Healthy Habits: Pelvic and Back Pain in Pregnancy and Postpartum

 Dr. Helene Darmanin, PT, DPT, CSCS, is the founder of Mama Bear Physical Therapy. She recently launched the site to provide personalized virtual care for all pregnancy and postpartum needs including ache/pain care, birth preparation, postpartum recovery and breastfeeding. 

Physical Therapy & Rehabilitation Journal found that up to 63% of pregnant women will experience pregnancy-related pelvic girdle pain and 8.5% of those women can continue to have symptoms up to 2 years postpartum.  Dr. Darmanin has worked with thousands of women helping them combat all of the changes our bodies go through.

I had a chance to interview her to learn more.

1.    What are some common causes of pelvic and back pain and what can pregnant women do?

Increased joint flexibility due to increasing estrogen levels throughout pregnancy, and change in posture due to weight gain can lead to low back pain or sacroiliac (SI) joint dysfunction

• Ideally, see a licensed physical therapist for a customized treatment, but if not possible, here are some techniques:
• Can wear a support belt, e.g. the Serola, to help stabilize and offload the SI joint and decrease the work that the muscles have to do
• Use a pillow between the knees when sleeping on your side
• Address with strengthening and dynamic stretching, here are some of my favorites:
• Dynamic lunge stretch
• How to do this
• Stand in a long, high lunge with the back leg straight and far enough behind you that the back heel is off the ground
• Keep the front leg bent to the same depth and the back tall as you bend the back knee, and then straighten it back to the starting position
• Why to do this?
• This stretches the rectus femoris, which is a hip flexor and quad muscle
• The rectus femoris is often very tight from sitting and can cause back, hip or knee pain if too tight
• In pregnant folks this is extra tight because as the girth of the abdomen increases, the pelvis tilts forward and shortens this muscle
• Open book
• How to do this
• Lie on your side with your knees bent and arms reaching out in front of you
• Open the top arm like a book, allowing your chest to rotate open with the arm
• Try to keep the hips stacked and look back towards the hand as it opens (we have a spinal reflex that allows us to rotate further in the direction that we're looking)
• Return to the start and repeat
• Why to do this:
• This mobilizes the thoracic spine/upper back (any vertebrae that have ribs attached to them)
• The thoracic spine is often tight from sitting/looking at computers or phones
• The spine is built to transmit force through all its 33 segments--if the middle (thoracic spine) of it is tight then motion becomes concentrated in only the neck and lower back, causing stress in those areas, which can also cause discomfort in the hips and shoulders. We transmit force from the ground up our skeletons when we walk, so we want to disperse that force as much as possible to prevent discomfort and injury
• In pregnancy, the upper back becomes tighter because of the changing posture and increasing abdominal girth. This stretch can help relieve that tension and decrease stress on the lower back
• Sit to stands:
• How to do it
• Sit on a firm surface such that your feet are firmly planted on the floor and about hips’ width apart (the lower the surface, the more challenging this will be
• Stand straight up, and then sit back down
• Try two sets of 10 repetitions
• If easy, do the same motion without actually sitting down in the middle
• Towards the end of second trimester and third trimester you can take the legs wider apart
• Why to do it
• This squat motion uses over 200 muscles, including the glutes which are the largest muscles in the body and play an important role in supporting the lower back and pelvic floor
• Clamshells
• How to do it
• Begin laying on your side with your knees bent and your pelvis square forward (one hip stacked on top of the other). 
• Open the top knee like a clamshell without changing the position of the pelvis (just the thigh bone rotating in the socket), then close the knee with control. 
• Repeat, and try two sets of 10 repetitions.
• Why to do it
• Strengthens muscles that stabilize the hips, pelvis, lower back, and SI joint, one of which helps form the side of the pelvic floor
• Round ligament pain
• The round ligament connects the uterus to the groin and can become over-stretched and uncomfortable, especially during the second trimester as the uterus grows rapidly
• This can cause sharp pains in the front, side of the stomach, especially with sudden movements such as sneezing, or changing positions (such as getting off bed, etc).
• Ideally, see a licensed physical therapist for a customized treatment, but if not possible, here are some techniques
• Engage the abdominal muscles to relieve stretch in the ligament when changing positions by gently hugging the belly in towards the spine like a corset
• Flex the hips when sneezing, couching, etc (can bring knees to chest or lean the back forward so that there is less than 90 degrees between the belly and thighs)
• Exercise
• Cow spine: On hands and knees, gently extend the spine (allow the belly to descend towards the ground) and look up. Return to a neutral spine, and repeat.
• This stretches the front of the body to decrease the pull in the front of the belly
• Primal pushup: On hands and knees, gently tuck the toes under (like you would in a plank), then float the knees 1-2 inches off the floor while exhaling slowly, and without tucking the butt under. Pause for a moment, then lower and repeat. Try two sets of five repetitions to start.
• This strengthens the shoulders, upper back, abdominal muscles, and thighs
• Sit to stands (see above)
• Pubic symphysis dysfunction
• The pubic symphysis is where the two halves of the pelvis meet in the front. They are held together by very strong ligaments, which have more flexibility during pregnancy, and the resultant increase in movement can cause pain and discomfort
• Ideally, see a licensed physical therapist for a customized treatment, but if not possible, here are some techniques
• Try not to spread the legs too wide in any activities of daily living (the inner thigh muscles attach on either side of the pubic symphysis, so pulling them apart from each other increases strain on the joint)
• When getting into car, sit down on the seat, then swing both legs in together (reverse to get out)
• To get into bed sit down on the edge, then lean over to lay down on your side and bring both legs up at the same time, then if you need to adjust use your arms to help you roll over with the legs staying together (log roll)
• Exercise
• Primal pushup (see above)
• Sit to stands (see above)

