Ep 203: Helping new mothers to move more, with Dr Jenna Schulz

[00:00:04] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research

[00:00:10] to quality practice. I'm Clare Ardern, the Editor-in-Chief of the Journal of Orthopaedic

[00:00:15] and Sports Physical Therapy. It's great to have you listening today. We're all familiar

[00:00:23] with the physical and mental benefits of regular physical activity. Unfortunately, after someone

[00:00:29] has a baby, there are many barriers to getting sufficient physical activity to reap the health

[00:00:33] benefits. And as many as two in three postpartum women don't meet the physical activity guidelines

[00:00:39] of 30 minutes per day of moderate to vigorous physical activity. And compounding the problem

[00:00:45] is that there's limited guidance for clinicians on how to best support return to sport and

[00:00:50] physical activity after childbirth. My guest today is working very hard to change this

[00:00:56] picture. Dr Jenna Schulz works at Fowler Kennedy Sports Medicine Clinic in London, Ontario,

[00:01:02] as a postdoctoral fellow and physiotherapist specializing in pelvic health and sport. Jenna's

[00:01:08] current research interests lie in women's health and improving longevity in sport for females

[00:01:13] across the lifespan. Dr Jenna Schulz, welcome to JOSPT Insights.

[00:01:19] Hi, thank you so much for having me today. I'm really excited to be here.

[00:01:22] Oh, thanks for making the time out of busy clinical week. Jenny, you've spent much of your clinical

[00:01:28] career as a physio and your research career focused on supporting athletes and non-athletes to get back

[00:01:34] to sport and to physical activity after childbirth, which is really lucky for us today because

[00:01:39] unfortunately, even though returning to sport and physical activity is a pretty common goal for people

[00:01:45] after childbirth, it's difficult to find strong guiding evidence for clinicians to rely on. There's plenty

[00:01:52] of opinions, but not so much solid, strong evidence. And you're definitely changing that picture for us.

[00:01:59] So we're very fortunate to have you join us today. Let's start with what should musculoskeletal

[00:02:04] rehabilitation clinicians consider when supporting people to set physical activity goals after childbirth?

[00:02:10] When we think about all other return to sport protocols, whether it's after an ACL tear or an

[00:02:17] Achilles rupture or even an ankle sprain or even someone who has like a patellar tendinopathy,

[00:02:22] we know that just thinking about how they're ready musculoskeletal is not enough for them to be

[00:02:29] efficient and get back to sport. So ACLs, for example, we know that there's that huge mental

[00:02:35] readiness component. If they're not ready mentally to get back to sport, then they're at a higher risk

[00:02:40] for re-enduring themselves. And I think when we think with this population, especially, we really

[00:02:44] need to think about that whole biopsychosocial approach and really think beyond their MSK system.

[00:02:51] So they obviously need to be physically ready, their endurance, they need to be strong, they need to

[00:02:56] have gradually progressed through their return to sport protocol. But equally as important, I think,

[00:03:04] is are they mentally ready? Do they have any symptoms of things like postpartum depression?

[00:03:08] Are they well-supported at home? Are they sleeping enough? Are they eating enough? Now not only do

[00:03:14] they have to take care of themselves, they're also taking care of their young baby at home. So

[00:03:18] there's a lot of other factors that really need to be considered when working with this population.

[00:03:24] And I think only they're ready to get back into sport when all of those things, even physical activity,

[00:03:31] when all of those things are kind of come together in peace and they're feeling ready from a whole

[00:03:37] systems readiness versus just that MSK system. And so as physios, we have a huge role in looking.

[00:03:44] I know we learn a lot about the MSK system, but we really need to look at that whole person and take

[00:03:50] a whole personal approach when dealing with this population.

[00:03:54] So Jenna, that could sound like a pretty daunting thing for someone who's usually dealing very much

[00:04:01] with musculoskeletal conditions and feels comfortable in the musculoskeletal space.

[00:04:05] Now I'm having to think a lot more like a nutritionist or maybe like a psychologist. So

[00:04:10] how do you approach that knowing where your scope of practice is, where you might need to refer on,

[00:04:17] and I guess finding the right balance there?

