Dr. Alicia Ferriere joins the podcast to discuss physical and pelvic therapy during and after pregnancy. She explains how pelvic physical therapy can focus on helping patients return to sports or exercises that they love as well as some common issues she sees in patients. Connect with Alicia online at fortifypt.com or on Instagram, @fortify_pt.
“Physical and Pelvic Therapy in Pregnancy and Postpartum: Preventative Care!” – with Dr. Alicia Ferriere
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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics on women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB/GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. Welcome, Alicia. How are you doing?
Alicia: Doing good this morning. How are you?
Dr. Fox: Good. I’m so happy you were able to join me in this early morning to record for the podcast. You’re taking the time to talk to our listeners about physical therapy, about pelvic physical therapy, about active women during and after pregnancy. A lot of stuff we’re gonna cover today.
Alicia: Yeah, I’m very excited. This is what I do. So I’m excited to talk about it.
Dr. Fox: Wonderful. So, just for our listeners to get a sense of who you are, give us like a brief story, you know, where you’re from, how you got into physical therapy, and all of that.
Alicia: Yeah. So, I’m originally from New Jersey.
Dr. Fox: Yay, go New Jersey.
Alicia: Yeah. No, not far. So I currently live there but I, actually, I work in Manhattan now, so I never left the coop too much. But my intro to PT really started when I was…I grew up as a dancer, a ballet dancer and, you know, going along with that comes a lot of injury. So, that was how I was introduced to it. Starting at college I was actually a biology major because I wasn’t exactly sure what type of medicine I wanted to go into. But from there, lots of observation and, you know, finding out what I really wanted to do. I love the aspect of physical therapy, of, one, how much I can move as a professional and, you know, keep movement as a big part of my life but also help people through movement and help people through, you know, really non-invasive means and help them be active and stay active that way. So plus I get to talk to people all day which is something that I really enjoy
Dr. Fox: You’re a schmoozer, you’re a talker.
Alicia: Absolutely. A big-time schmoozer, I love…a big people person.
Dr. Fox: Where did you do your training for PT, for physical therapy?
Alicia: Undergrad I did at University of Delaware, grad school, I did here inner city at Columbia.
Dr. Fox: And were you training at the time where getting a physical therapy degree was a doctorate degree or is a doctorate degree?
Dr. Fox: I don’t think people realize how much education and training goes into being a physical therapist nowadays, maybe as compared to before. Can you just, like, let everyone know what you had to do to finish? It’s pretty crazy.
Alicia: So, the profession has really evolved over, you know, the past several years. So, it went from a bachelor’s to a master’s to a doctorate relatively quickly in the span of, you know, the time. So for me, I had four years of undergrad and then went straight into a, like, accelerated clinical doctorate program that was three years, maybe three and a half really. And that is lots of…you know, it’s completely full-time didactic, and lots of clinical work. The clinical work varies based on the program, which is actually why I chose Columbia because I had a lot of clinical work, which I really valued, and then yeah, you come out really with a very broad knowledge, and then from there, you can start to figure out where you wanna go. I think the thing with physical therapy is, you know, you can do it in a hospital setting which is really quite different from the outpatient orthopedics which is also very different from neuro. So, there’s many different routes that you can take and then there’s pediatrics, there’s many, many specialties. But you come out of it with a pretty broad knowledge of how to treat a little bit of everything and then you go on…go from there and specialize as you want.
Dr. Fox: Right. And so, when you finished your initial stage of training, you’re already Dr. Alicia Ferriere. You’re a doctor of physical therapy. And what additional training did you do? Like, which direction did you go after your time at Columbia?
Alicia: Yeah. So, I had a little bit of Pediatrics background maybe because I was really…I think development is just really interesting. So I did a little bit of that at Columbia. And then from there, I knew I wanted to go into orthopedics. So I started to…I have a certification from the Postural Restoration Institute, which is this school of thought that really focuses on biomechanics, natural asymmetry, how your nervous system kind of keeps your postural system in check. Once I came out of school, I started to get really heavy into more orthopedic-based clinical training. So there’s…you know, I have a few certifications in functional exercise and applied functional movement. I have a certification from this place called the Postural Restoration Institute, which really focuses on alignment and natural body asymmetries. And from there I’ve started to also really, really get interested in the pregnancy, postpartum and pelvic floor, women’s health world and have continued to since taking education from there. I still keep a very, very strong orthopedic education background. Like, I literally just took a course a couple of weeks ago that was a dissection course just to really kind of further my understanding of not only the pelvic floor, but full anatomy, and really kind of understand a little bit more of how things are working in a system. So, you know, different avenues, very orthopedic-based, very women’s health focused with the attention of trying to keep myself as holistic as possible.
