GT, a 27-year-old primiparous caucasian professional netballer presented at four weeks post-CS for RTS screening and assessment of pelvic floor muscle (PFM) function. Her healthcare team included a sports physiotherapist, performance manager, coach, dietician, psychologist, obstetrician, sports physician, and pelvic health physiotherapist (author). GT consented to this case being published.
GT had been playing elite netball for 10-years and had no time off training or playing due to injury. Prior to childbirth, she had no prior urinary or anal incontinence, obstructive emptying or sexual health concerns during sport or daily life.
GT reported coping well throughout pregnancy and in the acute post-partum phase. Her weight gain during pregnancy was within normal range (11.5-16Kg) based on her pre-pregnancy body mass index. She experienced minimal medical, musculoskeletal, or pelvic health issues during pregnancy and continued to train non-contested with the netball team until 30 weeks gestation, remaining physically active until birth in line with current guidelines. She did not complete pelvic floor muscle training during pregnancy. There was no other relevant medical history.
GT underwent an elective low segment CS with standard wound closure due to breech presentation. There were no peri-operative or post-operative complications for mother or infant. Lochia stopped at three weeks post-partum. Breastfeeding was established on day four with no latching concerns, nipple, or breast discomfort. GT and infant were discharged on day five, a standard length of stay in an Australian private hospital. GT reported having a small pre-pregnancy breast size and an insignificant size increase. GT reported being well supported personally and by her team and team support staff. She reported her post-partum weight at her four-week initial review was 5Kg greater than pre-pregnancy.
At four weeks post-CS, she was walking 30 minutes daily at a casual pace and performing two sessions per week of three sets of light intensity unweighted squats and lunges (rate of perceived exertion 2-3/10). There was no itching, discolouration, or discomfort around the scar. She did not report any symptoms, nor bother related to her pelvic floor function. She had not returned to sexual activity. She reported general fatigue and an average of six to eight hours accumulated sleep per night. When asked, GT identified some concerns with RTS: "birth can cause pelvic floor muscle injury and prolapse and that it can get worse if you do the wrong thing".
Play in round one of the national competition at 16 weeks post-partum
Assess her individual PFD risk
Commence pre-season training at 12 weeks post-partum
Continue to exclusively breastfeed for the first six months post-partum
GT's history suggested a low predictive risk of PFD confirmed by the validated Australian pelvic floor questionnaire (APFQ) (Appendix A). Psychosocial screening evaluated factors known to influence RTS and post-partum wellbeing including post-partum depression and anxiety, sleep quality, readiness to return to sport, and fear of movement scales (Table 1).
Early post-partum physical performance tests were compared to pre-partum data (Appendix B) provided by GT's sports physiotherapist, and which were relevant to early intervention (Table 2). Evidenced-informed screening for high level neuromuscular performance in netball was planned to be completed by the sports physiotherapist at eight weeks post-partum. A summary of key examination findings is found in Tables 1 and 2.
GT did not meet diagnostic criteria for PFD such as urological or anorectal disorders, prolapse or pain syndromes or diastasis rectus abdominis (DRA). Given that the definition of PFM dysfunction requires patient concern and alteration in normal pelvic floor muscle function, GT's examination identified sub-clinical alterations in PFM:
Neuromotor deficits
delayed recruitment (voluntary and functional)
delayed relaxation
Reduced endurance with sustained and rapid contractions
Reduced power during a rise in intra-abdominal pressure (IAP)
Musculoskeletal screening identified reduced rectus abdominis strength (as per previously published testing guidelines), reduced lower limb strength compared to her pre-partum data (Appendix B) and reduced stationary balance testing of < 30seconds.
Biopsychosocial screening identified changes commensurate to four weeks postpartum including:
Moderate fear of movement
Belief that all women are at risk of PFD post-partum impacting her ability to RTS.
Stage one of GT's pelvic health physiotherapy management started in the immediate post-partum phase as part of a collaborative and criteria based RTS model (Figure 1). During this stage, the pelvic health physiotherapist directed case management.
Management was informed by time-based wound healing principles and criterion-based assessments such as asymptomatic response to exercise testing. During all stages, the patient was asked to keep a diary to record training, breastfeeding, sleep, and symptoms. Exploratory interviews with post-partum athletes suggest that social support, childcare, and training specificity are all enablers of successful return. The shared-decision and development of GT's netball-specific exercise program considered child minding, caring needs, lactation, and GT's availability while targeting optimal training dosage.
The focus of pelvic health physiotherapy intervention in Stage 1 was:
multidisciplinary engagement
education to reduce fear of movement and address PFD beliefs
sleep optimization
wound healing
PFM rehabilitation
Obstetrician clearance to return to a graded training schedule was given at six weeks post-partum. Nutritional and psychology reviews were initiated given their link to UI and RTS readiness, performance, and sleep. DEXA scans were undertaken as per the team's medical protocol for all athletes. For GT, this enabled monitoring of unattenuated axial bone loss associated with lactation and the consequent increased risk of bone stress injury.
Individualized education sessions provided clear, simple and evidence-informed knowledge that a CS is unlikely to result in pelvic floor muscle injury. This was facilitated by a lecture-style and teach-back approach that outlined the neuromuscular changes that occur in pregnancy and compare and contrasting modes of delivery. During the teach-back discussion and when asked GT reported reduced fear of PFM injury with RTS. Other major themes of generalized education were sleep optimization, feeding postures, bra considerations, and timing of physical activity around expressing.