[00:04:20] I usually just start by asking questions and maybe that's not your first visit and you're not

[00:04:26] diving right into these questions with this person in front of you on their first assessment. But once

[00:04:29] you kind of have that good relationship with them, just asking them questions about, you know, like,

[00:04:34] do you feel like you're ready to get back into activity? Do you feel like you're eating enough

[00:04:38] or sleeping enough to support those needs? And are you having any symptoms like pelvic floor dysfunction,

[00:04:45] things like that? And if they start answering yes to some of those questions, I know that

[00:04:48] some of those things are outside of my scope. So that's where I will bring in kind of that

[00:04:55] multidisciplinary team. I work closely with some dietitians who I send people to left,

[00:05:01] right and center because I think they have play a really huge and important role in sport in general,

[00:05:07] especially women's health and female athletes. So getting one of them on board,

[00:05:12] really getting that whole multidisciplinary team together, if they're having some of those

[00:05:17] potential postpartum depression symptoms, things like that, then I will suggest that they get

[00:05:22] referred to see either like a psychologist or psychiatrist if they can, or even a psychotherapist,

[00:05:28] someone that can help through some of those symptoms as well. So we have a really important

[00:05:33] role of being able to just identify when there's things that are beyond that MSK system that are going

[00:05:38] on and then refer out where appropriate when we know that it's beyond our scope or beyond what we can do

[00:05:45] as a physio. I think that's a really great point. The identifying, picking those things up at the

[00:05:50] right time is really important and that in itself is a key role. So thinking of yourself as not someone

[00:05:57] who necessarily has to solve all of these issues, because as you say, some of these are beyond our

[00:06:02] scope of practice. Simply identifying and helping someone get on the right path for managing, whether

[00:06:08] it's nutrition, psychological support, whatever it is, is a really key part of helping that person

[00:06:14] achieve their goals. Let's move to the return to physical activity, return to sport part specifically.

[00:06:21] What are the current recommendations for someone who's looking to get back to activity after childbirth?

[00:06:27] In general, the recommendations are the same as the general population. You know, you meet your 150 minutes

[00:06:34] per week of moderate to vigorous physical activity, but we really don't have phenomenal return to activity

[00:06:41] or sport guidelines, at least in our published literature that have those very specific guidelines.

[00:06:48] We also have done a scoping review, and in that review, out of 6,000 articles that we screened,

[00:06:54] we found only 33 guidelines in the published literature. And when looking through those guidelines

[00:06:59] pretty specifically, again, most of them did recommend that 150 minutes a week, but they didn't really give

[00:07:06] those specific fit principles. So that frequency, intensity, type time, we don't really have a lot

[00:07:11] of literature that has specific recommendations. A lot of them also recommended that at six weeks,

[00:07:18] you're basically good to go, safe to return back to activity, but they didn't really recommend,

[00:07:23] again, what clearance should actually look like. So someone is cleared, good to go, maybe physiologically,

[00:07:28] they're healed up, their tearing is all healed. But again, there's not really a lot of

[00:07:33] specific guidelines that exist out there, unfortunately. One way that you can think about it

[00:07:40] is instead of really focusing on timelines, is focusing on someone's ability in front of you.

[00:07:48] So similar to any other return to sport protocol, if you have someone in front of you that is not

[00:07:53] meeting those goals, or they're not meeting those strength goals, you're not going to progress them

[00:07:57] to that next stage. When we think in this population, really focusing on their abilities,

[00:08:02] if they are six weeks postpartum, and they are still having incontinence when they sneeze or laugh,

[00:08:10] then they're probably not ready to get back into running yet, because their system isn't ready. So

[00:08:16] really focusing on those abilities, that strength, that endurance, that muscular,

[00:08:21] kind of mental readiness piece as well, is really helpful. And then just really knowing that at any point,

[00:08:27] like at any of our other return to sport protocols, you can kind of return to that previous stage,

[00:08:31] just something does flare up. So if someone is having some symptoms of incontinence or pelvic girdle pain,

[00:08:37] it's okay to bring them back to that previous stage, knowing that rehab is not that linear process.

