Rehabilitation of the Postpartum Runner: A 4-Phase Approach : Journal of Women’s & Pelvic Health Physical Therapy

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Clinical Commentary

Rehabilitation of the Postpartum Runner: A 4-Phase Approach

Christopher, Shefali Mathur PT, DPT, PhD1,2; Gallagher, Sandra PT, DPT3; Olson, Amanda PT, DPT4; Cichowski, Sara MD, FACOG5; Deering, Rita E. PT, DPT, PhD6

Author Information

1Department of Physical Therapy Education, Elon University, Elon, North Carolina.

2Discipline of Physiotherapy, School of Health Sciences, The University of Newcastle, Callaghan, New South Wales, Australia.

3Department of Rehabilitation, Oregon Health and Science University, Portland.

4Intimate Rose LLC, Medford, Oregon.

5Department of Female Pelvic Medicine and Reconstructive Surgery, Oregon Health and Science University, Portland.

6Department of Physical Therapy, Carroll University, Waukesha, Wisconsin.

Corresponding Author: Shefali Mathur Christopher, PT, DPT, PhD, Elon University Department of Physical Therapy Education, Campus Box 2085, Elon, NC 27244 ([email protected]).

Sandra Gallagher, PT, DPT, has received honoraria from the Academy of Pelvic Health of the American Physical Therapy Association, Physical Therapy Association in Washington, and the Idaho Occupational Therapy Association. Amanda Olson, PT, DPT, receives income from Intimate Rose and honoraria from the American Physical Therapy Association Academy of Pelvic Health. Shefali Mathur Christopher, PT, DPT, PhD, Rita E. Deering, PT, DPT, PhD, and Sara Cichowski, MD, FACOG, have no conflicts of interest to declare.

This clinical commentary is dedicated to Kimberly (Kim) Seymour, PT, DPT, who was the inaugural and current director for the Pregnancy & Postpartum Special Interest Group of Academy of Pelvic Health Physical Therapy. Kim's passion to improve maternal care is the reason this commentary exists. To honor Kim and her leadership in this field, we hope that each reader can use this document to improve health and wellness in the perinatal population.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (http://journals.lww.com/jwhpt/pages/default.aspx).

Journal of Women's Health Physical Therapy 46(2):p 73-86, April/June 2022. | DOI: 10.1097/JWH.0000000000000230

Abstract

BACKGROUND

Running is becoming more popular during and after pregnancy. About 70% of runners who become pregnant continue to run during pregnancy.1 After childbirth, runners commonly resume running between 2 weeks and 2 months postpartum.1,2 Runners who are postpartum have reported pelvic floor dysfunction and musculoskeletal pain2–5; however, running also produces psychological and physiological health benefits, including reduced risk of premature mortality and cardiovascular disease, improved endurance, and weight management.6,7 Because of these benefits, and the ease of access to running, it is important to facilitate return to running after childbirth. Health care providers and people who are postpartum increasingly seek guidance on resuming running after childbirth. While high rates of running-related injury (RRI) have been reported in the general population,8 scientific evidence on resuming high-impact exercise after childbirth is lacking.9,10

Pregnancy and childbirth produce unique changes in the muscles and ligaments of the pelvic floor, trunk, hip, and foot, which could affect running form.11 Childbirth itself can result in major musculoskeletal changes that should require rehabilitation to return to sport like other major injuries.12 However, people are initiating or returning to running after childbirth without guidance. Despite the sparsity of literature in running after childbirth, a few expert opinions have proposed return to running screens and generalized progressions based on musculoskeletal changes in the general and postpartum population.9,13–15 Little guidance exists on progressions addressing muscular strength and endurance as well as running mileage progression for people who have recently given birth. This clinical commentary builds on the return to running screens13–15 to provide pelvic health and sports clinicians with a 4-phase rehabilitation framework for initiating or returning to running in the postpartum period. Our premise is that each individual runner should be empowered to decide when to initiate running, in consultation with their health care providers, especially if symptoms such as incontinence are present.