Relative contraindications to early post-partum exercise were increasing longitudinal wound tension and wound pain (> 4/10). In the immediate post-partum phase, there is minimal scar integrity (< 30% tensile strength). Scar dressing with silicone tape and daily massage to reduce hypertrophic scarring were taught and patient self-efficacy confirmed. Abdominal wall compression wear during activity was recommended given it may be more effective than core-based exercise in the immediate post-partum phase for pain intensity and perceived function. Abdominal wall exercises were not specifically given, and wound pain was used to guide her response to general exercise. To minimize longitudinal scar tension, verbal and visual instructions were given to avoid trunk rotation and limit cross-body exercises.
There is insufficient evidence in pelvic floor rehabilitation guidelines regarding pain rating and training load early post-partum. In early post-partum studies, women reported no pain from commencing PFM exercises immediately post-birth, therefore early PFM training was commenced.
GT's PFM training program (Table 3) was developed in line with exercise prescription and PFM training guidelines to target GT's impairments and train specifically for the characteristics of netball. Netball requires endurance and repeated explosive effort (power). Athletes involved in impact sports have been shown to have, and require above, normal PFM strength to withstand the increased IAP that occurs with running and jumping. The aim of this PFM training program was to achieve hypertrophy, speed of muscle recruitment during explosive tasks and endurance. Verbal feedback, digital palpation and patient verbal confirmation of awareness were used in all prescribed postures to facilitate a correct technique. Early training (week 4) focused on repeated daily exposure to achieve neural adaptation with normalisation of motor recruitment and relaxation. Initial intra-vaginal pressure biofeedback (Peritron , discontinued, Cardio-Design, Victoria) was conducted to guide correct sub-maximal voluntary contraction and relaxation at her first session. Progressive daily PFM training has been shown to be effective in addressing PFM dysfunction with greater benefit from a combined strength and neuromotor program (Table 2, week 6). GT was shown how to self-progress her repetitions and postural load if the quality of PFM contraction was maintained. Progressive overload was achieved by increasing repetitions or increasing load by modifying task to challenge IAP demands. Recommendations were given to perform the strength-based exercise earlier in the day and the endurance-based exercise later in the day to allow for sufficient recovery. However, a shared-decision making approach was taken to optimise the likely times of exercise completion around breastfeeding and other childcare needs. Other strategies included metronome pacing and an activity diary to facilitate adherence.
At her week eight assessment, GT had reduced abdominal strength compared to pre-partum. With wound and abdominal fascial strength continuing to increase to 80% at 12 weeks, graded abdominal strengthening and trunk rotation activities were permitted, with continued scar taping and symptom monitoring. Insufficient evidence currently exists for best-practice abdominal wall strengthening post-partum. All women post-partum, with and without a diagnosis of DRA, have reduced abdominal wall strength compared to nulliparous controls, however the importance of this remains unknown. Expert opinion supports a focus on integrated abdominal wall control compared to isolated muscle strength variables. In consideration of an integrated approach to rehabilitation, initial abdominal wall exercise was prescribed as isometric lower abdominal wall activation in supine and quadruped postures as outlined in Berg-Poppe et al and progression principles were applied as outlined by Christopher et al. Given the lack of specificity identified in the literature for post-partum abdominal wall rehabilitation, exercises were progressed when able to achieve five sets of 10, with 15-second recovery periods as based on abdominal wall training guidelines for sporting injuries. Quadruped exercise was progressed to add in upper limb movement once perceived as easy by GT and confirmed by the physiotherapist that there was minimal trunk deviation, no compensation, doming or breath-holding during the task. Static exercise such as plank and side plank were progressed from knee based to full versions using the same criteria of observed quality and once achieving one minute endurance, five repetitions. The abdominal wall program was completed three non-consecutive days per week.
The PFM training program was progressed to focus on power training and netball-specific dynamic exercises to induce pre-active and supra-maximal PFM contraction (Table 3). This included PFM pre-activation with a cough, a five-meter chest pass at rapid speed, lunge to knee drive, and progression from double to single leg jumping to volitional failure. Throwing distance, weight, IAP demand and hop distance were progressed based on symptom monitoring and perceived levels of exertion.
Having attained normal PFM function and being asymptomatic during Stage 1 functional testing, GT commenced a return to run program at 10 weeks post-partum.
Ongoing PFM training was integrated into GT's conditioning sessions to maintain function following the 12-week training program. Her program included PFM control during multi-directional stepping/hopping to volitional failure and PFM endurance. GT was prescribed PFM training three times per week to align with exercise prescription guidelines for rest and recovery given her high intensity training load at this stage. Abdominal wall exercise included cross-body control with load and progressive balance demands, and ongoing plank and quadruped exercise. Scar taping was ceased. Throwing and catching drills with reaching outside base of support provided ongoing challenge for abdominal function.
The primary outcome was successful return to full match play at 16 weeks post-partum. Reassessment at six months post-partum identified improved PFM function. There was no injury reported during the season. GT continued successfully breastfeeding. As little is known about early post-partum recovery and the influence of high-impact activity, a six-month review identified no de novo PFD. A critical component of GT's successful RTS was communication between all stakeholders and consideration of all biopsychosocial factors. GT provided her perspective on RTS: "It has really helped having Netball (state) and the state team, they've been amazing." Her satisfaction with intervention:"It was really well planned out for me; it was very doable".