Implementation of a Postpartum PT Program

 

If you have read any of my blog posts or attended any of the CE courses I have taught, you will know by now that one of my passions (or soapboxes, if you want to think of it that way!) is “marrying” the orthopedic and “women’s health” specialties more closely. Suffice it to say that I strongly believe that marginalizing and separating the two does our profession, and our patients, a huge disservice. There are many conditions traditionally managed (and trained for!) only by “women’s health” physical therapists that could and should be managed by anyone who offers outpatient musculoskeletal based physical therapy services! We are going to talk about one of those categories today.

If you do not offer musculoskeletal wellness oriented services to postpartum women, you are missing the boat on a patient population who really needs your services!

Think for a moment about the number of patients who seek our services who are female. Then consider that a large number (certainly not all, but a significant percentage!) of those women have undergone at least one pregnancy. My point here is: you are already caring for postpartum women, whether you acknowledge it or not-doesn’t it make sense to be aware of aspects of that which may impact your care-and hopefully make it a bit less intimidating sounding to provide care during the “sooner postpartum” period. Women see a healthcare provider frequently during pregnancy (as often as weekly for the last month or so!) and then once the baby arrives, they receive no health care aside from what is often a very cursory screening at 6 weeks-physical therapists should stand in this gap!

During pregnancy (and recovery from pregnancy) the human body undergoes significant changes (to say the least)-from organs repositioning themselves to the center of gravity changing to muscles being extremely stretched out to many times their normal length during the pregnancy itself and/or delivery; and sometimes cut through depending on how the delivery goes. Some women develop a diastasis rectus (the fascia of the linea alba splits, changing the mechanics of pull in the rectus abdominus – which I think we can all agree has the potential to have major ramifications in core function! Add to this the fact that many women begin engaging in activities (related to baby care) that have them doing repetitive motions in not terribly ergonomic positions, and you have a recipe for the creation of dysfunctional movement patterns that will cause pain immediately in the unlucky, or down the road in those who are more lucky/too tired or stubborn to seek out care. In many other first world countries, physical therapy following the delivery of a child is the standard of care-they recognize that we need to support women as their bodies recover from this feat. While not yet standard of care everywhere in the United States, these services ARE covered by insurance, and most physicians are more than willing to write a referral for it (if you need one) upon request by you or the patient.

 

So what should we be looking for in the postpartum population?

 

I have more good news for you here-you already know how to evaluate this population! In my mind, they fall into 2 categories-those having pain or problems and those who just need a wellness oriented screening and recommendations for returning to activity. The ones who are having pain and problems will most likely be experiencing pain in an area where you already feel a high level of comfort-lumbar spine, hips, thoracic spine, pelvic girdle, neck, etc. In patients who aren’t experiencing (or aren’t aware they are experiencing) dysfunction, I would recommend a functional movement assessment type screening and prescription of exercises designed to correct any dysfunctional motor patterns you may identify. You may find that some of those in the latter category do still need a course of physical therapy to really get their core activating appropriately.

I work for a fairly large teaching hospital system, which I realize gives me some access to patients that not everyone will have, but just for the sake of education, here is how we have handled incorporating this into our offerings. When I first moved here, no one was treating pregnant or postpartum women (and I was not pelvic health trained at the time, simply had a passion for these patient populations). At first, I focused on building relationships with the physicians-family medicine and OB/GYN primarily, and getting them to send me their pregnant and postpartum patients with pain (always the easiest sell!). Then as they started to buy in more after seeing results, I started talking to them about a musculoskeletal screen postpartum. They readily agreed that the exam they do is essentially “organs and birth control prescription only” and they don’t really have the training or time to do a musculoskeletal evaluation.

At this point, we were able to place a staff member on the postpartum floor (inpatient) to start talking to patients about ergonomics and help facilitate setting them up with an outpatient appointment at approximately 6-8 weeks postpartum if they fell into a high risk/clear need category.

We created and distributed a fairly comprehensive booklet containing ergonomic advice and return to exercise or sport advice (another thing that absolutely no one talks to them about). Just recently, we have been able to have our EMR staff build an outpatient physical therapy referral into the automatic order set that all women receive upon admission to the labor and delivery floor, so now the majority of women get at least an evaluation/personalized exercise plan and a course of therapy if they need it. We do a head to toe musculoskeletal screening, of course zooming in on any areas that seem to be dysfunctional or where the individual is having pain. So far, this has been incredibly well received by both physicians and patients.