SCREENING FOR READINESS TO RUN AFTER CHILDBIRTH

In addition to the normal physical therapy review of systems, the first step in determining readiness to run after childbirth should include a thorough physical therapy evaluation (review of systems,16 musculoskeletal examination,17–19 and questions on pelvic health20,21) as well as screening for impact readiness (musculoskeletal tolerance to impact), pelvic health symptoms, physiological variables (sleep, fatigue, nutrition, and systems review22–26), and performing a running gait analysis (see Supplemental Digital Content Appendix A, available at: https://links.lww.com/JWHPT/A76, and Supplemental Digital Content Figure 1, available at: https://links.lww.com/JWHPT/A77). A runner with musculoskeletal or pelvic health symptoms may be able to gradually initiate running in tandem with medical management. The expectation is to minimize these symptoms through exercise prescription, gait retraining, manual therapy, and support of the pelvic organs (eg, pessary). The screening or rehabilitation framework should be stopped immediately if the client has any absolute contraindications,24,27,28 and clinical judgment exercised with any client who presents with relative contraindications28,29 (see Supplemental Digital Content Table A, available at: https://links.lww.com/JWHPT/A78). Symptom screens (incontinence, pain, etc) should continue to be routinely performed as exercises are progressed and running distance increases, and training adjusted on the basis of symptoms (see Supplemental Digital Content Appendix A, available at: https://links.lww.com/JWHPT/A76, for more in-depth information on screening).

Screening for Pelvic Health

Running is an impact activity that increases intra-abdominal pressure.30 This increase in pressure challenges the pelvic floor to maintain continence and pelvic organ support.30 Stress urinary incontinence is prevalent in women performing high-impact activities31 and is observed in 19% of runners up to 2 years postpartum.2 Childbirth is also a risk factor for pelvic organ prolapse.32 Therefore, it is imperative to screen for incontinence and pelvic organ prolapse symptoms before running. Screening can be accomplished with the Pelvic Floor Disability Inventory short form (PFDI-20)21 or by asking screening questions20 (Figure 1 and see Supplemental Digital Content Appendix A, available at: https://links.lww.com/JWHPT/A76). A response of “yes” to any of the pelvic health screening questions warrants a referral to a pelvic health physical therapist or urogynecologist but does not necessarily prohibit initiation of the running portion of the framework.33 A pelvic floor muscle (PFM) examination is highly advised to determine degree of impairment and whether the impairment influences participation in the running portion of the framework.34–36

Screening for Impact Readiness

Two screens have been proposed to determine whether a person is ready to run.13,14 The screen proposed by Goom et al15 consisted of a series of movements to determine whether musculoskeletal pain or pelvic health symptoms are present with impact or increased load. The Run Readiness Scale proposed by Payne et al14 also evaluated musculoskeletal pain through a series of movements (see Supplemental Digital Content Appendix A, available at: https://links.lww.com/JWHPT/A76). Before beginning the return to running framework outlined in this document, we recommend screening for running impact readiness. It should be noted that neither of these screens have been validated in runners postchildbirth.

Screening for Running Gait

Many kinematic and kinetic factors have been investigated for the relationship between running gait and injury,37–39 including peak hip and knee adduction,38,40 knee stiffness,41 and step rate.42 We recommend a running gait analysis to assess biomechanical risk factors for RRI.9 For clinicians unfamiliar with running gait analysis, Souza43 provides a guide to 2D analysis.

Screening for Physiologic Variables

Decreased sleep,44,45 increased fatigue,46–49 and inadequate nutrition50,51 may contribute to RRI in postpartum persons.5,52–54 These variables should be screened when returning to running55–57 (see Supplemental Digital Content Appendix A, available at: https://links.lww.com/JWHPT/A76).

PROPOSED REHABILITATION FRAMEWORK

The American College of Obstetricians and Gynecologists advises postpartum exercise as soon as medically safe, sometimes within days of delivery.27 Postpartum recovery involves musculoskeletal,58 biomechanical,59–64 and physiological variables.65 The widening of the levator hiatus that occurs in vaginal birth may contribute to incontinence and prolapse; thus, runners with this risk factor may need to progress more slowly.66,67 Healing from birth injuries, such as perineal tearing or cesarean incision, may require additional recovery time.10,68–70 We recommend approaching recovery from pregnancy-related changes and delivery-related injuries in an individualized manner, similar to recovery from other injury or surgery, while respecting the unique postpartum physiological factors. For example, return-to-sport frameworks for anterior cruciate ligament injury involve formal rehabilitation protocols with functional progressions based on sport-specific goals.71 This proposed framework mirrors these return-to-sport protocols by proposing a phased approach targeting key muscle groups that influence running gait and those that are commonly impaired after childbirth: the PFM, abdominals, posterolateral hip muscles, calf, and foot intrinsic muscles. A progression through isometric, isotonic, and plyometric exercises is recommended to assist a runner to participate in running after childbirth and prevent RRI. This framework encompasses the entire kinetic chain to prepare the runner for effective load management.72

