The AfterBabyBodyStudy: Muscular changes, exercising, and activity limitations and their associations with pelvic girdle pain and urinary incontinence in the postpartum period

Aim: Pregnancy and childbirth can lead to several symptoms, changes in the pelvic floor muscles and a diastasis recti abdominis (DRA). This thesis aimed to assess and explore stress urinary incontinence, vaginal heaviness, pelvic girdle pain and muscular changes in the postpartum period, in relation to each other, and in relation to exercising, activity limitations and women’s experiences. Methods: This thesis comprises four papers based on a prospective longitudinal cohort study (n = 504) and a qualitative study (n = 14). The cohort study included questionnaires and clinical muscle assessments at 3, 6, 9 and 12 months postpartum, with double initial assessments (n = 222) to assess inter-rater reliability (Paper I). The questionnaires included measures to assess pelvic girdle pain (Papers II+III), stress urinary incontinence, vaginal heaviness and exercising (Paper III) and activity limitations (Paper IV). The qualitative study involved interviews regarding women’s experiences of physical changes and recovery postpartum (Paper IV). These 14 women were not included in the cohort study. Results: Good inter-rater reliability was shown for the assessment of maximal voluntary pelvic floor muscle contraction using vaginal palpation and for measuring DRA width with a caliper, but only fair inter-rater reliability for the assessment of pelvic floor muscle relaxation (Paper I). There were associations between weak pelvic floor muscles and DRA width ≥35 mm and increased pelvic girdle pain severity at 3 months postpartum. Participants with lower pelvic girdle pain severity showed no statistically significant decrease from 3 to 12 months postpartum (Paper II). Participants who engaged in low-impact exercise 2-4 times/week within the first 3 postpartum months experienced reduced pelvic girdle pain and stress urinary incontinence severity at 12 months compared to 3 months postpartum. Those who did not exercise experienced increased stress urinary incontinence at 12 months postpartum (Paper III). Women experienced activity limitations, e.g., running, exercising, and lifting/carrying, due to pain, vaginal heaviness, and urinary incontinence in the first 6 months. While most of these limitations were temporary, 41% of women continued to experience difficulties with running 12 months postpartum (Paper IV-cohort). The women were surprised by the physical changes postpartum. They expressed a need to understand whether these changes were permanent or temporary (Paper IV-interview). Conclusion: Several symptoms and physical changes naturally diminish during the first year postpartum. However, urinary incontinence and pelvic girdle pain can result in activity limitations. Women can feel surprised and insecure about these physical changes and seek support and practical advice on how to manage them. Primary care physiotherapists could play an important role for women with persistent symptoms and activity limitations in assessing their pelvic floor and abdominal muscles, encouraging and adjusting exercise, and helping to restore function in muscle groups associated with pain and urinary incontinence

The AfterBabyBodyStudy: Muscular changes, exercising, and activity limitations and their associations with pelvic girdle pain and urinary incontinence in the postpartum period