[00:08:46] And Jenna, how much of this is, I have a plan for increasing load that, you know, starts with

[00:08:54] in the pool or starts with a particular type of activity. And I use these different activities

[00:09:01] to progress irrespective of what the sport or physical activity the person wants to get back to,

[00:09:07] or how much of it is tailoring. So someone who wants to get back to running and she comes to you and

[00:09:14] says, you know, I've been running cross country and I want to get back to running on the trails.

[00:09:19] How do you think about tailoring that load progression from early postpartum to whatever

[00:09:25] the return to sport or physical activity goal is? Really early postpartum, again, really depends on

[00:09:31] some other, so if they've had C-section, things like that, but really early postpartum,

[00:09:36] things like pelvic floor exercise and locking is something that can be started bearing any of those

[00:09:41] major contraindications right away. And that's someone that everyone can start kind of at that same

[00:09:46] stage with some early exercises, some early pelvic floor. And then while progressing through like any

[00:09:54] other kind of return to running protocol, before actually getting into the running, you want to make

[00:10:00] sure that you're strong and ready to go. So usually, again, it depends kind of on the population who I

[00:10:08] have in front of me. An elite athlete might return much quicker than someone who was only running once or

[00:10:13] twice a week before or during pregnancy, but really focusing on like a good six-ish weeks of strength

[00:10:21] training to show that your pelvic floor is ready to go, your joints are all ready to go, your hips are

[00:10:27] nice and strong, your knees are nice and strong to support that load that you're about to put on your

[00:10:31] body. And in that time, getting back into other cardio, like biking, low impact, even elliptical,

[00:10:38] pool running, things like that is great. And then we're slowly progressing back into that running.

[00:10:42] And then I usually start with a little bit of a walk run program as well, just to get that body

[00:10:47] ready for the amount of load. Because when you are running, you're taking like eight times your body

[00:10:52] weight through every foot strike. So thinking of it that way is how I would progress someone into

[00:10:58] running. And then I always progress the duration of a run before the intensity. I'll say, okay,

[00:11:04] before I actually want you to get into doing an interval workout or increasing your speed,

[00:11:09] I want you to be able to tolerate 30 minutes of running first without any symptoms of easy running.

[00:11:15] And then once they're able to tolerate a good chunk of easy running is when I start kind of getting

[00:11:21] more into that return to competition or performance stage, which is more that end stage and back into

[00:11:27] those workouts.

[00:11:29] Does it matter how much activity the person has been able to do before having the baby? So if she's been

[00:11:36] exercising almost right up till delivery, does that make a difference to how you approach return

[00:11:41] to activity, return to sport, postpartum?

[00:11:44] A little bit. I think obviously when there are a lot of changes that happen when that child is born and

[00:11:50] a lot of changes to your MSK system. But I think that from a cardio standpoint, if they were running

[00:11:57] all the way up until they had their kid, then cardio wise, it won't be as hard to get back into some of

[00:12:04] that running. And so maybe we can progress through that walk run program a little bit quicker because

[00:12:09] their cardio is still pretty good and they're not lagging from that cardio side of things. And if

[00:12:14] they were doing a lot of really good strength beforehand, really working on that pelvic floor strength,

[00:12:20] that core strength, then again, some of that might come back a little bit quicker on the other end.

[00:12:25] Similar to we know the stronger you go in to your ACL surgery, the stronger you are on the other side.

[00:12:31] I think a similar sort of approach can be taken in this population. I don't know if we have a whole

[00:12:35] lot of evidence to support that, but anecdotally, that's kind of what I've seen.

[00:12:41] Jenna, I'm not a pelvic health physio. I'm a little bit concerned that I'm right at the top of my

[00:12:47] skill set in supporting someone to get back after having a baby. Where's the line between

[00:12:53] what I can manage confidently as a non-pelvic health physio versus when should I refer on to

[00:13:01] pelvic health specialists like you?

[00:13:03] As physios, we're used to dealing with the MSK system and thinking of the pelvic floor just as

[00:13:08] another muscle instead of being a little, because it can be a little bit scary and daunting.