Dr. Fox: How did you get interested initially in pregnancy and postpartum space, so to speak?
Alicia: So, at my previous job, I was actually in a very running-heavy, athletics-focused clinic, which was super fun, really great patient population. And I found in that space, I had a lot of both pregnancy and…both pregnant and postpartum patients that really just didn’t have a lot of guidance on how to manage their exercise or how to get back into running, or maybe they were having some sort of, you know, issue within…like, physical issue within the pregnancy that they weren’t sure what to do. So I was like, “Oh, this is an opportunity for me to really educate these women and help them in very easy ways.” And so from there, that’s where I really started to dive a little bit deeper into the pelvic questions we have in…like, in PT school, you’re given a little bit of it and I think it really varies on the program, you’re given a little bit of it, but the training is much more on the continuing education, postgrad end, so I wanted to further my education in that in particular.
Dr. Fox: You know, it’s interesting we had on last year a physical therapist who specializes in pelvic therapy, but her practice sounds a lot different from yours. Hers is a lot related more to pain, for example, some incontinence as well, but it wasn’t focused so much on athletes who are running a lot and having pelvic floor from pregnancy because of that. It was really, really much more, I would say, related to pain. She would see, like, a lot of young women who had pain with sex, for example, that was a lot of what she was treating, you know, vaginismus and whatnot, but it sounds like your focused more on the sort of athletic component of the pelvic floor. Is that accurate?
Alicia: Yeah, I mean, I definitely treat the, you know, the vaginismus, the pain with sex, all of that. I did find though that there was like a…sometimes with pelvic floor, there can be a little bit of a gap between treating the pelvic floor and then treating it as a unit and getting that back into function of whatever sport that they wanna do. So, I definitely try and be all-encompassing or give as much as I can to treating the acute issue, whatever that might be, whether it be incontinence, or, you know, pelvic pain, even, you know, pain postpartum and trying to make sure that they feel comfortable, and understand how to get back into whatever type of exercise they wanna do.
Dr. Fox: And how did your practice grow in this, meaning, was it just something that once you started doing it, everyone came out of the woodwork, or did you have to specifically advertise for it?
Alicia: No. Yeah, it was super organic. It was kind of awesome. I started at my previous job, but word just kind of got around and, you know, New York City is full of these little run groups and exercise groups and people who do all this stuff together, so it, kind of, it spread pretty organically. I definitely gave a few presentations on it and, you know, try and put the word out there a little bit. But people really are kind of seeking out this type of information, so I think when it was presented it was easily received.
Dr. Fox: Let’s focus now on, in pregnancy, what are women coming to see you for? Like, what kinds of issues or complaints or pains or problems do they have, where they would seek you or, you know, one of your colleagues for physical therapy?
Alicia: So, it can really start from something, you know, basic as like just pain, you know, they have sciatic pain, low back pain, SI joint pain, really like the basics of why people seek PT period is usually because they’re in some sort of physical pain. That’s a pretty standard one that people tend to seek me out for, kind of almost feel reassured that it’s not just something they have to handle because they’re just…they’re pregnant, but it’s like, “Oh, you have back pain. This is what you have to manage for the next six months.” It’s like “No, there are definitely things that you can do to work through that.” Beyond that people can come in if they are trying to remain active in a particular way. So, if they’re trying to either stay active running and they want some guidance behind that, or, you know, even…I’ve had people who are like how do I modify my Pilates or my yoga stuff with the…keeping in mind that they want to keep the pelvic floor healthy, and there’s a lot of concern around diastasis and how to prevent for that. And then also, too, I have some people coming wanting to really prep for the labor and delivery process, which can really look different depending on the person, but some of that sometimes, that can involve perineal tissue stretching and making sure that the pelvic floor is…that they are in tune with the pelvic floor and that they understand how to contract and relax and mobilize it so that the muscle tissue stays healthy for that labor and delivery process.
