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The Physio insights Podcast by Runeasi
Welcome to The Physio Insights Podcast by Runeasi, your trusted space for real conversations at the intersection of science and sport.
Every two weeks, we sit down with passionate clinicians, biomechanists, and rehab experts to share the insights, tools, and stories shaping the future of running performance, injury recovery, and movement science.
🔍 Created for physical therapists, gait geeks, and rehab specialists who care deeply about helping athletes move better, faster, and stronger.
Hit subscribe and elevate your clinical game!
Welcome to the Physio Insights podcast presented by Runeasi. I'll be your host, doctor Jimmy Picard. I'm a physical therapist, running coach, and team member here at Runeasi. On this show, we have real conversations with leading experts digging into how we recover from injuries, train smarter, and use data to better guide care. Whether you're a clinician, coach, or an athlete, we're here to explore what really matters in rehab and performance.
Jimmy:Let's dive in.
Jimmy:Amanda Olson, welcome to the Physio Insights podcast. How's your day going today?
Amanda:It's going great. Thanks so much for having me.
Jimmy:Of course. So we are on opposite sides of the country, and yet we're both experiencing we're talking about this off air, some smoke in the air. It's pretty bad out there?
Amanda:It is. I live in Oregon, and part of the deal is we have beautiful, beautiful trees and mountains. And roughly every summer now, they catch on fire. So we have we are in forestry fire season, unfortunately, and kind of in the thick of it.
Jimmy:I guess out here in Virginia I'm in Southwest Virginia. Moved from Salt Lake City to the East Coast, thought I was escaping all this smoke, yet it followed us. I guess ours is coming from the fires in Canada, but we'll stay inside and definitely not running outside today. Amanda, to get started, to kick things off, why don't you just tell the listeners a little bit about yourself?
Amanda:I am a physical therapist by background. I've been a physical therapist for almost twenty years now, and I started my career I expressly went to PT school to specialize in pediatric neurology, and I got my first job at a children's hospital. And during that time, I had a profound injury that led me to pelvic health. So I've been a pelvic health physical therapist now for seventeen, eighteen years. And I, in the course of my clinical care, treated all the people, all ages, all genders, all backgrounds with various pelvic health issues.
Amanda:My passion point is the overlap between pelvic health and running. I am a runner. I played all kinds of sports growing up and now as an adult, running is very special to me. I'm also from Portland and Eugene, Oregon, where running is part of life and culture. So I've ran in some capacity since I can remember since I was four or five.
Amanda:And I have also gone on to create pelvic tools that empower patients at home so that they can manage sensitive pelvic health issues like pain and incontinence and pelvic organ prolapse. And that's part of what I do, but I just enjoy educating and advocating and dispelling myths, especially around pelvic health and running.
Jimmy:There's a lot to unpack in there. I guess first question I have for you is going way back to starting PT school. You were originally interested in neuro peds. Where did that come from?
Amanda:I've known since I was 10 that I wanted to be a physical therapist. Wow. So that became apparent to me when I was very, very young. And I was an athlete. So, of course, I loved sports medicine and orthopedics.
Amanda:And I did a lot of shadowing. Was very lucky to have a wonderful physical therapist as a neighbor that I got to spend a lot of time with who was just really took me under his wing and was wonderful. But I have always loved children, and I taught summer camps all summer through high school and all the way through college. There was a brief moment where I had a thought that maybe I would be a teacher instead of a physical therapist, but stayed the course, went to physical therapy school, but just always really loved working with children and really wanted to be effective in the cerebral palsy diagnosis and Down syndrome. My doctoral dissertation was actually a postural perturbation study on children with Down syndrome.
Amanda:We had a perturbation machine at our PT school and we loaded up these adorable children with Down syndrome and rocked them all around. And it was very fun. So yeah, I got I was lucky to get my first job actually in a gait analysis lab at a children's hospital in Portland, Oregon. And I loved gait, and I got to put, you know, markers on, do the full analysis. It was me and an engineer, and that was my full job as a brand new baby PT.
Amanda:So it was really cool.
Jimmy:Sounds like you landed, yeah, a dream job right out of school. But then there was a twist in this story here. Somehow you ended up here in pelvic health, and you mentioned there was an injury. What happened?
