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Narrators: Welcome to this APTA podcast. Welcome to the PTJ podcast where you can get the story behind the research with insights into clinical applications, data design and future project plans.

Alan: I want to welcome listeners to this latest PTJ podcast. This is Alan Jette and today I'm very pleased to have as my guest Doctor Sabine Vesting. She's a physical therapist with the Department of Health and Rehabilitation at the University of Southbury, Sweden. Welcome Dr. Vesting.

Sabine: Thank you very much for this opportunity to talk today.

Alan: Looking forward to discussing your article. Let me give a brief summary to our listeners and then we can talk about it. The article she and her colleagues published in PTJ is the impact of exercising on pelvic symptom severity, pelvic floor muscle strength and diastasis recti abdominis after pregnancy. This was a cohort study with 504 subjects. The subjects had and did not have pelvic symptoms and the goal was to evaluate whether early, which they defined as during the first three months postpartum, whether early postpartum exercise would be associated with changes in pelvic symptom severity, pelvic floor muscle strength and diastasis recti abdominis from 3 to 12 months postpartum. And the researchers categorized their subjects as non-exercisers, minimal low pack, low-impact exercisers, regular low-impact exercisers, and high-impact exercisers. So my first question is what got you into doing this study?

Sabine: Yes, actually this project started from my clinical question about when can women start exercising after pregnancy and because I'm clinically I am working in the center of Gothenburg and the replication center. And there we have a lot of women, really highly motivated to start exercising after pregnancy, so they are asking when can I start? Can I start like 3 weeks postpartum for or should I wait three months? So there I was, really clinically interested in this question. What can this woman do and what should they answer? So I started looking into the literature and found some studies about this and that early exercising was not associated to the prevalence of urinary incontinence and pelvic organ prolapse. And I also found a lot of this clinical guidelines about when they can start exercise and how they should start exercising and postpartum.

But there is very often really short sections about what they can do and what they not can do. And there are this short sentences about when it's medically safe. And they're talking about that say we should screen for urinary leakage and that we should screen for pain. And we not know what should we do then when they are have this leakage and when they have pain and where we are going from there. Because when I think my patients are in at our clinic and a lot of women postpartum and we know 30% of women have urinary leakage and early get 25% have pelvic girdle pain, and then they have this diffuse problem of vaginal heaviness that they feel that they are pelvic organs leak a little bit of support during the first month and that are the group I am meeting, so I'm not meeting the group which are not feeling anything and they just can start. They have this kind of problems and after childbirth and there I was seeing this knowledge gap about what should we say to this patients having problems, having pain after childbirth should they start or should they see that as a warning sign to wait a little bit more until they start exercising?

Alan: So there's quite a bit of lack of clarity in the field, it's.

Sabine: Yes, exactly. It was like this like that. The skyline is good and I know a lot when I have this healthy person that would get just start exercising. But if I have this woman with and often they don't have just one problem. And they have pelvic girdle pain and urinary leakage and what can I say to this woman? So that was the motivation and the big question for this, for this study, which I did.

Alan: Could you briefly describe what your major hypotheses were going into the study because you categorized people in those several groups? What were you hypothesizing would be the association?

Sabine: My hypothesis was that the pelvic floor muscles and the dioceses maybe would improve during the first year, but that there would be more like a dose response curve there. So that maybe non exercising would not affecting this and then that where there would be an improvement in their, like we recommend right now, slip gently starting with low impact, exercising. Maybe not on the high to higher level, so the reason why we categorize these groups was that we were wanted to see if they're like this. Yes. Is there a curve in this that that some people are getting better and if high-impact exercising might be too much load on the muscles or on the on the symptoms that it would there maybe late to more symptoms instead.

Alan: One of the limitations in the study that you talked about and we'll get into the findings in a minute, but one of the limitations is you said that the number of high-impact exercisers was low relative to the other groups.

Sabine: Yes, OK. We had 32 high-impact exercises. So we had no statistically power to say anything about impact on particular pain and urinary incontinence in this study.

Alan: So that would be, yeah, good. Talk. Let's talk a little bit about the findings. You showed that the women who engaged in low impact exercises during the first three months postpartum, they reported decreased pelvic girdle pain, less vaginal heaviness, decreased diastasis, and increased pelvic floor muscle strength at 12 months. In terms of the magnitude of the associations where those findings, those associations clinically significant?