We can also go through how to, like, generate force downward, which some people have a really easy time with, and some people maybe with not so great mind-body connections have a difficult time with. Ultimately in that process, you know, their body kind of takes over. But I find that a lot of the times, if someone goes into that process with confidence, that like, “Okay, I think I know what’s going on here,” they feel much more in control over the situation.
Dr. Fox: So it’s really interesting, you’re talking about almost two different populations of pregnant women. One of them come to see you because there is a problem, right? They’re having pain. And either they, I guess they find you however…maybe their doctor refers them to you or whatever it might be, and then you sort of, you know, assess them, where’s the pain, why is there pain, and focus on, you know, exercises and stretches and strengthening and all the things that you do to help alleviate that pain, versus the group that find you sort of as maintenance or as preparation, meaning, I’m fine now but, you know, I run 6 miles a day, and I wanna continue to run while I get more pregnant and, you know, not hurt something or, you know, not trip or whatever it might be or in preparation for labor. What percentage do you practice now of pregnant women, let’s say, would be the former, the ones who come because of pain, versus the latter, the ones who are coming sort of to prep for something else?
Alicia: Honestly, it is much more of the latter. Like I think…
Dr. Fox: Wow.
Alicia: Yeah. Which is awesome. I find that that…like, I love the proactive approach of, like, you know, this is what I wanna do, and I wanna stay healthy. And I find too a lot of people, there’s a lot more of the pelvic floor awareness, especially postpartum. So, sometimes I see people just once because they wanna kind of form a little bit of a relationship and be like, okay, this is what my baseline is so that when I come in postpartum, we know what we’re kind of working with and we know that just like a baseline of where they’re at. But I would definitely say a lot more…you know, aches and pains come up, don’t get me wrong, but I think to seek out my services is much more of the preventative or, you know, maintenance type patient.
Dr. Fox: That’s so cool. And again, how do they know to even find you, to seek you out? Is it someone like a physician recommends it or it’s usually just, you know, family and friends and running groups and Facebook and those types?
Alicia: Yeah, it’s a little bit…sometimes, like, I’ve had some people come from their physicians, but oftentimes, it’s more like their acupuncturist, or their Pilates instructor or a little bit more of the word of mouth really.
Dr. Fox: Wow, that’s pretty cool. So, let’s say someone’s coming to you and, again, they’re athletic, what are sort of the top high-level things you go over with them, or work with them on or teach them to help them remain athletic during pregnancy?
Alicia: So it depends on, like, what their activity is, right? If they’re a runner, we’re going to look at their one form and just be like, “Okay, what is going to change?” because ultimately, you know, throughout the course of pregnancy in any person, their postural system completely changes, their center of gravity changes, how they compensate for that change is really unique per person. You know, there’s the standard, typical compensations that you would see because the baby only grows one way really, only in the abdomen, and it’s only one spot, that change in the center of gravity is going to maybe affect whatever they wanna do. So like I said, if it’s running, we’re gonna talk through how to maintain control in their run form, like maybe they need a little bit more knee drive, maybe they need to lead with their pelvis a little bit more versus letting the belly fall, like, fall forward, simple cues like that. And again, if they’re lifting, we go through lifting mechanics with that change in mind and how to…more so how to, like, keep them doing what they want with modifications that are gonna allow their muscular system and then to, like, as a person, to stay healthy.
Dr. Fox: Wow. Do you find that for the women who are seeking you out, that their expectations are greater than you think is appropriate or less than you think is appropriate? Meaning, are they coming to you saying, “I’m trying to run the Ironman,” and you’re like, “Dude, back off,” versus the, like, “Hey, I’m a big runner. Can I walk down the block?” and you’re like, “No, you can run.” Because people are always, you know, asking me these questions and it’s people are always in one direction to the other. It’s so fascinating. I’m just curious, what’s your experience been?