Amanda:Oh, I landed flat on my bottom into pelvic health. This is the gist of it. You know, I had gone to PT school in Colorado and came back to Portland for my job and found myself one weekend very early in my career out on a river, out on a weekend camping adventure. And I'm not a thrill seeker. I'm a runner.
Amanda:I like my feet on the ground, and I'm very steady as she goes. But it was a 40 foot jump into a still very deep section of the river, and all the boys were going off. And I'm also not one to be left behind. So off the cliff I went, but I didn't get the tutorial. Apparently, when you jump off of a cliff into water, you're supposed to land straight like a pencil, and I landed like an owl bottom first.
Amanda:And at 40 feet, water feels a lot like cement, and I had significant injuries to my low back, my pelvis, all the soft tissue. I mean, landing bottom first, you can imagine everything that came in contact with the water. So I was very lucky. I mean, I had significant injuries, but if I'd rotated a little bit more, I could have hit my head and I think I'd be gone. But I was able to get in to see my primary care physician right away when I got home, and they had the good sense to recommend me to a pelvic health colleague.
Amanda:And at the time, this was seventeen, eighteen years ago, there was only like 300 in the country. Public health physical therapy has been a profession for forty five years now. A lot of people don't know that, but we have our whole entire section and accreditation with the American Physical Therapy Association. We just had our forty fifth anniversary. So it's been around a long time, but not a lot of people are doing it.
Amanda:And I was just so lucky to have a fantastic one in Portland, Oregon. And we did an extensive course of pelvic physical therapy, and she fixed me up and changed my life. And at the end of the course, she said, Amanda, you need to quit peds. You need to do this. You have the right personality for it, and there's not enough in the country.
Amanda:And so I did. I slowly but surely went back and did the the training. It's it's pretty extensive, as you can imagine, to redirect your skill set to be doing internal vaginal and rectal exams and all of the different professions that we work with, urology, gastroenterology, pain medicine, all of those different things. And it's still orthopedics. It's just done in a cave.
Amanda:So you're applying all of these different skills. But, yes, that is what I do. It it really changed my life, and I know that it's my purpose. And I enjoy helping people get through other challenging and sometimes shame shrouding different diagnoses.
Jimmy:It's quite the journey and it's it's funny how life does that one little incident kind of change the trajectory of your career. As you made that transition, was that pretty hard?
Amanda:It was interesting. I remember my first we do weekend intensives that are three days and common to physical therapy different from medicine as we practice on each other. So when you go to your first lab, you're you're practicing and you're being practiced on. And I remember coming out of my first weekend being like, I don't want anybody to look at me or touch me. It's it's very intense, but it also puts you in the position of the patient on the table and recognizing how, you know, nobody loves to take their pants off and have these kinds of exams and and not that they have to.
Amanda:So in pelvic health physical therapy, we have a lot of different ways of doing an assessment, but usually doing an internal evaluation gives us a lot of really important information. But if someone has a history of trauma or abuse, there's a lot of different ways we can go about getting that information. But it's really, I think, valuable to be the person on the table experiencing that too so that it softens your manual skills and it gives you a very high dose of empathy for what the person coming to see you is experiencing.
Jimmy:Yeah. That makes a lot of sense. It's kind of, I mean, a completely different example, but just being a runner and helping treat runners when you understand what they're going through, you can treat them a little bit better. And so for you personally, as your journey getting into this specialty evolved, how did you then start tying in the like your passion for running?
Amanda:I recognize I had some colleagues. And again, pelvic health physical therapy has grown. We now have tens of thousands of providers just in The US and globally. There are pelvic physios everywhere. But I would say roughly even ten years ago, we had some idea of how to go about managing, say, postpartum or post surgical people to return them to run.
Amanda:But I had a lot of colleagues who were telling patients not to run if they had a condition like pelvic organ prolapse or they are rare incontinent. I had one colleague in particular say, you shouldn't run unless a bear is chasing you. And unless there are very hard contraindications like a fracture fracture or a medical condition of those organs that is extreme enough. I mean, and the only ones would be blood pressure that's not regulated. And if they had like an injury during the delivery process or during the pregnancy such that their physician is saying no exercise.
Amanda:There's no reason why someone cannot run, but we need to return them to run-in a very methodical in a very strategic way. Birds are escaping me this morning just the same way we would with somebody with an ACL tear. You know, we have a process. We have expectations. We have exercises.