 

2.    Why do women need to be aware of the effect that pregnancy has on pelvic floor muscles?

Pelvic floor muscles naturally tighten because of the increased downward pressure from the natural weight gain from pregnancy--but they need to be able to relax for vaginal birth (which a physical therapist can coach in preparation)

Need to relax post-birth if have Cesarean. Current thinking is that the pelvic floor is forced to relax the tension that has built up during pregnancy during a vaginal birth. Therefore, after a cesarean birth, the pelvic floor may stay tighter and cause issues, such as difficulty completely emptying the bladder, constipation, painful sexual intercourse, or hip or back pain. You should see a licensed physical therapist if that is the case.

Need to be aware of possible issues that can arise: a lot of these issues are assumed to be something that you "just have to live with" postpartum, but they are common medical conditions (completely without shame, like having diabetes or high blood pressure) that can be treated!!

• Urinary incontinence (leaking of urine or frequency of urination)
• Incomplete bladder emptying
• Constipation
• Painful sexual intercourse
• Pelvic organ prolapse
• Hip or back pain could originate from pelvic floor tension or weakness

 

3.    What are some exercises you recommend for mothers during the postpartum period?

• Breathing.
• The pelvic floor and diaphragm work together for breathing when you take deep breaths. Start laying down (then the pelvic floor isn’t working against gravity), and take 10 deep breaths which cause the abdomen to expand circumferentially (360 degrees).
• Progress to sitting, then standing

• Sit to stands (see above)
• Heel raises
• hold on a wall and raise your heels so that you are on tippy toe, then lower and repeat
• Calves are the primary muscle group responsible for propelling you forward in walking, so strengthening them decrease the force going through the body with walking
• Squeeze shoulder blades together
• Sit in a comfortable position with the spine up tall and gently squeeze the shoulder blades together, keeping the chest soft. Hold for ten seconds, then release and repeat 10 times total.
• Wakes up the postural muscles in the upper back, which are especially important if you’re nursing and have to sit up and hold a little one
• Bridges
• Lay on the ground with the knees bent and the feet flat. Lift the hips towards the ceiling on an exhale, keeping the thighs parallel and the chest soft away from the chin. Lower and repeat. Try one or two sets of 10 repetitions.
• Engages the glutes, core, inner thighs which help support the pelvis and lower back which can be very achy in the postpartum period, all in a position that is not stressful for the pelvic floor (not working against gravity)
• Just move--there is lots of fear mongering, but moving is always going to be better than not moving--as long as you breathe!
• Get help if you need it (e.g. something hurts)

DR. HELENE DARMANIN, PT, DPT, CSCS

Founder Mama Bear Physical Therapy

Orthopedic and Pelvic Health Physical Therapist

Kane School-certified Pilates Mat Instructor

Research Contributor

Author

Dr. Helene Darmanin is the founder and president of Mama Bear Physical Therapy, a personalized virtual practice clinic that provides orthopedic, pelvic health, lactation, and nutritional care and support for pre and postpartum women via personalized one-on-one sessions and virtual group classes. An orthopedic and pelvic -health physical therapist expert, with over a decade of experience, Dr. Darmanin is seen among her peers as the leader for her innovative, empowering, and steadfast approach to preparing and healing expectant and new moms.

 

Dr. Darmanin received her Bachelors in Exercise Science from Smith College and went on to complete her Doctorate in Physical Therapy at New York University. She was inducted into the Sigma Xi Honor Society.

 

Dr. Darmanin presented at the American Physical Therapy Association's annual conference, the Combined Sections Meeting in 2017. As a published researcher, Dr. Darmanin has contributed to two studies including: “Assessment via the Oculus of Visual “Weighting” and “Reweighting” in Young Adults”; and two books including: ““Brehm-Curtis, Barbara. Encyclopedia of Nutrition: Science and Application, ABC-CLIO” and “BrehmCurtis, Barbara. Psychology of Health and Fitness, Applications for Behavior Change. F A Davis Company”. Dr. Darmanin has been featured in prominent research journals and publications such as MyFitnessPal Blog, Journal of Human Kinetics, Institute of Electrical and Electronics Engineers Journal, NYC Birth Village Doulas, Mission Driven Podcast, and Healthy Wealthy Smart Podcast.

 

A proud Trekkie and pet parent to a rescued calico cat, when Dr. Helene Darmanin is not helping pre and postpartum women, you’ll find her testing out new recipes from the NYT Cooking app, reading fantasy novels, volunteering for her alma mater, Smith College, and spending quality time with her family.