Alicia: Yeah, it’s a little bit of both. Like, I find less so probably the people that are like, “Oh, no, I’m running the Boston Marathon while you’re doing this.” It’s like, “Okay, well, like, let’s talk about how that’s gonna look.” Like it’s probably fewer of those people versus, like, more of a generalized hesitancy towards what they can do. It’s more of, like, how do I get there safely? And most of the time it’s like boosting them, being like, no, if you did this before, you can say after there might have to be some modifications to it and we can talk through what that looks like, but oftentimes, it’s more of that versus the person who’s trying to do all the things while they’re still pregnant, or even really, really soon postpartum, then I have to [inaudible 00:15:34] a little bit.
Dr. Fox: Yeah. I think that, in my experience, there’s definitely more women who underestimate their ability to exercise during pregnancy, or maybe not just ability, but the sort of, like, the allowance for it, meaning…because there’s so much messaging from doctors, from, you know, whatever, the general public that pregnant women are very delicate, and should not exercise and just, you know, lie in bed all day and drink green smoothies, or whatever it might be and that’s it. And I think that, okay, like there’s obviously like you said, there’s some modification that has to take place, and there has to be some, you know, thinking about it, but most pregnant women can exercise. And again, it’s really not getting hurt, it’s not so much the cardiovascular, the business with the heart rate’s a bunch of [inaudible 00:16:20]. It’s really just, you know, it’s making sure that they can stay fit, without injuring themselves because as you said, the body changes in pregnancy, both, you know, sort of physically in an obvious way, but also the joints change and the laxity of the joints change, and people’s posture changes. So their back changes, like, everything sort of changes. And so I think that some people can just figure it out on their own, and they sort of use their…you know, the cues from, you know, what hurts and what doesn’t, and sort of adjust. But I can see why it’d be really helpful to proactively, you know, see a professional to say, “Hey, I’m thinking of continuing to run,” and you talk about, “Okay, let’s talk about your gait, let’s talk about your speed, let’s talk about, you know, what shoes you wear.” I mean, there’s a lot of things that might have to change that you don’t think about. That’s pretty cool. I like that. I like that people find you for this.
Alicia: Yeah. And, you know, it’s fun too, because oftentimes, that if we can… There’s particular muscles that get over lengthened in pregnancy, right? Like, no matter what, your ab wall is gonna get, like, get lengthened. It can’t not. Similarly, with pelvic floor, it’s taking way more of an intra-abdominal load than it has ever. So in those in particular, like, no matter what, if somebody’s seeing me during pregnancy, I’m making sure that they understand how to connect with those muscles, they understand that they can…it’s healthy to have them contract and relax and generate blood flow. And that’s how we keep muscles healthy. They like movements. So, sometimes I find that people are really afraid of using their abs during pregnancy, which is again just messaging in the community, but those abs like to be used, and they have to stay…that’s how the recovery postpartum is even easier is when things don’t atrophy and get, you know, deconditioned over the period of time. So, no matter what, like making sure that they know how to handle those muscles. I find that even if they’re not trying to run 5 miles a day or whatever, making sure that they can keep particular muscle groups healthy and balanced and keep their mind-body connection to those muscles, it can be super helpful to maintain stability along the pregnancy, but also have that connection postpartum that’s just there.
Dr. Fox: Yeah, I mean, people always say to me, “Well, I know that I can’t do crunches.” I’m like, “Why can’t you do crunches?” And I’m always, like, bewildered by that. They’re like, well, and they’ll sort of, like, pause, and they’ll say, well, it’s…they think for a while and they’re like, “It’s gonna hurt the baby.” And I’m like, “No, it’s not gonna hurt the baby.” I’m like, “Well, how’s that gonna hurt the baby? Like, it’s, you know…I get it, like, people don’t…they don’t spend a lot of time thinking about this and they’ve been told you can’t work your abs during pregnancy, and it’s the opposite, you probably should work your abs because those are the ones that are really gonna stretch out, and, you know, getting thinner. And also, there’s such an important part of the core and if you don’t work your abs, your back might hurt. And so, it’s all connected. I mean, these things are connected one to the other somehow. And it’s, you know, I know you know how but it’s really…it’s important so people, you know, who are doing things like yoga or Pilates or some sort of core workout, their backs tend to be a lot better when they’re pregnant. They don’t have as much because they’re really keeping that area, you know, strengthened and healthy and it’s helping keeping their posture upright, as opposed to just the weight of the pregnancy pulling everything forward.