[00:13:12] When you would refer on is if someone is having some of those symptoms of incontinence or pelvic

[00:13:18] girdle pain, and they're not getting any better with any sort of strength training or endurance

[00:13:25] training that you've tried to do, whether that's, you know, you've done, you've tried a little bit of

[00:13:30] breathing with them, and that's not really helping, or you've tried to really get them to work on

[00:13:36] using that pelvic floor when they're like timing that breathing with their squat. And if that is

[00:13:42] something that isn't really helping, then definitely a pelvic floor physio can be helpful because at

[00:13:48] that point they can maybe do an internal assessment if they think that it's necessary, but they can

[00:13:53] really help guide that pelvic floor contraction with the contraction of all those other muscles that

[00:13:59] you're trying to use. And that will help with some of those, should help with most of the symptoms

[00:14:04] of incontinence and pain. Now I want to pick up on some of the cardiorespiratory, cardiovascular

[00:14:10] fitness points that you talked about earlier, and you've just analyzed the effects of exercise-based

[00:14:16] interventions for returning to activity and for boosting cardiovascular fitness after childbirth.

[00:14:22] What were the key findings of your systematic review, Jenna? We screened about 6,000 articles.

[00:14:28] We found 29 that used some sort of exercise intervention for postpartum, and now the population

[00:14:36] that they use the exercise intervention differed, and we really weren't looking at the effect of the

[00:14:41] exercise intervention itself on things like postpartum depression or low back pain, which

[00:14:47] were often some of the outcomes, but really wanted to look at the effect of that exercise intervention

[00:14:52] on those measures of physical activity and cardiorespiratory fitness.

[00:14:55] So we found 29 studies that were included in the whole systematic review piece, that qualitative part,

[00:15:01] and then 19 were included in our meta-analyses. And we found that there was actually a small to

[00:15:06] moderate improvement in those measures of cardiorespiratory fitness after postpartum, but really no

[00:15:13] improvement in physical activity levels. And this kind of differed between some groups measured it using

[00:15:19] devices like accelerometer. Other studies measured it using just self-report. One of the main, and I would say

[00:15:27] probably the most clinically relevant finding, is that those, that fit criteria varied drastically

[00:15:33] between those studies. So the frequency, intensity, type, and time, the duration, when should they start

[00:15:41] doing the exercise intervention, how long it lasted, was very different between all 29 studies.

[00:15:47] And really that was one of the big findings too, is that only four used any sort of guideline for

[00:15:56] their exercise intervention. So whether it was even just the ACSM or 150 minutes per week,

[00:16:02] or the American obstetrics guidelines, and then only 11 of those studies ensured that they were actually

[00:16:10] exercising at that substantial enough intensity. So again, whether that's that 60 to 80% of heart rate acts.

[00:16:18] So I think that, clinically, that is probably the biggest piece, is that we're not really, you know, using

[00:16:26] exercise in the way that we can to help see some of these changes in things like physical activity levels.

[00:16:34] So cardiorespiratory fitness improved a bit. It was a modest improvement, which is, that's not bad.

[00:16:40] And overall physical activity levels didn't really change. What do you think this means beyond what

[00:16:47] you've discussed just now in terms of how the interventions were designed? I guess, what are the

[00:16:52] clinical implications for someone listening today and thinking, oh, well, I still don't know what sort of

[00:16:58] cardiorespiratory fitness program I should prescribe or how to best support someone who's wanting to get

[00:17:03] back to sport after having a baby?

