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Returning to Running in the Postpartum period. How do I know when is safe, and am I ready to start?

Written by our Pelvic Health Physiotherapist, Emily Parker


Is returning to running a goal of yours? For most running mothers, returning to running will be a very important part of their postpartum journey. However, after having a baby getting back into running is no longer just about finding the motivation, the time or the energy to put on your running shoes; it is actually about knowing if your body is ready to handle the load.


Recovery of your pelvic floor and abdominals muscles

There has been some incredible research recently into the importance of appropriate rehabilitation after having a baby before trying running for the first time. This is because of the changes your body goes through during pregnancy and then what happens during the delivery of your baby. We need to have appropriate time for tissues to heal, scars to heal and to re-build tolerance to increased load and impact safely. It is now understood that the pelvic floor muscles, associated connective tissue and nerves take 4-6 months to heal following an uncomplicated vaginal birth (Stær-Jensen et al, 2015), not like the 6 weeks that we previously thought. It is also now understood that abdominal fascia has only regained 51%-59% of its original tensile strength by 6-weeks post caesearean section and 73%-93% of its original tensile strength at 6-7 months postnatal (Ceydeli et al, 2005).


It is therefore important to not go back to running too soon. It is strongly advised that you follow a low impact training programme for the first 3 months, and that you wait at least 3 months, but for some women it can take 6-12 months to be ready before you try a return to running programme (Goom et al, 2019).


Pre-Screening

But how do you know if you're ready to try? Here is a little pre-screening list of requirements to consider first:

  • Has it been at least 3 months since you had a baby?

  • Have you had a postnatal check with a pelvic floor physiotherapist?

  • Have you been partaking in low impact exercise?

  • Are you experiencing any pelvic floor concerns - i.e. urinary or faecal leaking, prolapse symptoms (bulging, pressure or dragging), or any vaginal bleeding (unrelated to your menstrual cycle)?

  • Are you experiencing any musculoskeletal pain - ie lower back pain?

  • Are you experiencing any abdominal separation, doming or coning?

  • Have scars fully healed (c-section and perineal scars)?


If you have passed the prerequisites then the next thing you want to ask yourself is, is my body ready to tolerate the impact and load of running. Have a go at the following exercises and see how you feel:

  • Can you walk for 30 mins at a moderate pace without experiencing any pelvic floor or musculoskeletal symptoms (as described above)?

  • Can you challenge your pelvic floor muscles in standing?

    • 8-12 x 8 sec max holds

    • 10 x quick max pulses

    • 60 sec low level hold (30-50% contraction)

  • Is your body strong enough? Can you perform the following exercises?

    • 20 x single leg calf raises

    • 20 x single leg bridges

    • 20x side lie hip abduction

    • 20 x single leg sit to stands from a chair

  • Is your body able to tolerate the load? Can you perform the following exercises?

    • 10 sec single leg balance

    • 60 sec jogging on the spot

    • 10 x hopping on the spot on each leg

    • 10 x forward bounds

    • 10 x ‘running mans’ on each leg


What Other Factors Should You Be Considering?

Returning to higher level activity is not just about how strong your body is. There are many aspects to your postpartum recovery which you should be considering:

  • Weight: Women are considered at a higher risk of pelvic floor related symptoms if they have a BMI >30 (Pomian, 2016). Therefore working on weight management prior to returning to high impact sport is important for pelvic floor and musculoskeletal health.

  • Mental Wellbeing: How has your mood been? Are you showing any signs of Postnatal Depression, and if so are you seeking appropriate support?

  • Scar Mobilisation: both c-section and perineal scars can result in pain and restriction, as well as alteration of mechanical function of your muscles (Tomasek et al, 2002). Proposed benefits of scar mobilisation include reducing inflammation, fibrosis, and improving tissue remodelling (Benjamin et al. 2008).

  • Breastfeeding: breastfeeding prolongs the presence of a hormonally altered environment, with lower levels of oestrogen and the possibility for slightly raised levels of relaxin to continue, which may increase the mother’s risk of developing injury or dysfunction, including pelvic floor dysfunction or pelvic organ prolapse (Marnach et al, 2003). Having said this, it doesn’t mean you can’t return to running, but assessment of joint laxity and potential risk of injury by a physiotherapist is strongly recommended.

  • Supportive clothing: women may benefit from wearing a personally fitted sports bra that offers support rather than compression (McGhee et al. 2013) as this provides significantly increased breast and bra comfort compared with a standard sport bra during exercise. Supportive footwear is also very important when returning to running after having an extended period off. Wearing clothing that provides extra support to your abdominals and perineum has also been shown to reduce the risk of stress urinary incontinence (Okayama et al, 2019).

  • Sleep: sleep is key for recovery from both physical and psychological stress and is frequently restricted in the post-partum period and beyond. Day-time naps can be used to extend sleep and reduce the effects of sleep deprivation (Bird 2013). It can be challenging to increase sleep time so it’s important to optimise sleep quality by creating a relaxing routine to prepare for sleep. This includes reducing stimulation from ‘screen time’, creating a cool, comfortable sleep environment and avoiding consumption of alcohol or caffeine (Bird 2013).


If you are concerned about any of the above factors, discussing these with your GP or pelvic health physiotherapist is advised.