Dr. Fox: Wow, cool stuff. So, what do you do for women during pregnancy in preparation of the pelvic floor that’s gonna get altered during delivery, let’s say, for lack of a better word.
Alicia: Altered. Kind of similar to the abs, it’s just another set of muscle groups, I think sometimes people forget that. You know, it’s just it because of the location and where it is, like, obviously, it’s a huge function of bowel and bladder and sexual function, but also, like, it controls a lot of intra-abdominal pressure and that’s a lot of force during pregnancy. So, from a just exercise perspective, making sure that they understand, okay, this is how it contracts, this is how it relaxes, knowing how that relates to…especially maybe closer to that [inaudible 00:20:16] delivery point, knowing how that relates to labor and delivery, like, okay, we don’t want to contract, we want to make sure we’re opening and lengthening during that process. And, you know, I usually have my patients stop doing any sort of contract work for pelvic floor around like 33/34 weeks, just because there’s no need to kind of put more of that load into it, we just need to make sure that we can lengthen it out. So, first and foremost, the awareness because then again, that mind-body connection postpartum is really, really helpful for healing depending on, you know, whatever happens in the delivery room. And then beyond that, too, part of being a pelvic floor therapist is doing some manual work and having that, the…number one, a form of feedback for the patient, because in that case, you know, they could be a little bit disconnected.
So, you know, if they’re contracting, I can give them feedback of, like, “Okay, this needs to be a little stronger, or we need to work through the relaxation a little bit. It really depends on the patient. And then from there, we can do, like I said, some of that manual therapy for the perineal tissue to make sure that just like any other skin muscle tissue, it’s hydrated and it feels like it has give so that during potentially like a vaginal delivery, there’s a little bit more blood flow, a little bit more stretch to go around to hopefully…the goal is to prevent severe tear. And grade one, grade two, you know, really depend on the baby and the person but the more severe tears that require more recovery postpartum are what the goal of trying to generate blood flow, generate more muscle awareness and pliability in that area really, really [inaudible 00:21:49]
Dr. Fox: And when you say feedback, do you mean with, like, an exam, and you’re saying, you know, left, right, you know, more or less, or is it with sort of like a manometer or some sort of like pressure probe that you use?
Alicia: It’s usually with, like, a manual exam, like, my finger, but there are plenty of things on the market that you can use that you can play a game on your phone and be like, “Oh, this is what’s happening.” And it’s, you know, that biofeedback group.
Dr. Fox: Right. And so, in terms of women who come to you postpartum, I’m gonna ask you the same sort of percentages that I asked you before, how many are coming to you because, “I’m postpartum, I’m in pain, I’m having a hard time recovering, I’m having incontinence,” versus sort of maintenance, like, “I’ve had my baby, let’s sort of…what do I need to do to get, you know, back, you know, back in like, Pilates class or, you know, back doing my, you know, CrossFit or running or whatever it is?”
Alicia: So I would say that goes more maybe 50/50. Like, I find that, you know, it depends on what’s going on at home. Do they have support? Can they get out? Like, how are they handling new motherhood and whatnot? I do find that probably more often they’re coming because they’re having some sort of incontinence or pain with sex, or that…most of the time they are coming to me for that. I think it’s becoming more and more common for women to seek me out just to be like, “Okay, I know I wanna run in eight weeks, like how do I do that safely or…?” You know what I mean? Like, having that goal. But I do find that there’s usually some sort of pain associated with it. And then you have some people who are just like, “Oh, I know that I tore a little bit, can we, like, make sure my scar is mobile because I wanna have another child or make sure my pelvic floor is okay.” But definitely more…a little bit more balanced on that postpartum end.
Dr. Fox: Yeah, I think that makes sense because I think most women, if not all, are gonna have some sort of pain after delivery and a very high percentage are gonna have some sort of incontinence. I mean, fortunately, with time, a lot of it gets better, but not all of it, and it may not come as quickly as you’d like. So when you’re seeing her, is it normally within a couple of weeks after delivery, or normally you know, after four or eight weeks?