How to Use the Framework

The runner may begin running at any time postpartum if they have been medically cleared and screened for running readiness (Figure 1), as recent literature suggests that early return to exercise does not negatively impact pelvic health outcomes or increase injury risk in athletes.73,74 Symptoms should be continuously monitored and addressed by the health care team. As each individual may have unique pregnancy and postpartum experiences, this framework should be used to assist each runner in achieving their running goals. The physical examination will determine which phase of the framework to initiate (Figure 2). We highly recommend returning to a previous phase if musculoskeletal symptoms worsen. In addition, an extremely fatigued, sleep-deprived runner may need to stay in the current phase of rehabilitation, or regress in some parts of the framework (ie, running) until they are recovered. We recommend runners and health care providers monitor training, recovery, and symptoms throughout the phases of this framework to ensure appropriate physiological and musculoskeletal adaptation to training load.75 Clinical judgment should be used to progress or regress each component of this framework as indicated by the runner's tolerance and symptom profile (Figure 2).

F1
Figure 1.:
Decision tree to guide PT evaluation and screening of runners after childbirth. Care of runners after childbirth begins with a full physical therapist examination, which determines the phase of the framework to initiate. As with any runner, a full systems review—with particular emphasis on cardiovascular and bone health after childbirth—should be performed to determine appropriateness for physical therapy intervention and need for referral to other health care providers. If no major concerns (physiological red flags, need for further pelvic health examination, or severe musculoskeletal impairments) are present, the runner may undergo the Running Readiness Screen. If the runner passes the Running Readiness Screen, analysis of running gait should be performed to identify whether kinematic risk factors for running-related injury are present. FI indicates fecal incontinence; MD, medical doctor; OB-GYN, obstetrician-gynecologist; PFDI-20, Pelvic Floor Disability Inventory short form; PT, physical therapist; UI, urinary incontinence.
F2
Figure 2.:
Running progression decision tree. Determining the phase in which to begin the running progression is based on the runner's ability to pass the screening criteria, running habits and symptoms prior to evaluation, and the presence of running-related injury risk factors. Runners may progress to the next phase if progression goals are met, or regress to a previous phase if symptoms are exacerbated or new symptoms arise. Continuous monitoring of symptoms is key! CV indicates cardiovascular; MSK, musculoskeletal; PSQI, Pittsburgh Sleep Quality Index; RRI, running-related injury.

Key Elements of the Framework

Exercise Prescription

The proposed framework is based on the principles of exercise prescription established by the American College of Sports Medicine,28 providing the specific parameters of frequency, intensity, type, and rest (see Supplemental Digital Content Table B, available at: https://links.lww.com/JWHPT/A79). Exercise types discussed are isometric, isotonic, and plyometric. Isometric exercise has been shown to increase tendon stiffness and muscle hypertrophy.76 Midrange joint positions are commonly used, and duration of isometric holds ranges from 10 to 45 seconds with 20 to 90 seconds of rest. Isometric exercises can also evoke exercise-induced hypoalgesia.77,78 Isotonic exercises improve muscle strength and hypertrophy.79,80 Eccentric exercises have added neural benefits81 and exercise-induced hypoalgesia82 but increased risk of delayed-onset muscle soreness; however, neural adaptations seem to help muscle recruitment and override inhibitory signals from pain and swelling.81 Plyometric training in female athletes may decrease knee injuries83 and improve running performance84 by augmenting tendon extensibility and active muscle stiffness.85

The 4 targeted muscle groups in this framework (Table) are the abdominals, pelvic floor, gluteus medius, and foot muscles. Example exercises for each phase were chosen on the basis of evidence—with specific attention to electromyography (EMG) studies to help determine exercise intensity, and running-specific research regarding injury risk and rehabilitation—and expert opinion. We recommend exercises with low EMG activity initially to build strength and neuromuscular control, progressing to exercises with higher EMG activity. 86,125 Example exercises are to guide clinicians, not to act as an exhaustive list. Clinicians are encouraged to use clinical judgment in identifying appropriate exercises for their clients. On scheduled run days, strengthening exercises should be performed after running to avoid muscle fatigue that could alter running mechanics. Clinicians should work with runners to identify barriers (eg, lack of time) and create an individualized version of this framework to ensure success.126 For example, a limit of 4 exercises has been recommended in a home exercise program to ensure compliance.127 Phase goals for when to advance have also been provided (see Supplemental Digital Content Table C, available at: https://links.lww.com/JWHPT/A80).

