditioning, it was something that was felt immediately in runs – as if I just did not have the capacity to take a breath in. This is where we started our treatment – rib cage and thoracic spine mobility.
From there, Tina continued treating based on observation of my running pattern. She continued to work on hip, spine mobility and core control based on what she saw was insufficient in my running. My breathing improved greatly, as well as my mobility. I began to run completely pain-free with ease.
About 2 months away from Marathon Day, I injured my right foot trying to complete a 16-mile training run. I was unable to walk without pain and was limping around the office. Tina quickly observed that I had a bone in my foot and ankle that were compressed and out of alignment. Her work to align my foot and ankle, working all the way up again through my hip and trunk helped me to get back to pain-free running.
I am all set to run the NYC Marathon Sunday, November 4th! I am incredibly thankful to Tina for helping me to get through my training pain-free, manage an injury along the way, and quickly get me back on track for race day. And I am thankful for Team TISCH for allowing me the opportunity to join their team and support a great cause that affects many men and women.
Are you training for a marathon? Looking to improve your running form? OR even improve your golf swing? I would highly recommend seeing a physical therapist for an injury prevention screen for any and all sports, recreation or exercise. Setting yourself up for optimal movement and mechanics will enhance your activity, as well as reduce the risk of injury. It worked for me!!
From the Therapist’s Perspective:
Tina Cardenia PT, DPT, CFMT
Victoria LaManna is such an inspiration. She volunteered to run the NYC marathon this year with little to no running experience and I was lucky enough to help prepare her! I have been working with Victoria for the past 6 months and I am amazed by how far she has come and how much she has already accomplished. Each week during our PT sessions there were a couple of things that I would look at to monitor her progress. I would observe her running, assess her core with tests called the Lumbar Protective Mechanism* and the Elbow Flexion Test*, her standing posture, her single leg stance, double leg squat, single leg squat, her glut and hamstring strength and how it connects to her trunk, and trunk rotation range of motion.
I saw that Vicky’s main limitations when I was observing her run were her limited trunk rotation towards the right, poor landing control on both of her legs especially her right one, and running with her feet turned out. One of the main things I looked for when observing Vicky run is the force transfer through her body from her feet to her trunk, and how the force translates through the rest of her body. It looked as though the force transfer wasn’t as efficient as I would have liked and this repetitive stress through her back and legs could potentially lead to injury.
Vicky’s limitation with trunk rotation correlated to one of her complaints of having difficulty breathing during her runs. It seemed as though she was only able to get a good breath through only one side of her body. Upon examination, I found that she was limited into rib cage expansion especially on the right side. After some rib mobilization and breathing inhalation retraining and working thoracic spine rotation Victoria was able to rotate more symmetrically and reported an increased ease of breath with running.
Vicky’s lack of control with landing while running meant that she had a lack of eccentric (the motion of an active muscle while it is lengthening) control through her pelvis, causing compression through her back every time she lands. This could explain the low back pain Vicky has been experiencing. To address this, I worked on increasing the mobility and range of motion through her hips, pelvis, and back. I then worked on retraining her body with specific neuromuscular techniques called Proprioceptive Neuromuscular Facilitation (PNF) and specific exercises to help Vicky create a core first strategy with her running. This means, with every step and every movement Vicky is able to initiate with her core muscles first, which prevented her from overusing her bigger muscles which tend to fatigue quickly and can lead to injury and pain.
Vicky was running with her feet turned out causing poor force absorption from her feet up to her body. This style of running can also result in muscle overuse injuries and pain over time. This could have also been contributing to her complaints of shin splints while running. To work on this, I evaluated Vicky’s foot and ankle mobility, her knee tracking with squats, and single leg squats. With knee tracking, I noticed that she went into valgus with both of her knees, but it was worse on her right. Valgus means that her knees were “knocking in” which was an issue of having weak hip strength as well as lack of mobility and flexibility through some of her leg muscles and joints. I did a lot of manual work to restore good range of motion and mobility and a lot of muscle retraining and drills to train Vicky to use those muscles appropriately and to be able to carry it over into her running.
After all this training and all the hard work that Vicky has been putting into running, Vicky’s running form now looks great! She has much more mobility through her trunk, is able to control her landing much more efficiently and is able to connect her feet for a better push off during running! Even as Vicky increased her mileage, she kept reporting to me how much easier her runs have been feeling, how much easier it was to breathe and how much more ease of motion she had through each run, and I couldn’t be more proud of her hard work!