Alicia: You know, I kind of get…it’s a pretty wide variety. I usually tell, especially when I’m able to see them in pregnancy, and I know that they have a grasp on like, okay, you can start, you know, finding those abs as soon as you feel comfortable finding your pelvic floor and just like engaging those muscles, if I know that they have that, I’m like, “Give yourself four to six weeks just to heal and just to adapt to the fact that you now have an infant.” So most of the time, I’m not seeing people immediately postpartum. Just from a healing perspective, they need some time just to heal in general. But it does tend to lead into a little further down the line when they wanna get back into more intense exercise and these things are coming up and this uncomfortable or other…like, pain, incontinence or they wanna make sure that they’re doing it safely to not hurt themselves down the road.
Dr. Fox: Putting aside the women who want to get into more heavy exercise, so let’s just talk about sort of, you know, “typical births” women and whatnot, what would be your advice to women as to, okay, everyone’s gonna have some sort of symptoms after birth, right? Everyone’s gonna have some pain, maybe a little bit of incontinence here and there. At what point do you think they should start seeking you out or someone like you? I mean, at what point do you say, “All right, this is not normal, so to speak, or this is something that we treat,” is it like everybody with any symptom, or is it after X amount of time, or a certain amount of, like, severity? How would you advise women? And obviously, we’re totally cool with you saying they should see you right away, but, you know, what would you think is sort of…
Alicia: I’m a little biased.
Dr. Fox: Yeah, which is just fine. Okay, listen, I mean, you work with them, and you see the results and that’s great. But, you know, let’s see, not everyone can go to a physical therapist after birth. Like, what would you say is a good benchmark for women to know, all right, if this is happening, you probably should seek someone out?
Alicia: If there’s no, like…people heal really well, and that feels completely fine. I mean, there are in other countries like immediately post-birth, they get a script and they go to a pelvic floor PT, at least for an evaluation to see like, okay, what’s happening here, how can we help these muscles along. But I would say like after that four to six-week mark, like, if everything is cleared by your OB/GYN, and you’re still having discomfort, like, if they say you can go back to exercise, but you don’t feel comfortable, there are plenty of people that can help you get there. Or if you’re having pain, like, if there’s a significant amount of pain, and it doesn’t sit right, you know, whether that be a C-section scar, or, you know, in the perineum, if the vaginal tissue doesn’t feel great for any reason, even a little bit of guidance, whether it be one visit or a few can be really, really helpful.
Dr. Fox: What about with incontinence?
Alicia: So incontinence, I usually say, like, in the first couple, you know, week, like first couple of weeks, the pelvic floor is just like coming to, everything is coming back to its normal space, and all of that, I kind of go on the same route, like, if they’re still having incontinence and they’d been cleared by their doctor for exercise, that can be taken care of.
Dr. Fox: Yeah, I think that makes a lot of sense. I think it’s probably unnecessary in a routine situation to seek anyone out within the first four weeks, and probably after six weeks, if you’re still having pain or incontinence. Again, it may go away on its own, but that’s probably a reasonable time to seek someone out. Four to six weeks is sort of that gray zone, and also usually people don’t see their doctors at four weeks postpartum, it’s usually six. Why that is, whatever, it’s sort of random. But, you know, okay, so I’d say I think earlier than four is probably a little early and after six is probably really an appropriate time for women to seek you out. And what kind of things would you do with them to make it better, again, with incontinence or with pain after birth?
Alicia: So, definitely a pelvic exam, of seeing is the pelvic floor functioning how we want it to? Sometimes whatever the mode of delivery either…like, I find often with sometimes with C-section, the pelvic floor actually compensatorily gets really tight because the abdominal wall has been cut into and there needs to be a form of stability, so incontinence can be from a variety…it’s not always just weakness that can cause it, sometimes it’s the pelvic floor is too tight, there’s no give, so when you cough or sneeze, you know, there’s no room for anything to move. So, really kind of finding out why, like, figuring out what’s happening, as to what’s causing the incontinence, and then working on whatever that might be. So, if it’s too tight, we’d be like, okay, how can we make sure that the ab wall is a little bit stronger, that we’re working through lengthening the pelvic floor, making sure that we’re managing those pressures in the abdomen a little bit better. And if it’s weakness, okay, is the scar moving? Like, if there is a perineal scar or anything, like, is the tissue healthy and moving so that it can accept load and accept work in the right way?