Amanda:We have things that we're watching as providers to ensure that they are dosing appropriately. And then we put them in a run to walk program. So we don't just toss them out to the wolves and say, you're clear, go run. But we also don't take away that thing that's bringing them joy and that they love without a sound medical reason to do so. So specifically, to answer your question, I started recognizing some of these faulty reasoning patterns and wanting to provide better education to other clinicians.
Amanda:So I actually teach on this topic and also empowering patients to know that they don't have to run hang those running shoes up after they have a baby or after they've had a surgery or a cancer diagnosis if they don't want to. But if they are symptomatic, that there's a reasonable way of getting them back to the thing that they love.
Jimmy:Nice. So that ties in nicely with the papers you've written on the topic of return to run postpartum. So you have basically three consensus statements. Is that right? So before we dive into the papers, can you just tell the listeners and me what was the motivation there?
Jimmy:Why did you feel did you feel like there was something missing out there that that you were trying to fill the space of?
Amanda:A big thing that was missing was how to specifically dose exercises. You know, some people were going out about it on timestamps, like if you are this many weeks postpartum, you should do this. But we recognize that physiologically, everyone heals differently. Every pregnancy is different. Every delivery is different.
Amanda:And all of those things can be different in the same person that has had those processes over and over again. So wanting to provide a clinical reasoning sort of on ramp for clinicians to understand where their patient is and what they should be doing, also to provide evidence based exercise recommendations. What I saw was a lot of things happening in clinic or even on social media where they're like, do these three exercises. And it's like, there's no evidence behind those exercises. They look fun.
Amanda:They probably strengthen things. But when you're dealing with a patient, first of all, especially if they're postpartum or post surgical or post cancer, we wanna be really concise with that exercise program. Every exercise needs to have a reason. They are tired. They are busy.
Amanda:And we wanna make sure that we are providing them with sound exercise recommendations. So for example, in the four phase return to run article, every single exercise listed there is advanced back in peer reviewed journals. It's not just like, oh, these are the exercises that I enjoy doing with my patients. You should do them too. There's there's reasoning behind it.
Amanda:And then also, we wanted to provide clinicians with the understanding that running is jumping from one foot to the other, and we need to be training the patient with biometrics and different hopping and running drills to prepare them for running. What I saw was a lot of colleagues giving them the same exercises that were either lying down or even standing, but not getting them ready to accept that two to three times their body weight with every single step. So that last section of the rehabilitation process was often missing and important. And they're saying, okay. You're close.
Amanda:And perhaps the patient discharges or they say, like, go try to run. And then they go try to run and they have symptoms. And it's because their body hasn't been trained for mitigating the impact of running.
Jimmy:Got it. You felt like the gap was just lack of education on how to prescribe or dose exercise postpartum. I have three kids. All three were born at home. So we did home births for all three of them.
Jimmy:And looking back at my wife getting back into running after each kid, I didn't have the information. I hadn't come across your work. And I didn't like, I'm a sports PT. I focus on yeah, not this not this stuff. And for her, she was just kind of like had no idea what was what she was supposed to do.
Jimmy:Maybe there was some timeline she had heard, like you mentioned, it was like, I don't know, twelve weeks postpartum, she can start returning to run. But after the first two pregnant or deliveries, she ended up with stress fractures. First one was in her femur, second one was fibula, and this time, knock on wood, our third kid just turned one yesterday and no injuries after this one so far. So yeah, it seems like there's just like a lack of awareness as to what to do. And so your papers help kind of fill this space and your work and what you're doing educating is helping clinicians like me who are not as familiar with this space, least have some tools to guide patients that come into my door, if not referring to somebody like you.
Jimmy:But yes, if we pick up on the four phases that you kind of went through, do you want to walk us through those four phases?
Amanda:So the four phases, one of the things that you'll notice and it's an open access article, anyone can access the full length of it. That was very important to us on all three papers, actually. The four phases are absent of any timelines, and it touches on the fact that, you know, as we discussed, every pregnancy is different. Every delivery is different. So different factors are going to have people healing at different times.