Table. - Four-Phased Rehabilitation Framework for Initiating or Returning to Running Postchildbirtha
Example Exercises
Hip86 Foot PFM Abs87
Phase I Supine:
Bilateral bridge88,89
Side lying:
Clamshell90
Standing:
Double leg body weight squat86,88,91		 Seated92,93:
Towel scrunches
Bilateral heel raise
Isolated great toe extensions
Arch doming		 Supine, side lying, sitting:
Isolated quick flicks (1-2 s)
Endurance (3-5 s)		 Supine, side lying, sitting, or quadruped:
ADIM with breathing
Supine94:
Knee raise to 90-90 position (Sarhmann level 1)
Knee lowering from 90-90 (Sarhmann level 2)
Supine87,95–97:
Double leg bridge stable surface 10-30 s (TrA focus)
Double leg bridge (stable) with end exhalation (obliques focus)
Single leg raise to 45° (all abdominal focus)
Running progression: (RPE 11)
Level 1: Walk 10 min
Level 2: Walk 15 min
Level 3: Walk 20 min
Level 4: Walk 30 min
Phase II Supine88,89,98:
Bridge unilateral stable or bilateral unstable
Prone:
Double limb plank89
Prone hip extension with flexed knee (90) progressing to LE straight, foot plantarflexed (triple extension)88,99
Quadruped:
Straight knee hip extension; WB or NWB88,99
Side lying:
Hip abduction neutral or with lateral rotation88,100
Standing:
Hip abduction (focus on stance leg, pelvic stability)101
Standing single leg pelvic drops (eccentric hip abduction)88
Single leg squat102,103
Lunge forward89
Step up front,88 retro,102 lateral102		 Standing92,93:
Towel scrunches
Bilateral heel raise
Isolated great toe extension
Great toe flexion with second to fifth toe extension
Medial arch doming		 Supine, side lying, sitting:
PFM activations simultaneous to hip and ADIM exercises
Sustained contractions and quick flicks		 Quadruped ADIM:
Adding UE and LE movements104
Plank on forearms and knees87,105,106
Supine:
Double leg bridge unstable surface (TrA)97,107
Curl-up108,109
Side lying:
Side plank knees and elbow87,106
Running progression: (RPE: 11-13)
Level 1: 0.25 walk, 0.25 run; 0.25 walk, 0.25 run (weekly mileage: 1.5 miles)
Level 2:0.25 walk, 0.28 run; 0.25 walk, 0.28 run (weekly mileage: 1.65 miles)
Level 3: 0.25 walk, 0.30 run; 0.25 walk, 0.30 run (weekly mileage: 1.82 miles)
Level 4: 0.25 walk, 0.33 run; 0.25 walk, 0.33 run (weekly mileage: 2.00 miles)
Level 5: 0.25 walk, 0.36 run; 0.25 walk, 0.36 run (weekly mileage: 2.20 miles)
Perform each level 3 times with 48 h of rest and progress if symptom-free and RPE <11
Phase III Prone:
Front plank single limb NWB and WB98
Quadruped:
Bird dog89
Side lying:
Hip abduction with medial rotation100; or with added resistance110
Side plank89
Standing:
Hip abduction progression98
Single limb deadlift98,111
Single limb deadlift with rotation (navel to wall)112
Step-up front retro or lateral102
Lunge lateral111
Single leg squat: stable98 or unstable113
Skater squat98
Single limb stance: NWB in circumduction98
Monster walk111
Plyometric:
Jumping B LE:
Forward/backward progressing to lateral/medial		 Standing92,93:
Single limb pelvic rotation on fixed femur stance leg (IR/ER of pelvis on femur) focus on foot posture
DL heel raise with increase weight
Isolated great toe extension
Great toe flexion with second to fifth toe extension
Movement transitions (sit to stand):
Maintain arch doming
Plyometrics:
Jump with doming of arch		 Standing:
Pelvic floor muscle activations: Quick contractions for 3 sets of 10
Endurance holds in combination with hip exercises
PFM activations simultaneous to other exercises114,115
Plyometrics:
Jumping with pelvic coordination (attention to landing)116		 Supine94:
Unilateral heel slide from 90-90 position (Sahrmann level 3)
Bilateral heel slide from 90-90 position (Sahrmann level 4)
Standing117:
Back squat (RA focus)
Bulgarian squat (unilateral) (EO and RA focus)
Quadruped ADIM:
Adding UE and LE movements with resistance/weight118
Front plank on forearms and toes87,105,106
Front plank with scapular adduction and posterior pelvic tilt (IO focus)119