[00:17:05] It really shows that the exercise interventions are really kind of ill-defined. And I think for us

[00:17:10] as clinicians, it means that we really have an opportunity in this postpartum period for physical

[00:17:16] activity counseling. And if our messaging is inconsistent, or really there is a lack of guidelines,

[00:17:22] and that's another big piece of us as researchers that we need to fix. If there's no guidelines for

[00:17:27] clinicians, it's hard for them or hard for athletes to follow. But I think that we as clinicians play a

[00:17:33] huge role in counseling our patients on not only the benefits of physical activity during pregnancy

[00:17:40] and during postpartum, but also how much physical activity should they be doing? So, you know, what is that

[00:17:47] minimum duration, intensity type, progressing them through that staged process from starting activity,

[00:17:54] starting with just walking and pelvic floor, all the way to that return to competition stage if they

[00:17:59] are wanting to get back into sport and really making sure that we're tailoring our approach to the

[00:18:05] individual that we have in front of us. And really take the time to counsel on the benefits of

[00:18:12] physical activity in that postpartum period or even better during pregnancy if this is someone that

[00:18:18] you're seeing before and during their entire pregnant time and then in through postpartum,

[00:18:24] because we know that physical activity has a multitude of health benefits for both mom and the baby as well.

[00:18:31] Jenna, you're a runner and we're talking about physical activity and I can't help but make the link to

[00:18:37] wearables. What are your suggestions for using things, the easy sorts of wearables, the smart

[00:18:45] watches, the phone that's in someone's pocket monitoring their step count? What are some ways

[00:18:49] that you like to build in information from wearables into your return to activity, return to sport,

[00:18:55] planning, postpartum? An easy one is step count. So again, the recommendation is about 10,000 steps a

[00:19:02] day. I think probably busy moms, especially if they already have other kids at home and they're

[00:19:07] chasing around a toddler are getting a lot of steps. But I also find, especially with this busy

[00:19:13] population is encouraging those movement breaks or those movement snacks throughout the day. And a

[00:19:18] wearable can be really helpful for that. Whether it's you set an alarm on your phone every hour to get up

[00:19:25] and move around or do 10 squats or do 20 jumping jacks. So I know some of the watches themselves

[00:19:32] actually have those alerts. They tell you to get up and move. The other pieces, the heart

[00:19:37] piece can be helpful as well. So if I'm asking them to try to increase the intensity that they're

[00:19:42] exercising at, they can use that heart rate monitor. Again, it's not 100% accurate, but does give us a

[00:19:49] good kind of idea of where that heart rate is at. And similarly, on the other flip side, if I'm saying,

[00:19:55] okay, it's time to go out for a run, you're good to go. We're going to start with an easy run. So your

[00:19:59] heart rate should be in that easier zone under that 150 minutes or 150 beats per minute. And that

[00:20:07] wearable can be really helpful to give some feedback to the patient without me having to be

[00:20:14] there the whole time. And then they'll come back and tell me, especially the runners, because runners

[00:20:20] love their data. They'll come back and show me everything that has gone on. So it's great.

[00:20:25] That's a really nice way of keeping track. And also, as you say, it's almost helping someone calibrate

[00:20:30] into their own body and get a sense of what should it feel like and get a sense of RPE matched with

[00:20:37] the heart rate zones that they're getting from whatever the wearable is that they're monitoring.

[00:20:42] Sometimes too, even keeping like a little bit of a journal can be super helpful. Again, it depends on

[00:20:47] the person I have in front of me if they like doing that. But sometimes I have them just write some

[00:20:51] things down in a journal and tell me how did the run feel? How did their body feel? What was their

[00:20:56] heart rate? What was their RPE? So then when they come back and see me, we can kind of adjust as

[00:21:00] needed from then. Jenna, how do you deal with setbacks? How do you coach people, particularly

[00:21:06] in this postpartum period, if there are setbacks or pain comes back? How do you manage that?

[00:21:13] The important part is always reminding our patients that rehab is a process and this process

[00:21:19] is no different. And so it's not always going to be a linear kind of step up. There are unfortunately

[00:21:27] going to be those times where you have a little bit of a dip in your process or a little bit of a

[00:21:31] setback. But I think I really try to remind people that a little bit of some pain or discomfort

[00:21:37] during this process doesn't necessarily mean, and it probably doesn't mean that we actually caused any

[00:21:42] more damage or did anything, made anything worse. We just pushed the limits of that tissue tolerance.