Amanda:So in the first phase, for all of the phases, what we've done is outline exercises that cover the entire kinetic chain. So you'll see exercises starting at the ground up for the foot, for the hip, for the pelvic floor, and the abdomen. And a lot of times too, what we've created is some carryover where you can do the pelvic floor exercises and say that abdominal exercises or the hip exercises together. And as quickly as possible, we're including multiple joints and multiple muscle groups so that we can be, again, really precise getting as much bang for our buck with each exercise for that runner. So we have all of those segments, foot, hip, abdomen, pelvic floor, and then four phases.
Amanda:The four phases begin with the exercises being in a very supported body position. So supine, sideline, prone. They touch on reintegrating the neuromuscular function of each because it I suppose I should outright say it's for postpartum return to run. There certainly can be carryover for a post surgical or a post cancer person. But when we think about pregnancy, the body changes.
Amanda:Like, every cell in that person's body changes. Oftentimes, the foot increases in a half a size to a full size of shoe. The pelvis is opening, so the dynamics of how their hip is functioning changes. And also, there are changes that can occur to the pelvic floor both during pregnancy and during the delivery, depending on the delivery mechanism. On top of that, abdominals are extended.
Amanda:That's a natural part of having that growth. And if they had a cesarean section, all four layers of those abdominals are cut. So all of those muscle groups are really important to the mechanics of running, and all of them change during the pregnancy, period. And some of them can change during the delivery period as well. So what we do is we start with relearning how to activate those muscles because we can have the fact that they were a little bit elongated during the pregnancy process.
Amanda:We might have pain that it's inhibited muscle function, and they need to relearn how to activate. A caveat to that is a principle in pelvic health is we always say lengthen before strengthen. So they if they are experiencing pelvic pain, if they've had a perineal tear or they had a episiotomy, really recommend that they work one on one with a pelvic health therapist, either physical therapy or occupational therapy to address that pain first so that they can utilize all of those muscle fibers. Long winded way of saying restart them in a very controlled environment to relearn those mechanisms, get them going on. When you look at the exercises, they are common.
Amanda:Most physical therapists and even, fitness people are gonna recognize them. They include things like fridges and clamshells and pelvic floor muscle isolations and engaging transverse abdominis and foot scrunches to get the foot going again. And then when those exercises are easy and they have been able to do them with good form, they're not feeling challenged at the end of their sets and reps, they can go on to phase two, and they become progressively more challenging. We start moving the body up to a higher center of mass. And then we eventually, by phase four, get them very dynamic, including the plyometrics and the hops.
Amanda:So it's just a progression basically from lying down to the mechanics of rotting. And we've differentiated each of the segments because it could be that somebody gets their glutes firing really well or gets their foot firing really well, and they're ready to get on to more challenging exercises, but pelvic floor is still lagging so that the patient can move through these protocols according to where their body is at that time. And then if they experience flare up in symptoms, they can just simply go back to the previous level and reintegrate those exercises and move through because we recognize, especially in postpartum, things like sleep or stress or returning to work, changes in their schedule can all impact their healing time and how they're moving through rehabilitation as well. So sometimes back slides happen, and they just pick it up where they're ready to go.
Jimmy:So in this four phases, sprinkled in there is a graded return to run program.
Amanda:Very conservative. Yeah. Did you see it?
Jimmy:Yeah. I did see it. Yeah. Starts at, I think, like, two or quarter mile at a time and kinda slowly builds up from there. What's the criteria for like, if a patient shows up to your door, your clinic, postpartum, they're fresh postpartum and they want to get back to running, what's the how do you help them make the decision of when they can start that that simple return to run program?
Amanda:That's the perfect question. So when we think about fresh postpartum, it could be at really any point because sometimes in pelvic health especially, they may be coming to see us at like week two. Mhmm. So one of consensuses that we achieved on the DALFI study that we did with the larger global group is that we came to a consensus that a minimum of three weeks of rest is advised. What that three weeks does not mean is that at three weeks up and go.
Amanda:And what it doesn't mean is prior to three weeks, you can't go for a walk or do some things or get some isometrics going. But it generally is such that that three weeks minimum is recommended. So depending on when they're coming in from there, the decision of if they're ready to run is going to go through a funnel of screening. And so the funnel of screening includes asking the patient questions about symptoms. Those questions include it's very basic.
Amanda:Do you experience leakage when you cough, sneeze, or laugh? Do you experience a sense of pressure? Do you experience pain during movements or a bulging sensation? And asking questions about just pelvic pain in general that would touch on, like, if they had their first speculum exam, was there pain with that? Have they had intercourse and experienced pain with that?