*The Lumbar Protective Mechanism and the Elbow Flexion Test are special tests that come from the Institute of Physical Art. If you would like to learn more about their approach to PT, click here.
In this blog, our guest writer is talking about pelvic girdle pain (PGP), which can often get confused with pelvic floor dysfunction (PFD), although they are related, they are different conditions. For pelvic floor dysfunction, we often caution against just strengthening the pelvic floor. Often times the pelvic floor muscles are over tightened and tense and strengthening often can worsen the situation. Pelvic girdle pain refers to issues around the pelvic bones and sacrum. Both can occur during pregnancy but often require different treatment approaches. If you have pain, come see us at BBPT.
Exclusively written for BeyondBasicsPTBlog.com
Back in college, I used to be an avid tennis player and even had the chance of representing my school in intercollegiate tournaments. I would wake up at 5 am for three-hour training sessions all the while trying to balance my studies. But after college, the corporate life sucked me in, and I was lucky if I got to play for an hour every other week.
Then after childbirth, my life consisted of trying to raise a beautiful baby boy. I haven’t picked up my racket in months. It’s not because I don’t have time for things other than raising my child – I’ve been blessed with a husband who assumes his fair share of the responsibility. What’s holding me back is my physical state. The pelvic girdle pain (PGP) I experienced during pregnancy never really went away postpartum. In truth though, it is not uncommon. The American Physical Therapy Association notes that many women continue to have the symptoms of PGP after birth.
It’s a scary thought not to be able to do something you used to love so much. Compared to other stories I’ve heard, my case can be considered mild, but I had to seek help if I wanted to play again. Beyond Basics Physical Therapy led me to Pilates and I learned to channel my breathing in a way that it gently engages my pelvic floor [ remember this may be appropriate for PGP but not necessarily PFD]. It has been a great way to reintroduce strength to my core, considering that pregnancy has changed my body in more ways than one. When I get nostalgic and look at pictures from my glory days, I barely recognize myself. Where are the muscular legs, rock hard abs, and enviable arms? Not in this 34-year-old body of mine, that’s for sure. But I’m committed to gaining control over my body and getting back to the court.
But in the five months that I’ve been doing painstaking therapy, my sacroiliac joint feels a lot better, and I no longer feel stiff. During my recovery, Serena Williams was a great inspiration to me. For one, she’s a fantastic player, and Coral identified her as the highest paid female tennis player. More importantly, though, she’s a mom who never used her pregnancy as an excuse not to get a hold of her life. She probably even went through the same pain many other women, and I did. When I was bed-bound during my pregnancy, my idol was playing in the Australian Open while she was 8 weeks pregnant and even won the final.
Not all women’s bodies are the same or even experience pain similar to mine, but Williams continues to be my inspiration on and off the court. I have been playing tennis with my trainer—sometimes with my husband—and we sometimes play for as long as my stamina allows it. Torquing my hips doesn’t worry me anymore, in fear of a sudden crack of my bones anymore. On excellent days, I think that my backhand is even returning. Although I suspect that it will be a long time before I regain the level, I was playing at during college
Note from Fiona McMahon, PT, DPT at Beyond Basics Physical Therapy
We are so grateful to have AvaFreya share her experience of returning to tear up the court post baby! Everyone’s story evolves so differently with pregnancy and childbirth, which is what makes it both terrifying, exciting, and momentous, all the same time. The truth is some women bounce back on their own, (lucky duckies), others find it to be much more complicated. We recommend coming to visit a Pelvic Floor Physical Therapist during pregnancy and after you give birth to guide you to a program that is right for you. We often run into women, who with the very best of intentions, started down a path that actually made them worse! Often times we see this with women doing excessive Kegels when their pelvic floor is already too active secondary to weakness somewhere else in the body. Frankly, it’s a total bummer and delays getting back to the things you love. If you have recently had a baby or are currently preggers, you owe it to yourself to see a pelvic floor physical therapist who can advise you on exercises to do on your own or treat you more intensively if you need it. Your time and your health are way too precious.
For more reading on pregnancy and pregnancy-related conditions, please check out these blogs:
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):
· 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)
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).
· 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)
· 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
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
· 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!
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