Dr. Fox: And what about the other group of women, the ones who aren’t, let’s say, having symptoms, but the ones who sort of saw you during pregnancy, you know, prophylactically and now the same concept after birth, and they’re like, “Listen, I’m a runner, I wanna get back into running and I’m gonna come see you,” what do you do with them?
Alicia: So, making sure that they’re kind of starting out… Strength is the number one goal, even if your goal is running, if your goal is really anything because your body just went through an enormous muscular transformation, making sure that their body feels stable is 100% my first step. So key target muscles, like, in general, are gonna be your abs, your pelvic floor, making sure your hamstrings and your glutes are…everything’s keeping everything really solid. And then from there, starting to whether, like, for…I’ll use the example of a runner, starting to load the system in whether that be single leg and then starting to work towards a little bit more plyometrics, so jumping, making sure that the system can tolerate it because if they…you know, depending if they have to run in pregnancy because it didn’t feel good, okay, we have to recondition the system to adapt to those forces. And if for the pelvic floor, I know people are very…has hesitancy with running and the pelvic floor is that they’re gonna have prolapse or they’re gonna have leakage or whatnot, so really just kind of slowly but surely giving them a program that is challenging and loading the pelvic floor through jumping, plyometrics or weights, and then transferring that into more running-specific type things. So, doing some drills, making sure that everything feels good with that. And then getting back into a running program. I’m a huge fan of intervals for both pregnancy and postpartum in general. Like, it’s just such a better way to, you know, work the system.
So often you hear people, they’re like, “Oh, I’m just gonna go do a really slow mile.” It’s like, “Okay, well, what does that do?” When you go slower than you’re normally used to, your cadence slows down, your ground contact time increases, so the true, like, actual gravitational load on your body is pretty high compared to if you’re like, “All right, I’m gonna do a minute on and 30 seconds off.” When you’re running, you’re running and it feels there’s control in that. And then if you’re walking, you’re walking, and the gravitational load doesn’t really change very much. So, I’m all about intervals for not only trying to run during pregnancy, if it feels uncomfortable, but also getting back into it, plus it’s a great way to just cardiovascularly kind of train your system.
Dr. Fox: Oh, that’s so interesting. Now… Wow. That is really interesting. I never thought about it that way with the gravitational load and all that when you’re running slowly, that you’re hitting the ground a lot more in that sense.
Alicia: That could be a reason that people have incontinence with running postpartum is that they’re running slower than they’re used to and there’s just so much more, like, pounding on the body that, you know, when you’re normally running, the entire muscular system is like trying to be explosive in a sense, right? Like, everything is trying to get you to progress forward and up. But when you’re spending more time on the ground, there’s just so much more time, especially on a relatively lax system, right, like, all of the joints are a little bit more lax too, so the muscular system has to compensate even more than it’s used to. So if it can’t handle that load, that’s when things can start to go awry.
Dr. Fox: Well. And so, when people are coming to you for this, again, we’re talking about sort of the group without specific complaints or coming to just sort of get back into exercise and you talk about a program, is that something where they need to see you once or twice a week, or is it you sort of see them and check back with them in three weeks, you know, give them sort of like an exercise regimen? How does that work? I assume it’s tailored for every person, but what’s typical?
Alicia: Yeah. It’s definitely tailored for every person, but I’m usually not wanting to see them two times in a week, just because if they’re not coming to me for pain, if there’s nothing acute, like, that we have to work on, that requires, like, hands-on skill, and it’s more of just like, okay, let’s see how you’re adapting, you need time to be able to do that. So that might look like once a week for the first couple of weeks to really keep an eye on things and then have it spaced out, it could be every two weeks. Generally, if there’s no, like, acute pains that we have to work through that I’m, like, really wanting to keep my eye on, it’s much more spaced out because you need to have the time to, like, do the work and see how it feels. And oftentimes, you know, with new moms, finagling the schedule is also difficult as well. So, I try and give them as much time so that there’s not pressure to be like, “Uh-oh, I have PT next week. I have to make sure I, like, do my stuff.” You know, there needs to be that variability and adaptability,
Dr. Fox: I find that a lot of postpartum women also underestimate their ability to get active again. And frequently, this is because they’re told, “You’re not allowed to do anything until six weeks,” which I think is incorrect. I mean, obviously if you have a C-section, it’s a little bit different because just pain’s gonna limit you. I mean, you know, it’s not that it’s like dangerous to the body, it’s not like your incision’s gonna open up if you’re active, it’s just gonna hurt. And so, it’s not really…you know, it’s not gonna be enjoyable and it’s gonna limit you and you’re gonna be, you know, using other muscles sort of to compensate. It’s gonna be unpleasant. But for someone who had a vaginal delivery, you know, I usually tell them whenever you’re up to it, like, it’s fine with me. You know, I say start slowly, because obviously, you wanna, you know, not, you know, injure yourself. And my general rule of thumb is, and this is true for women with a C-section, too, is if you’re doing something and it does not hurt you, it’s probably okay. But if you start, you know, pushing yourself to the point that you have pain, then probably you need to back off. And this is again during the first, you know, [inaudible 00:34:08]. There’s very few people who are doing any exercise in the first two weeks, three weeks. Some people feel great after two or three weeks and are ready to start. I would say most people are probably ready by four weeks, and they’re usually holding back because someone’s told them they have to hold back.