Amanda:They screen for pelvic floor issues that need to be addressed, and that would be regardless of running status. Any person who's been pregnant or given birth needs to be screened for pelvic floor issues. From there, we would run into a what you will recognize in sports medicine and orthopedics as a running readiness screen to determine how their how their lower chain endurance and strength wise is performing to see if they are ready to handle that impact. So we we recommend the running readiness screen that includes five items. The patient does them for a minute, and we're so we're looking at form, and we're looking at endurance of those muscle groups.
Amanda:So it includes step ups, single leg hop, or maybe it's a double leg hop. And then a wall sit, they are all included in the paper. So we are looking oh, and single leg squat, if I didn't mention that already. And so we're looking at form, we're looking at symmetry, and, again, they're held out over a minute. So we're looking at the endurance.
Amanda:If they clear that, then we're gonna watch them do a couple things in clinic like running in place and bounding and jumping and hopping. And we're asking them subjectively also, are you leaking when you do that? Are you experiencing pain or a sense of pressure? And if they are, then that's driving our plan of care to address those. And in some cases it can be that they need exercises for strengthening.
Amanda:It could be that they have some muscle groups that are too tight and we need to address that. And it could be that they need a supportive device. So one example of that is a pessary. A pessary is a device that goes inside the vagina and it helps support the organs very similar to a knee brace with an ACL tear. They get a little bit of a bad rap because for a long time, I think they were considered more for an older patient, but they can really be a game changer and a life changer for a young athletic person who maybe has a little bit too much flexibility around the bladder neck.
Amanda:That could be a byproduct of the pregnancy or the delivery that they've lost some of the support around the urethra. And regardless of how strong we get them, we're not gonna get that back. So the pessary can go in and stabilize them, and then they can jump and run and lift and lift the toddler and stroller and all the good things and not have the symptoms.
Jimmy:So alright, for a therapist like me, let's say postpartum, a woman comes in to see me, she wants to get back to running, I'm gonna help her get back to running. But what are there things I would need to look out for that would flag me to refer her to somebody like you?
Amanda:Yes. I advocate that every clinical intake form process for regardless of clinical type, orthopedic or otherwise, includes those five questions. Because what it does, especially in an orthopedic environment, if it's an open gym sort of situation, the patient is not going to bring it up. And if you ask, they might be really unwilling to have that conversation in front of a gym full of people that are lifting and doing other things with other therapists. By having it on the intake form, you've asked those questions.
Amanda:They're by themselves. They can make a little check. And one thing that you can do so it's, again, do you experience the leakage? Do you experience the bulge, pain with bowel movements, and a sense of pressure? You can see that and you can just say, I see that you've checked this.
Amanda:That is often a symptom of a pelvic health issue. I have a colleague that I can refer you to that can help you with that. And sometimes those pelvic health issues can flare up when you're trying to return to run or they can be part of the symptoms of your hip or your low back that you're here to see me for. And then would you like that referral? And in some cases, all of those therapists are working together under one roof.
Amanda:You know, a lot of orthopedic clinics now have a pelvic health physical therapist in house. But if not, I just strongly advocate for making friends with one in your area. As pelvic health therapists, we're not gonna take your patient. We're gonna work together. You know, it could even just be a consult where we kind of get them going on some exercises that they can do at home or they finish their plan of care with you and then they come and see us.
Amanda:Or perhaps they take a pause in your plan of care because the pelvic health symptoms need to be addressed first. But there's just so many different ways that we can collaborate and work together, and it's a really important part of that puzzle. That's one thing that I tell my pelvic health colleagues as well is if you're working with an athlete or a runner and they are still symptomatic with their running, they probably need to have their running mechanics looked at and assessed. And if you don't know how to do that, if you don't have that skill, you need to find a great orthopedic colleague you can send your patient to because that is a that could be a gap in their care that's preventing them from reaching their goal. So it goes both ways.
Jimmy:Yeah. So if a woman comes to me postpartum, I'm gonna screen for those things. If she answers yes to any of those questions, I'm gonna guide her towards pelvic health specialist. Yeah. And I can continue.