Aim: Pregnancy and childbirth can lead to several symptoms, changes in the pelvic floor muscles and a diastasis recti abdominis (DRA). This thesis aimed to assess and explore stress urinary incontinence, vaginal heaviness, pelvic girdle pain and muscular changes in the postpartum period, in relation to each other, and in relation to exercising, activity limitations and women’s experiences. Methods: This thesis comprises four papers based on a prospective longitudinal cohort study (n = 504) and a qualitative study (n = 14). The cohort study included questionnaires and clinical muscle assessments at 3, 6, 9 and 12 months postpartum, with double initial assessments (n = 222) to assess inter-rater reliability (Paper I). The questionnaires included measures to assess pelvic girdle pain (Papers II+III), stress urinary incontinence, vaginal heaviness and exercising (Paper III) and activity limitations (Paper IV). The qualitative study involved interviews regarding women’s experiences of physical changes and recovery postpartum (Paper IV). These 14 women were not included in the cohort study. Results: Good inter-rater reliability was shown for the assessment of maximal voluntary pelvic floor muscle contraction using vaginal palpation and for measuring DRA width with a caliper, but only fair inter-rater reliability for the assessment of pelvic floor muscle relaxation (Paper I). There were associations between weak pelvic floor muscles and DRA width ≥35 mm and increased pelvic girdle pain severity at 3 months postpartum. Participants with lower pelvic girdle pain severity showed no statistically significant decrease from 3 to 12 months postpartum (Paper II). Participants who engaged in low-impact exercise 2-4 times/week within the first 3 postpartum months experienced reduced pelvic girdle pain and stress urinary incontinence severity at 12 months compared to 3 months postpartum. Those who did not exercise experienced increased stress urinary incontinence at 12 months postpartum (Paper III). Women experienced activity limitations, e.g., running, exercising, and lifting/carrying, due to pain, vaginal heaviness, and urinary incontinence in the first 6 months. While most of these limitations were temporary, 41% of women continued to experience difficulties with running 12 months postpartum (Paper IV-cohort). The women were surprised by the physical changes postpartum. They expressed a need to understand whether these changes were permanent or temporary (Paper IV-interview). Conclusion: Several symptoms and physical changes naturally diminish during the first year postpartum. However, urinary incontinence and pelvic girdle pain can result in activity limitations. Women can feel surprised and insecure about these physical changes and seek support and practical advice on how to manage them. Primary care physiotherapists could play an important role for women with persistent symptoms and activity limitations in assessing their pelvic floor and abdominal muscles, encouraging and adjusting exercise, and helping to restore function in muscle groups associated with pain and urinary incontinence

Exploring Intra-Abdominal Pressure Measurements During Physical Activity And Exercise: A Scoping Review

Intra-abdominal pressure (IAP) measurement is commonly used in studies to assess the load on the spine, abdominal wall, or pelvic floor during physical activity and exercise. IAP can be measured using various sensors, including intragastric, intrarectal, or intravaginal methods. However, there is a lack of a comprehensive overview regarding how IAP is measured, inferred, and interpreted in research involving physical activity and exercise. This scoping review aims to explore how IAP is measured during physical activity and exercise in studies involving healthy individuals. A secondary aim is to evaluate how these measurements are influenced and interpreted in relation to their potential impact on structures such as the abdominal wall or pelvic floor. The findings from this review will provide valuable insights for future research on IAP measurement techniques and offer guidance to clinicians and researchers on interpreting literature regarding the role of IAP in pelvic floor loading

Exploring Intra-Abdominal Pressure Measurements During Physical Activity And Exercise: A Scoping Review

Intra-abdominal pressure (IAP) measurement is commonly used in studies to assess the load on the spine, abdominal wall, or pelvic floor during physical activity and exercise. IAP can be measured using various sensors, including intragastric, intrarectal, or intravaginal methods. However, there is a lack of a comprehensive overview regarding how IAP is measured, inferred, and interpreted in research involving physical activity and exercise. This scoping review aims to explore how IAP is measured during physical activity and exercise in studies involving healthy individuals. A secondary aim is to evaluate how these measurements are influenced and interpreted in relation to their potential impact on structures such as the abdominal wall or pelvic floor. The findings from this review will provide valuable insights for future research on IAP measurement techniques and offer guidance to clinicians and researchers on interpreting literature regarding the role of IAP in pelvic floor loading

Exploring Intra-Abdominal Pressure Measurements During Physical Activity And Exercise: A Scoping Review

Intra-abdominal pressure (IAP) measurement is commonly used in studies to assess the load on the spine, abdominal wall, or pelvic floor during physical activity and exercise. IAP can be measured using various sensors, including intragastric, intrarectal, or intravaginal methods. However, there is a lack of a comprehensive overview regarding how IAP is measured, inferred, and interpreted in research involving physical activity and exercise. This scoping review aims to explore how IAP is measured during physical activity and exercise in studies involving healthy individuals. A secondary aim is to evaluate how these measurements are influenced and interpreted in relation to their potential impact on structures such as the abdominal wall or pelvic floor. The findings from this review will provide valuable insights for future research on IAP measurement techniques and offer guidance to clinicians and researchers on interpreting literature regarding the role of IAP in pelvic floor loading

Educating women to prevent and treat low back and pelvic girdle pain during and after pregnancy: a systematized narrative review