Sabine: If we see if we take a look, I think for public floor strength and diastasis recti abdominis I would definitely say yes because there we could see that the strength was increasing and the dioceses was decreasing. And in terms of that we in clinical clinic often see that a lot of women are scared about that I'm too weak in my pelvic floor muscles. I can't start exercise or I have still the separation between my abdominal muscle. So I maybe should wait with something. So we have a really important message that we know we can see in this study that the pelvic floor muscle strength is getting better and that they will. Yes, they will recover. And even if we I think that we have to acknowledge that a lot of these changes are just due to natural recovery, we still can that you can start. We don't have this like awareness or no, we shouldn't start yet. So that is a really important finding here. For pelvic girdle pain, we are borderline within this range of what is seen in other studies as a minimal clinical important difference. But even here we can see that pelvic girdle pain is even just slightly, but it is decreasing. If you are exercising and we could not see any change in the non-exercising group. So even here if we see all this other health benefits of exercising and especially in the postpartum period, if you think of postpartum depression, weight management, sleep problems, then I think it's really even if like the symptoms are just slightly changing it's an important message to see that we can get away a little bit of from this being so careful and feeling like the body is fragile and can't do anything yet because we really can use all these other health benefits. And that's the same for urinary incontinence, but because from there, if we taking a look on the scale, the changes are really slightly, but if you see that your incontinence is a really barrier for getting active again after pregnancy, this is an important result to see that it shouldn't be the barrier. There are a lot of other barriers like lack of energy, sleep and all these things but urinary incontinence shouldn't be a barrier to getting active again.

Alan: Let's talk a little bit about the urinary incontinence finding. The non-exercisers reported increased severity of stress urinary incontinence at 12 months. Those who exercise two to less than five times per week, So there were the less consistent exercises, They reported less severe urinary incontinence. But this symptom persisted in the regular low-impact and the high-impact groups. Were you surprised by that group of findings?

Sabine: No, I was not so surprised because I knew that urinary incontinence is an a persisting symptom in the postpartum period. It's still like with 30%, it's even seen in other studies that they are, it's about 30% during the first year experience this kind of problem. I was a little bit surprised that the non-exercising group is increasing in pelvic floor muscle strength, but they are not as that the pelvic floor muscle strength is increasing and the urinary incontinence is also increasing, which is kind of a little bit of confusing because when you're thinking run logically, if the pelvic floor muscle is getting stronger the urinary incontinence should getting better, so there I am a little bit like what is this saying about this group. Another problem is it's maybe like the hip muscles after a week like that, it's something with the weight we had not, we had not the confounding factor of BMI in the in the study. So it's a lot of thinking about what could the problem be instead.

Alan: You noted in your study that at 12 months there was still a substantial minority of women who still had stress urinary incontinence regardless of their exercising.

Sabine: Yes.

Alan: What kind of recommendations do you give women that you work with, who are still having that problem at 12 months?

Sabine: Yes, I am the general recommendation for urinary leakage is pelvic floor exercising and so that they really do specific exercises for the pelvic floor muscles which I also work with with the woman. And it has really good evidence in the general population to do pelvic floor muscle exercising against urinary incontinence. In the postpartum population this evidence is a little bit less clear, but I think it's a lot about that the women are not knowing how they should do that that they maybe don't have the structure exercise program for the pelvic floor muscles. We actually had a question about pelvic floor exercises in our questionnaire to the study, but it was, yes, it was that. The woman who were leaking were doing more pelvic floor exercising and that is maybe just because it is a cohort study. So that's the reason why they were doing pelvic floor exercising well because of the leakage. So that was the wrong study design to study this question, but in general it's pelvic floor exercising and so and that was not really what the study was about. It was more like should we also do general exercising additionally to the pelvic floor exercising.

Alan: Yeah, I was just curious. I knew it wasn't related to your study, but I was just curious clinically. You also in the article talked about brisk walking was the most common exercise that these women were doing. But you noted that walking can be difficult for women with pelvic girdle pain. What do you recommend for people for whom walking is a is a challenge because of their symptoms?

Sabine: Yes, and that's a really interesting question because that's really the problem with this population, because they want to walk. That's the best and most accessible way for them to exercise and then they want to go with the stroller because it's the best way to put the baby asleep so that I have this woman walking like 3-4 hours per day because they think that's the best way to do so. There we have really this challenge to find solutions for them and think we have a great responsibility as physical therapists to find solution for them to do something instead so that they're not walking and they're. I can't give like a general program because there's no evidence for this general program, but I am working a lot with this finding this solution to how can this woman has she the economical possibilities to go to the gym, is accessible to the gym and can she go to a swimming pool? Maybe doing some exercise with her baby in the water? And can I give her an exercise program but she can do at home in her living room. So that's really finding this solutions for this woman, how she could get active instead of just waiting to get it better, yes.

Alan: Are you continuing this line of investigation and if so, what? What are you involved in?

Sabine: Yes, I am. I now I actually finished my PhD for just a few days ago. So. So now my next projects will be more about we I want to know more about this high-impact exercising. So that's my plan because now in this study we had to yes to we had no idea how many women will do this high-impact exercising because we tried to find earlier studies about high, high-impact exercising after pregnancy and are based on lack on that we just found that it would be maybe like 10 to 20% doing this high impact, but it was really less. So we now have to find a better study design to look further to this how high-impact exercising is affecting pelvic problems after pregnancy. Yes.

Alan: Dr. Vesting, first, congratulations on completing your PH.D.

Sabine: Thank you.

Alan: Thank you for publishing your work in PTJ and for taking the time to talk to me about it today.

Sabine: Thank you.

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