Of course, I can’t do this population justice in a simple blog post! However, hopefully I have piqued your interest a little. If you want to learn more, check out this weekend course that is largely focused on this patient population (and other “pelvic health” oriented treatment that can be incorporated into orthopedics with no internal assessment knowledge needed).

Don’t forget too, even though I’m focusing more in this post on the immediate postpartum population, many of the challenges presented during the postpartum period (in combination with the lack of good support and education for recovery) are the underlying causes of pain and problems experienced by your patients down the road—so even if you are not interested in working with the “immediately postpartum” population, it might behoove you to learn more about the impact of pregnancy and delivery upon the musculoskeletal system. Your patients probably won’t thank you for it (because they won’t know the difference)—but your care will improve and you will open the doors to a whole new population of individuals in need of your services.

 

8 responses to “Implementation of a Postpartum PT Program

  1. Lisa says:

    Thank you for the wonderful overview of post-partum PT needs of women! I recently worked with a high-level athlete who was told she could go back “all your regular activities” a month after the birth of their 2nd child. Fortunately, this individual was well educated and recognized that she had developed diastasis recti (4 finger breadths wide at one point), but not until she had tried to jump back into their pre-pregnancy routine.

    She sought out a pelvic floor physical therapist based on information she found on a blog from a CrossFit trainer. Attention initially focused on piston breathing/diaphragmatic breathing and physiological quieting followed by postural awareness and gradual core strengthening with attention to avoiding habitual patterns that resulted in increased intra-abdominal pressure (including proper body mechanics). I recommended an ultrasound assessment based on an article I referenced, and she was scheduled to see a surgeon who thankfully did not feel surgical intervention was warranted as she was improving by that time with our treatment plan.

    Like you I feel we need to link the post-partum (and also menopausal) concerns of women to our orthopedic practices to ensure women can continue to participate in daily activities and sports they enjoy without suffering consequences related to physiological changes that occur post-partum or with hormonal changes related to illness or reaching menopause. I find many women think their experience is “normal” because they remember their mother or other relative speak of like symptoms and they do not realize that physical therapy treatment may be helpful.

    1. Jennifer Stone says:

      Thanks for sharing this story, Lisa! The great thing is, most diastasis patients can be treated very effectively without having an intimate working knowledge of the pelvic floor. I agree that there is far too much of a “this is normal/inevitable” attitude in this country about this problem-which actually represents a great opportunity for us! Most physicians will readily admit that they are not trained to do musculoskeletal evaluation and don’t have the time to do so even if they were-so we have a great opportunity to partner with them to facilitate best possible care for our mutual patients! Thank you for your willingness to try to help “marry” the worlds!

  2. Christina Penny says:

    Thanks for the information! You talked about a comprehensive booklet on ergonomics and return to exercise/sport. Is there a way we can access that information, or were might we find some information as educational handouts to patients?

  3. Jenn Stone says:

    Feel free to email me ([email protected]) and I can send you some information to help you develop something!

  4. Amy Shute says:

    I have had ten babies. I would love to know how I can heal my pelvic floor and diastasis recti. I also have developed an inguinal hernia following my ninth pregnancy. I want to heal naturally without surgery, if at all possible.

    1. Jenn Stone says:

      Hi Amy,
      The absolute best way would be to try to find a provider near you who can help you with this-every person’s underlying problems are different, so a personalized approach will be by far the most effective. You are welcome to email me (jstone @ eimpt.com) and I can try to help you locate a provider in your area.

  5. Madeline says:

    Hello, thank you for this blog post! I am a physical therapy student, and I’m providing an inservice at my clinical site regarding the role of physical therapy immediately postpartum, so I really appreciate your views on the topic. If you’re able to share, what resources or sources of evidence did you find to be most helpful in providing ergonomic and exercise based information to postpartum patients?

  6. I would love data showing that the PT postpartum care reduces hospitalizations, complications, and also that it helps reduce long term disability! I know it does this, I just can’t find hard evidence of other countries vs ours!

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