Purpose This review evaluated the effectiveness of patient education and information on low back pain (LBP) and pelvic girdle pain (PGP) in pregnant and postpartum women and evaluated their alignment with modern pain education principles rooted in the biopsychosocial model.Method A systematized narrative review was performed, including a systematic search of three databases and reference screening from relevant systematic reviews. The methodological quality of the included randomized controlled trials (RCT) was evaluated using the PEDro scale.Results Eighteen studies, including nine RCTs with PEDro scores ranging from to 2–8, indicated that patient education during pregnancy can help reduce pain and related disability. Most studies did not differentiate between LBP and PGP, which limits the specificity and targeted approach of educational interventions. Education alone is less effective without accompanying active treatment. Current programs primarily emphasize biomechanics, covering anatomy and physical changes, but often neglect lifestyle factors, such as stress and sleep.Conclusion Although patient education is important for managing pregnancy-related LBP and PGP, its effectiveness may be improved by tailoring programs to specific pain conditions and integrating a biopsychosocial perspective on pain

Clinical assessment of pelvic floor and abdominal muscles 3 months post partum: An inter-rater reliability study

Objectives Evaluation of the inter-rater reliability of clinical assessment methods for pelvic floor muscles and diastasis recti abdominis post partum. Design A multicentre inter-rater reliability study. Setting Three primary care rehabilitation centres in Sweden. Participants A total of 222 participants were recruited via advertising at Swedish maternity care units and social media. Eligibility for participation included female gender, ≥18 years, at maximum 3 months after childbirth. Exclusion criteria were chronic pelvic girdle pain and/or low back pain and/or pelvic floor tear grade III/IV. At each centre, 2 physiotherapists, with training and experience in pelvic floor assessment, assessed the 222 women according to a standardised protocol in random order. Outcome measures Inter-rater reliability of the assessment of pelvic floor muscle function (involuntary and voluntary contraction and voluntary relaxation) and diastasis recti abdominis (width, depth and bulging). Results Vaginal palpation of maximal voluntary contraction revealed a kappa value of 0.69 (95% CI 0.62 to 0.76). Assessments of involuntary contraction and voluntary relaxation yielded inconsistent results, with slight-to-moderate weighted kappa values ranging from 0.10 to 0.51. After 2 months of training in applying this method, diastasis recti abdominis width measured at the umbilicus by calliper yielded an intraclass correlation coefficient value of 0.83 (95% CI 0.76 to 0.87). Assessments of diastasis recti abdominis depth and bulging showed moderate kappa values, with reservation for some inconsistency between the centres. Conclusions Vaginal palpation of pelvic floor muscle strength is a reliable method for the postpartum muscle assessment. Additional research is needed to identify reliable assessment method for other pelvic floor muscle functions like involuntary contraction and voluntary relaxation. With some training, a calliper is a reliable instrument for measuring the postpartum diastasis recti abdominis width. This study provides novel thoughts about how to measure diastasis recti abdominis depth and bulging. © Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ

Assessment of pelvic floor and abdominal muscles three months postpartum: A reliability study

Abstract Background Pregnancy and childbirth often result in alterations of core muscles, and women may require postpartum assessment of pelvic floor muscle function and abdominal wall changes, e.g. diastasis recti abdominis (DRA). However, there is currently no gold standard for postpartum assessment of these muscles´ function. Here we aimed to evaluate the reliability of clinically applicable methods for assessing pelvic floor muscles and DRA after pregnancy. Methods We recruited 222 postpartum women from Swedish antenatal and childbirth centers, and via social media. Pelvic floor and DRA assessment were performed via observation and palpation at three rehabilitation centers in Sweden. At each center, two independent physiotherapists performed the assessments in random order. Results Assessment of the maximal voluntary contraction and pelvic floor muscle endurance revealed kappa values ranging from 0.49–0.69. Assessments of voluntary contraction by observation, involuntary contraction, and voluntary relaxation yielded inconsistent results, with slight-to-moderate weighted kappa values ranging from 0.10–0.51. DRA assessment by caliper yielded ICC values of 0.73–0.83 after physiotherapists underwent 2 months of training in applying this assessment method. The standard error of measurements for this method was about 4 mm, and the minimal detectable change was 12 mm. Assessments of DRA depth and bulging showed moderate kappa values of 0.43–0.51, with reservation for some inconsistency between the centers. Conclusions Palpation of maximal voluntary contraction and pelvic floor muscle endurance are reliable postpartum assessment methods. With some experience and training, a caliper is a reliable instrument for assessing the postpartum DRA width. Additional research is needed to identify a reliable assessment method for pelvic floor muscle functions other than voluntary contraction, and for DRA depth and bulging.</jats:p