It is also helpful to focus on ‘What you CAN do?’ Set some realistic, short term, achievable goals that can help with motivation and keep you moving closer towards your ultimate goal of returning to running:

  1. Improve physical and mental wellbeing.

  2. Education - importance of postnatal rehab and graded return to running

  3. Improve pelvic floor and abdominal function

  4. Build strength and fitness

  5. Facilitate safe return to sport


Returning to Running

If you have passed all of the prerequisites and considered the additional factors then you may be ready to try your first run! It is important to take it slow, pick a short, flat route, and consider doing interval type training - alternating between walking and running to ease into it slowly. Setting a return to running plan with a healthcare professional will make this process smoother and reduce the risk of injury.


If you are able to start introducing a bit of running again, follow the below steps to gradually increase your load and tolerance without risk of injury:

  1. It’s important to be able to walk before you run! When you first start running, consider doing walk/run intervals, gradually increasing your running distances until you can run consistently for 30 mins. Building training volume (e.g. running distance/time) prior to increasing training intensity is recommended. A ‘couch to 5km’ programme can be helpful

  2. Try to think about returning to running postpartum in a similar way to recovering from an injury. Take it slow. Heaviness, dragging, incontinence or moderate to severe pain may suggest you have overdone it and you need to take a step back.

  3. Try to avoid running on consecutive days. Allow your body to rest and recover. You could also consider cross training, complementing your running with swimming or cycling to give your body a break from the impact.

  4. Continue with regular strength training as part of your running programme, ensuring you also incorporate pelvic floor and abdominal exercises. And don’t forget to stretch!

  5. Aim to increase your distance by 10-30% every 2-3 weeks. Then every 3 weeks, reduce your mileage by 30% to absorb the stress and work on speed.


Take home message

Here at The Pelvic Health Physio we strongly advise any new mums to come for a screening of their pelvic floor and general physical health before returning to higher level exercise - this does not just mean running, but also weight lifting, HIIT training, team sport etc. Equally, if you have already tried to return to activity and you are concerned that something doesn’t feel right, it’s never too late to be assessed by a pelvic health physiotherapist.


Allowing your body the appropriate time to heal and regain strength, and for you to settle into a new routine, focussing on sleep, nutrition and mental wellbeing will mean you can get back to your goals with reduced risk of injury and increase the chance for success.


Everyone’s postpartum journey is different. Take your time, listen to your body and most importantly, remember that you are doing an incredible job! There are many steps you can focus on prior to running, and we are always here to help.




References

Bird, S. (2013). Sleep, Recovery, and Athletic Performance. Strength and Conditioning Journal 35(5), 43-47.


Ceydeli, A., Rucinski, J. and Wise, L. (2005) Finding the best abdominal closure: an evidence-based review of the literature. Curr Surg 62, 220–5.


Benjamin, D.R., Frawley, H.C., Shields, N., van de Water, A.T.M. and Taylor, N.F. (2018) Relationship between diastasis rectus abdominis muscle (DRAM) and musculoskeletal dusfunctions, pain and quality of life: a systematic review. Physiotherapy, in pres. [www.document]. URL https://doi.org/10.1016/j.physio.2018.07.002.


Brækken, I. H., Majida, M., Ellström Engh, M. and Bø, K. (2015). Can Pelvic Floor Muscle Training Improve Sexual Function in Women with Pelvic Organ Prolapse? A Randomized Controlled Trial. The Journal of Sexual Medicine, 12(2), 470–480.


Goom, T., Donnelly, G. and Brockwell, E. (2019) Returning to running postnatal – guideline for medical, health and fitness professionals managing this population. [https://mailchi.mp/38feb9423b2d/returning-to-running-postnatal-guideline]


Marnach, M. L., Ramin, K. D., Ramsey, P. S., Song, S. W., Stensland, J. J. and An, K. N. (2003) Chatacterization of the relationship between joint laxity and maternal hormones in pregnancy. Obstetrics & Gynaeocology 101(2), 331-335.


McGhee, D.E., Steele, J.R., Zealey, W.J. and Takacs, G.J. (2013) Bra-breast forces generated in women with large breasts while standing and during treadmill running: implications for sports bra design. Appl Ergon 44(1) 112-118.


Okayama, H., Ninomiya, S., Naito, K., Endos, Y. and Morikawa, S. (2019) Effects of wearing supportive underwear versus pelvic floor muscle training or no treatment in women with symptoms of stress urinary incontinence: an assessor-blinded randomized control trial. Int Urogynecol J [Accessed online 24/02/19] https://doi.org/10.1007/s00192-018-03855-z


Pomian, A., Lisik, W., Kosieradzki, M. and Barcz, E. (2016) Obesity and Pelvic Floor Disorders: A Review of the Literature. Med Sci Monit 22, 1880-1886.


Stær-Jensen, J., Siafarikas, F., Hilde, G., Benth, J.Š., Bø, K. and Engh, M.E. (2015) Postpartum recovery of levator hiatus and bladder neck mobility in relation to pregnancy. Obstet Gynecol 125, 531–539.


Tomasek, J.J., Gabbiani, G., Hinz, B., Chaponnier, C. and Brown, R.A. (2002) Myofibroblasts and the mechano-regulation of connective tissue remodeling. Nat. Rev. Mol. Cell. Biol. 2(5), 349-363.


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