[00:21:48] So maybe we pushed a little bit too hard and got back into some of the running or those in the

[00:21:54] intervals a little bit too quickly when the body wasn't a hundred percent ready. And so using those pain

[00:22:00] signals as information is, is really helpful. And I just tell my patients that, okay, this is

[00:22:08] sorry that this happened, that it's a little bit, you know, you think that you've taken this huge step

[00:22:13] back. We really haven't. We just knew that we were going a little bit maybe too quickly, or you were

[00:22:18] doing a little bit too much. I also use it as an opportunity to try to get them to evaluate other

[00:22:22] things that are going on as well. So I'll say, okay, yeah, that one run really hurt, but you know,

[00:22:28] did you sleep really well the night before? How were you eating beforehand? Were you really stressed out

[00:22:34] about something? Were you just trying to really get this run in super quickly because you only had half

[00:22:39] an hour because you had X so many different things on the go? So that I find can be really helpful.

[00:22:47] And then just trying to get them to take a step back and look at big picture. So sure, maybe they're

[00:22:52] three months postpartum and they finally started getting to some running, but now it's starting to

[00:22:57] feel their, their knee flared up on them or their pelvic floor all of a sudden flared up on them and it,

[00:23:03] hadn't been bothering them for a while, but really trying to get them to take that step back and say,

[00:23:07] okay, well, three months ago, we weren't even close to running. So looking at big picture can be super

[00:23:13] helpful. And I think we're back to where we started talking about the biopsychosocial approach and

[00:23:18] thinking through that postpartum, lots of stuff has changed in someone's life. There's a new small

[00:23:25] person in your family unit, whether this is the first time baby or the athlete or the active person

[00:23:33] is juggling other children in their family. So I think it's, some of it is, is taking that step back

[00:23:39] and going, yeah, I've got a lot going on in my life. My life has changed a lot and I just need to be a little

[00:23:46] bit gentle with myself. Yeah, absolutely.

[00:23:49] I think it's worth touching on the, particularly the nutrition component here and just how much energy

[00:23:56] someone requires to exercise and take care of a baby, particularly if someone's breastfeeding and

[00:24:04] trying to get back to activity. Can you tell us a little bit about where things are at with

[00:24:09] understanding energy deficiency and just how much energy is needed for someone who's wanting to get

[00:24:16] back to activity postpartum? When we think about this energy system, really that low energy or where it

[00:24:21] becomes that problematic low energy availability is when there's an imbalance between the amount of energy

[00:24:26] that you're taking in and the amount of energy that you're expending and it becomes, over time, can become

[00:24:32] this chronic or problematic thing. And for someone who is at home with a new baby and they're trying to feed

[00:24:42] this baby, they're probably getting up multiple times a night to feed. They're probably not eating a lot of

[00:24:48] things as much themselves. And then they're also expending more energy solely because they're

[00:24:55] lactating because the amount of calories that you expend when you're breastfeeding is substantial,

[00:25:00] but then they're also getting back into activity. So there can be that mismatch between the amount

[00:25:05] of energy taken in and the amount of energy expended. And if it becomes something that becomes a little

[00:25:10] bit more chronic, it can lead to something like reds. As physios, we are not the ones who are

[00:25:18] diagnosing necessarily or treating reds from a nutritional side of things. But I think we are

[00:25:24] often the first contact that a lot of these moms will have with the healthcare system. We're the

[00:25:30] first contact for a lot of athletes as well. So I think we play an important role in being able to

[00:25:34] potentially flag if there is this energy mismatch or flag it before it gets to that problematic stage

[00:25:42] and then use our healthcare system and use our referrals and get this postpartum athlete in to

[00:25:49] see someone who can help them with their energy demands.

[00:25:52] It's a really good reminder, Jenna. Thank you. And I think it brings us nicely to the end of our

[00:25:59] discussion on supporting someone to get back to physical activity and to sport after having a

[00:26:05] child. It's a complex area. You've done a brilliant job of breaking it down. So Dr. Jenna Schultz,

[00:26:11] thank you for joining me on JOSPT Insights.

[00:26:14] Thank you so much for having me.

[00:26:19] Thanks for listening to this episode of JOSPT Insights. For more discussion of the issues in

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