Clinical assessment of pelvic floor and abdominal muscles 3 months post partum: an inter-rater reliability study

ObjectivesEvaluation of the inter-rater reliability of clinical assessment methods for pelvic floor muscles and diastasis recti abdominis post partum.DesignA multicentre inter-rater reliability study.SettingThree primary care rehabilitation centres in Sweden.ParticipantsA total of 222 participants were recruited via advertising at Swedish maternity care units and social media. Eligibility for participation included female gender, ≥18 years, at maximum 3 months after childbirth. Exclusion criteria were chronic pelvic girdle pain and/or low back pain and/or pelvic floor tear grade III/IV. At each centre, 2 physiotherapists, with training and experience in pelvic floor assessment, assessed the 222 women according to a standardised protocol in random order.Outcome measuresInter-rater reliability of the assessment of pelvic floor muscle function (involuntary and voluntary contraction and voluntary relaxation) and diastasis recti abdominis (width, depth and bulging).ResultsVaginal palpation of maximal voluntary contraction revealed a kappa value of 0.69 (95% CI 0.62 to 0.76). Assessments of involuntary contraction and voluntary relaxation yielded inconsistent results, with slight-to-moderate weighted kappa values ranging from 0.10 to 0.51. After 2 months of training in applying this method, diastasis recti abdominis width measured at the umbilicus by calliper yielded an intraclass correlation coefficient value of 0.83 (95% CI 0.76 to 0.87). Assessments of diastasis recti abdominis depth and bulging showed moderate kappa values, with reservation for some inconsistency between the centres.ConclusionsVaginal palpation of pelvic floor muscle strength is a reliable method for the postpartum muscle assessment. Additional research is needed to identify reliable assessment method for other pelvic floor muscle functions like involuntary contraction and voluntary relaxation. With some training, a calliper is a reliable instrument for measuring the postpartum diastasis recti abdominis width. This study provides novel thoughts about how to measure diastasis recti abdominis depth and bulging.Trial registration numberNCT03703804.</jats:sec

Pelvic Floor Muscle Strength and Bothersome Urinary Incontinence After Pregnancy: A Cohort Study

Introduction and HypothesisPostpartum urinary incontinence (UI) is prevalent, and women with bothersome UI tend to seek more help. This study was aimed at evaluating the association between pelvic floor muscle (PFM) strength and bothersome UI in the 1st year postpartum.MethodsA prospective cohort study was conducted with 504 participants. UI was evaluated by the International Consultation on Incontinence Questionnaire Short Form (online) and PFM strength was assessed via vaginal palpation (Modified Oxford Scale, MOS), at 3, 6, 9, and 12 months postpartum. Logistic regression analysis was used to analyze the data.ResultsAt 3 months postpartum, 52% of women had a PFM strength of >= 3 MOS, increasing to 84% at 12 months. 42% of women reported UI at 3 months, which remained unchanged by 12 months. PFM strength >= 3 MOS was moderately associated with less UI at 3 months (OR = 0.63, 95% CI 0.42-0.94) and at timepoints 6, 9, and 12 months. Antepartum UI was strongly associated with postpartum UI at all time points: 3 months (OR = 10.23, 95% CI 4.90-21.37), 6 months (OR = 7.75, 95% CI 3.95-15.21), 9 months (OR = 9.95, 95% CI 4.61-21.47), and 12 months (OR = 4.55, 95% CI 2.29-9.04). Grade 2 perineal tears were moderately associated with UI at 9 months postpartum (OR = 1.82, 95% CI 1.11-3.0).ConclusionsA stronger pelvic floor was associated with less bothersome UI in the 1st year postpartum. UI during pregnancy was most strongly associated with bothersome UI after childbirth. Antenatal screening for UI and promoting PFM training may be warranted to support postpartum recovery and minimize UI