Forward plank with single leg hip extension (EO focus)119
Side lying:
Side plank on forearm and toes87,106
Running progression: (RPE: 11-13)
Level 6: 0.25 walk, 0.40 run; 0.25 walk, 0.40 run (weekly mileage: 2.40 miles)
Level 7: 0.25 walk, 0.44 run; 0.25 walk, 0.44 run (weekly mileage: 2.65 miles)
Level 8: 0.25 walk, 0.48 run; 0.25 walk, 0.48 run (weekly mileage: 2.90 miles)
Level 9: 0.25 walk, 0.53 run; 0.25 walk, 0.53 run (weekly mileage: 3.20 miles)
Level 10: 0.25 walk, 0.58 run; 0.25 walk, 0.58 run (weekly mileage: 3.50 miles)
Perform each level 3 times with 48 h of rest and progress if symptom-free and RPE <11
Phase
IV		 Side lying98:
Side plank single limb
Standing (add resistance/challenge surface)
Step-up front or lateral102
Hip abduction progression98
Single limb deadlift98,111
Single limb deadlift with rotation (navel to wall)112
Step-up front retro or lateral
Lunge lateral98,111
Single leg squat: stable98 or unstable113
Skater squat98
Plyometric:
Hop forward, sideways, or transverse98,111
Box jumps down (start up, jump down)
Step hops forward and sideways		 Standing92,93,120:
Single limb heel raises (cueing for stability in the first metatarsal head and through the ankle)
Rear foot elevated split squat with lead leg in slight plantar flexion. Heel hovering 2 cm off the ground
Isolated great toe extension with resistance (resistance band, rubber band)
Great toe flexion with second to fifth toe extension with resistance (resistance band, rubber band)
Plyometric:
Hops with doming		 Standing:
Vaginal weight in standing for proprioceptive input. Active contraction (3-5 s, 3 sets of 10)121
Vaginal weight with endurance hold during gentle activities of daily living for no greater than 20 min/d116,122		 Standing:
Pallof press
Diagonal rotations with resistance
Back squat (RA focus)117
Bulgarian squat (unilateral) (EO and RA focus)—unstable117
Standing 1 leg press, skiing
Quadruped:
Plank on toes and hands (forward, side, star)
Roll-out plank (RA focus)117
Forward plank: with single leg hip extension, forearm on Swiss ball (stir the pot),123 or suspension systems106,124
Side lying:
Side plank with leg lifts: upper body rotation, added resistance, challenge base of support
Running progression: (RPE: 11-13)
Level 11: 0.25 walk, 0.63 run; 0.25 walk, 0.63 run (weekly mileage: 3.80 miles)
Level 12: 0.25 walk, 0.70 run; 0.25 walk, 0.70 run (weekly mileage: 4.20 miles)
Level 13: 0.25 walk, 0.77 run; 0.25 walk, 0.77 run (weekly mileage: 4.62 miles)
Level 14: 0.25 walk, 0.83 run; 0.25 walk, 0.83 run (weekly mileage: 5.00 miles)
Level 15: 0.25 walk, 0.92 run; 0.25 walk, 0.92 run (weekly mileage: 5.50 miles)
Level 16: 0.25 walk, 1.02 run; 0.25 walk, 1.02 run (weekly mileage: 6.10 miles)
Level 17: 0.25 walk, 1.12 run; 0.25 walk, 1.12 run (weekly mileage: 6.70 miles)
Level 18: 0.25 walk, 1.50 run; 0.25 walk, 0.75 run (weekly mileage: 6.75 miles)
Level 19: 0.25 walk, 1.75 run; 0.25 walk, 0.50 run (weekly mileage: 6.75 miles)
Level 20: 0.25 walk, 2.0 run; 0.25 walk, 0.25 run (weekly mileage: 6.75 miles)
Level 21: 0.25 walk, 2.25 run; 0.25 walk (weekly mileage: 6.75 miles)
Level 22: 0.25 walk, 2.48 run; 0.25 walk (weekly mileage: 7.43 miles)
Perform each level 3 times with 48 h of rest and progress if symptom-free and RPE <11
Abbreviations: ADIM, abdominal draw-in maneuver; B, bilateral; DL, double leg; EO, external oblique; ER, external rotation; IO, internal oblique; IR, internal rotation; LE, lower extremity; NWB, non–weight bearing; PFM, pelvic floor muscles; RA, rectus abdominis; RPE, rate of perceived exertion (Borg); TrA, transverse abdominis; UE, upper extremity; WB, weight bearing.
aExample exercises for each muscle group and detailed progression of running through the 4 phases. Note that a runner may be in different phases for each component of the framework, and it is acceptable to progress or regress only 1 component, if necessary.