Alicia: Exactly. And, like, I find that, too, it’s like, well, if you…you know, what’s your definition of exercise? You’re squatting down to pick up the baby multiple times a day. You’re doing all these things. Like, you know, that’s work, that’s load and if you feel good, that’s your body’s way of being like, okay, maybe let’s, like, go for a longer walk or whatever it might be. Like, I think some…that six-week mark is very…it’s just a number, right? So, it depends on how your delivery was. And some people feel they still need a little bit more recovery. It depends on the person.
Dr. Fox: Yeah. Yeah, yeah. Birth can be rough to a lot of people, no question about it. It could really beat someone up and, yeah, there’s definitely people who need, well, more than six weeks to recover physically, from their birth. And I do think it’s really more about, you know…I mean, it sounds, you know, kooky, but you know, the listen to your body stuff, it’s true. You know, like, it’s real. You know, people, you get feedback from your body. You know, if you’re doing something and your body doesn’t like it, it’ll tell you, right, very quickly.
Alicia: Absolutely. I talk about this all time, like you know your body better than anyone else and it’s gonna tell you. The hard part is, is making sure that people listen to it, which depending…like, you know, with those people who are like, “Oh, I’m gonna run like this triathlon during pregnancy,” they have a history likely of like shutting down some of those signals, so in those cases, you’ve got to rein it in, but oftentimes your body will tell you what’s up, you’ve just got to listen.
Dr. Fox: So Alicia, all of our listeners are obviously now, you know, totally obsessed and infatuated with you. How could they find you?
Alicia: My business is called Fortify Physical Therapy. That website is just fortifypt.com. All my contact info is there. I’m located in Chelsea, in Manhattan over on 26th street. I am on Instagram as well, @fortify_pt.
Dr. Fox: Woohoo.
Alicia: I know. I’m trying to up my Instagram game. I’m trying to do my best.
Dr. Fox: And what was it? Sorry, I interrupted your…whatever it’s called, your tag, your hashtag, your address, whatever you call it in Instagram.
Alicia: Oh yeah, @fortify_pt.
Dr. Fox: Beautiful. Alicia, thank you so much for coming on the podcast. This is really enlightening to me. And I really love the idea of preventative care for women who are pregnant or postpartum. Again, if you have the time, if you have the, you know, the means, if you have the wherewithal to sort of get ahead of a lot of this, I think it can be really beneficial. And for those who can’t, or don’t, or won’t, obviously if things start hurting or you’re having, you know, symptoms, it’s important to be on them pretty quickly, because they’re usually treatable if you focus on it and see the right people. So I’m really happy that you exist for all my patients, that’s for sure. And also for our listeners, you know, many of whom either they can see you personally or someone like you around the country, around the world, wherever they are.
Alicia: Yeah, absolutely.
Dr. Fox: Wonderful. Well, thanks for coming on the podcast. We will see you around.
Alicia: Thank you so much.
Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at email@example.com. Have a great day. The information discussed in “Health Woman” is intended for educational uses only. It does not replace medical care from your physician. “Health Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan. Paid sponsors of the podcast are not involved in the creation of the podcast or any of the content. Support for our sponsors should not be interpreted as medical advice from the podcast, the host or the guest.