Frequency: The strength exercises suggested in each phase of the framework should be performed 2 to 3 nonconsecutive days a week; however, isometric exercises and very low-intensity exercises, such as those in phase I, may be performed 3 to 7 days per week.28

Intensity: To build strength, the American College of Sports Medicine recommends low repetitions (8-15) with high load.28 As “high” load is runner-specific, we recommend a rate of perceived exertion (RPE) of 7 to 12 on the Borg Scale in phase I and 13 to 16 in phases II, III, and IV. Muscular endurance is achieved with high repetitions (15-25) of low load (RPE of 11-14).28 During running, RPE recommendations remain constant throughout the phases.

Rest: Two to three minutes rest between sets has been recommended when strength training.28 However, longer rest periods (≥5 minutes) may be needed after childbirth due to potentially increased fatigability.128–130

Exercises

Many muscles contribute to running propulsion and stability during stance. Key muscles associated with perinatal changes are included later. To limit the time to complete the home exercise program, we recommend choosing exercises that target multiple muscle groups in each phase (see Supplemental Digital Content Table D, available at: https://links.lww.com/JWHPT/A81).

Abdominal: Studies have shown that following childbirth, the anterior trunk muscles demonstrate decreased strength and steadiness of contraction and increased fatigability.128,129 More severe impairments in muscular function are associated with wider interrecti distance or diastasis recti abdominus.128–130 Rehabilitation of all muscles of the abdominal wall is essential, as trunk flexion and rotation and lumbopelvic stabilization have been shown to be impaired following childbirth.128–130 Conflicting evidence exists on which exercises are best to reduce interrecti distance in the long term131–134; however, ultrasonographic studies suggest that performing an abdominal draw-in maneuver prior to an abdominal curl-up reduces linea alba distortion.135,136 Therefore, abdominal draw-in maneuver exercises start in phase I of the framework, and curl-up exercises (only in the absence of abdominal doming) are added in phase II. Phases III and IV focus on higher-level exercises that require significant activity of all abdominal muscles.

Pelvic floor: The exercises starting in phase I of the framework are quick contractions held for 1 to 2 seconds and performed repeatedly with proper rest, and endurance contractions held for 3 to 5 seconds for 8 to 12 repetitions, increasing hold time to 10 seconds in later phases.

Hip: The key muscle targeted in this section is the gluteus medius, as it stabilizes the pelvis in single limb stance.137 Specifically, it prevents hip adduction, a risk factor for RRI.138,139 Gluteus medius weakness has also been associated with low back pain in pregnancy, due to a Trendelenburg gait or a strain in the muscle itself.140 In females with stress urinary incontinence, strengthening the hip abductors along with the PFMs resulted in less daily urine loss.141 Exercises in phase I (low EMG activity) are bilateral leg bridge, squat, and prone bent knee hip extension. Phases II and III (moderate to high EMG)125 include quadruped straight leg hip extension and single limb stance exercises. Phase IV includes single limb side plank and hops.

Foot: The foot has important roles in running including impact absorption at contact and propulsion.142 Feet experience changes during pregnancy leading to altered biomechanics and pressure patterns.143 Excessive pronation has been linked with RRI.144 Pronation is present in runners during pregnancy and is not observed to return to baseline at 6 weeks postpartum.143 Foot strengthening exercises were included in this framework as they have been observed to improve foot muscle volume and propulsive forces in healthy runners.93 The exercises in phase I begin in sitting and include foot intrinsic isometric holds to improve neuromuscular coordination, strength, and stability. Phases II to IV include progressively more challenging exercises for arch doming and foot intrinsic strength.92,93

Running progression: The runner must be able to walk for 30 minutes without symptom exacerbation and pass the run readiness screen before starting the running progression component of this framework; as such, the runner may progress through the phases for muscular endurance and running progression asynchronously (eg, phase 3 for strengthening exercises but phase I for running). The runner should first be evaluated for shoe fit as foot dimensions may increase and dynamic arch stability may decrease after childbirth.143,145,146 Running should begin on a flat surface, every other day to ensure recovery between sessions. The runner should monitor symptoms such as pain, incontinence, swelling, prolapse symptoms, or muscle stiffness during and after running. We recommend slow progression, through the levels 0 to 22 suggested (Table), to ensure appropriate adaptation to impact loads. If symptoms arise or worsen, running should stop and a running gait evaluation by a physical therapist should be sought. Elite athletes or runners who ran throughout pregnancy and desire a quicker progression may do so under supervision; however, it is recommended that only 1 variable (velocity, distance, frequency) is increased weekly and running distance increases by no more than 10% weekly.147 Runners with a step rate below 170 steps per minute should be encouraged to increase step rate by approximately 10% to decrease ground reaction forces.42,148,149 As research highlights workload optimization, it is also important to monitor recovery, fatigue,150 sleep,151 pain,2 and heart rate.152

The running progression is based on mileage, not time, as increased mileage has been associated with RRI, and this is a more conservative approach.147,153 We recommend a speed that feels comfortable to the runner, as changing speeds has been associated with increased loading rate.154 To control for intensity, we recommend using an RPE of 11 to 13 throughout the plan. Before initiating each run, a dynamic warm-up should be performed. A walk-run progression is used, beginning with a total of 0.5 miles (2 bouts of 0.25 miles) of running interspersed with walking. The framework progresses running mileage up to 2.48 miles per run (weekly mileage of 7.43 miles) by level 22. Each workout should be performed 3 times a week for at least 1 week, and symptoms should be stable or improving to advance to the next level.147,153

Phases of Progression

Detailed information regarding exercise prescription and recommendations for each phase is provided (Table). Runner report of ease of exercise performance, and meeting the objective criteria described later, indicates readiness for progression.

Phase I: The aim of this phase is to establish neuromuscular coordination, strength, endurance (muscular and cardiovascular), and control of the hip, trunk, pelvic floor, and lower extremity muscles. This phase may be prolonged for runners who experienced bed rest or complicated pregnancies, deliveries, or postpartum recoveries.9,155

  • Intensity and type: Exercises with low to moderate EMG activity (0%-40% maximal voluntary isometric contraction (MVIC)125; primarily isometric, open chain isotonic, and bilateral closed chain).
  • Cardio/general fitness: Low-impact aerobic exercises including walking, cycling, elliptical, and swimming are ideal. It is recommended to progress by increasing time before intensity.28

Goals and progression to the next phase: The runner should demonstrate good lumbopelvic control, proper breathing, and adequate abdominal engagement during all exercises. Monitor for Trendelenburg sign in single-limb stance (see Supplemental Digital Content Table C, available at: https://links.lww.com/JWHPT/A80). Pelvic floor muscle strength should be adequate to avoid leakage during exercise. For the foot, the runner should demonstrate smooth quality of movement with no compensations (eg, medial or lateral deviations or rotations at the ankle). Running may be initiated in the next phase (phase II) if the runner can walk symptom-free for 30 minutes and pass the running readiness screen (see Supplemental Digital Content Appendix A, available at: https://links.lww.com/JWHPT/A76). As runners may compensate with other muscles while performing an exercise, it is important to query them on where they feel the exercise to ensure correct exercise performance.

Phase II: The aim of this phase is to continue to improve strength, coordination, and endurance of the muscles pertinent to running, as well as continue to progress cardiovascular endurance. Phase II introduces positional and stability changes to further challenge neuromuscular control.

  • Intensity and type: The goal is moderate-high EMG (20%-60% MVIC),125 primarily achieved through isometric and isotonic exercises progressing from bilateral closed chain or unilateral open chain to unilateral closed chain. Challenging positions such as a narrow base of support or against gravity are utilized.
  • Cardio/general fitness: If the running readiness screen is passed, and the runner can walk 30 minutes without symptom exacerbation, running is introduced via a walk-run program starting with level 1 (weekly mileage up to 1.5 miles) progressing to level 5 (weekly mileage up to 2.2 miles). Running should be performed only 2 to 3 days per week with 48 hours of rest to monitor symptoms. Each running level should be performed 3 times for a minimum of 1 week. Cross-training may be progressed to increase cardiovascular endurance, with a goal of 30 minutes of aerobic exercise per day.

Goals and progression to the next phase: The runner should demonstrate good motor control and biomechanics with all exercises. No exacerbation of symptoms with running/aerobic exercise or strength exercises, abdominal wall doming, or musculoskeletal compensations should be noted.

Phase III: The aim of this phase is to build on muscular endurance, power, dynamic stability, and load management. Phase III progresses exercises in the standing position, bringing added challenge to the muscles against gravity, and includes low-level plyometrics. If a runner has not yet passed the impact screen, plyometric training will be especially important to facilitate improved load tolerance to eventually pass the impact screen and initiate the running progression portion of the framework.

  • Intensity and type: The goal is high to very high EMG (>60% MVIC),125 primarily achieved through resistance training and unstable surface variations (foam surface, ball, roller, disk, etc)
  • Cardio/general fitness: If earlier running phases have been performed with no exacerbation of symptoms, running is progressed to level 6 (weekly mileage up to 2.4 miles) through level 10 (weekly mileage up to 3.5 miles). If the running workout takes less than 45 minutes total and the runner is eager to exercise longer, walking or a low-impact exercise choice can be added to reach a total of 45 minutes.

Goals and progression to the next phase: The runner should demonstrate good motor control and biomechanics with all exercises. No exacerbation of symptoms with running or strength exercises, abdominal wall doming, or musculoskeletal compensations should be noted.

Phase IV: The aim of this phase is to return to full participation in running. Exercises challenging muscular endurance and power are progressed by adding increased resistance and changing surface stability. Strength exercises and plyometrics are progressed to single leg to increase load tolerance and strength in running-specific positions. Compound movements with higher resistance are also recommended. It is imperative to use weights for resistance as running forces can be up to 5 times a runner's body weight.156

  • Intensity and type: The goal continues to be high to very high EMG (>60% MVIC),125 primarily achieved through resistance training and unstable surface variations (foam surface, ball, roller, disk, etc).
  • Cardio/general fitness: If the earlier levels of running have been performed successfully, the goal of this phase is to increase cardiovascular endurance to match the runner's running goals. The running progression begins at level 11 and continues until desired goals are reached. At level 18, the amount of walking decreases, while the amount of running increases. In levels 18 to 21, length of running interval increases but total mileage is held constant. Some runners may end at level 20 with goals of running 2 miles; for others, the progression may continue after level 22. We recommend the runner conservatively increase weekly mileage (only 10% per week).147 If the runner wishes to add speed work or tempo runs after level 22, running mileage should be held constant as other variables are manipulated. Each level should be performed without exacerbation of symptoms and at least 3 times before progressing.

Goals and progression: At the end of this phase, the runner has been symptom-free (or mild symptoms have remained stable) and running up to 2.48 miles per run. If musculoskeletal or pelvic symptoms appear or reoccur, the runner is advised to return to an earlier phase of the running progression framework or scale back within the current phase (eg, level 22 to level 20) (Figure 2). If symptom-free, it is recommended that the runner continues to engage in strength and plyometric training while advancing or maintaining total weekly running mileage.

CONCLUSION

Research-based rehabilitation guidelines regarding running after childbirth are limited. Therefore, this clinical commentary proposes a comprehensive 4-phase progression, guided by evidence, for clinicians to assist runners after childbirth. Clinicians should ensure that a runner is medically cleared, able to walk 30 minutes without symptom exacerbation, has had a thorough musculoskeletal examination, and passes a running readiness screen before beginning running in this framework. This framework is not exhaustive; however, it provides evidence and expert opinions on how to progressively rehabilitate a runner through a comprehensive continuum of care after childbirth. Clinical judgment should be exercised with each runner, and modification of the framework based on runner-specific examination findings is essential. Future research is necessary to validate this framework in people returning to running after childbirth.

ACKNOWLEDGMENTS

The authors thank the leaders of the pregnancy and postpartum special interest group (Academy of Pelvic Health) for the initial framework for this document. The authors would also thank Kevin Jermyn, Elon cross-country and track and field coach, for his guidance with the running progression and levels, and Jay Dicharry for his guidance of foot exercise protocols.

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              Keywords:

              athlete; childbirth; incontinence; running; strength

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