Jimmy:We can follow your program. We can do all that stuff, but she needs to see at least get screened by somebody like you. I'd like to take a moment to
Jimmy:thank our sponsor, Runeasi. Runeasi is a running and jumping analysis tool that helps provide objective data on things like impact loading, dynamic stability, and symmetry. I've been using it in the clinic for the past three years and I love how easy it is to add to my Not only that, but it backs up my clinical reasoning and helps me with my decision making process when I'm doing exercise prescription. So if you're a physical therapist or running coach, head on over to Runeasi and book a demo. If you're lucky, it will be with me.
Jimmy:So a couple of things. So you brought up the device. Now I'm just curious.
Amanda:The pessary.
Jimmy:Is that something that needs like, once a woman is, like, diagnosed with it, she needs that? Is that something she has to continue with, like, indefinitely?
Amanda:Sometimes people graduate out of it. So it can it can go in a number of different ways. It could be in the first two years or so postpartum that they are working on rebuilding strength, and sometimes the the organs are resettling, and they are getting their running mechanics back under control. And they might graduate out and not need that pass rate after a couple of years, especially if they are if the muscles are performing the function of supporting those organs. In some cases, there's been injury to the ligaments suspending the organs such that it's the same thing with the shoulder is if we have lost the static constraint integrity, we're not gonna get that back necessarily.
Amanda:So there are ligaments that suspend those organs. And if they are injured in such a way that their pelvic floor muscle strength is not going to be able to support it, then they might use that pessary for life. And, I mean, I think the interesting thing is a lot more runners are running around with them than people realize. So they might feel a lot of feelings about having to use this device, but that's why I always just liken it to, you know, if you tore your ACL, you'd probably be wearing some sort of knee brace for a certain period of time, and maybe it feels good to just have the lightweight one on when you play basketball years down the road. You know, it's it's just another way of supporting your body.
Jimmy:What are the most common things you see happening or deficits are occurring postpartum? And that like first year postpartum that working with runners, I think most of our listeners have are trying to focus on working with or treating runners. And so we end up seeing a lot of those patients and maybe we're at a loss. Maybe there are certain things we should be looking out for. Are there things that you think that one year postpartum that I should be looking for screening for besides those questions?
Amanda:Yes. And the most common and easy one would be incontinence, stress incontinence. Prevalence is high even in non postpartum runners. Interestingly, it's right around 45 to sometimes as high as 80 in younger female athletes that have never been pregnant. So certainly that prevalence can increase in the postpartum period, and there can be a variety of different reasons why.
Amanda:But stress urinary incontinence is a big one. Another one that I think surprises a lot of orthopedists is new onset of IT band pain. So when we think about hip mechanics and we think about the role of hip endurance and hip strength and stability and eccentric control during the running phase, the other side of the hip is the pelvic floor. It is a fascial plane. There is no magic separation between the hip musculature and the pelvic floor.
Amanda:It is a sheath of fascia. And if there has been a tender point or restriction or scar tissue in the pelvic floor muscles, they can create inhibition of the hip function. And so I've seen a lot of my wonderful orthopedic colleagues doing all the right things for the lower extremity regarding IT band issues, and the patient's not getting better and they're feeling stuck and they're just not really certain why. And it's because we need to look on the other side of that fascial plane and address the pelvic floor. And then the same thing would go with deep hip pain that they can't stretch.
Amanda:Like, they get in figure four, and they're like, no. That's not quite it. And everyone wants to blame piriformis. Literally, the other side of that piriformis is pelvic floor musculature, and it can be wound up. It can be tender.
Amanda:Sometimes after experiencing a tear or episiotomy, the pelvic floor muscles are guarding, and they're very tight just the same way as people can get temporomandibular joint pain and clenching in the masseters. They can have that stress response in the pelvic floor, and they're not aware of it. They don't see it. So it's not like you can see the the stress forming. They're doing it involuntarily, and that can really get in the way of the hip rehab.
Amanda:And it can feel like it's it's a it's a driver for what feels like hip pain, but it's coming from the pelvic floor.
Jimmy:Yeah. So that's an interesting one. So if you have like a pesky hip injury with for me, like, a runner, first thing I would think about would be maybe like a femoral neck stress fracture or something like that. But yours is like, so we should also have this on our radars if it's like, let's say we got an MRI, we rolled that out, then this could be something that's driving that pain. I'm thinking of a patient I have right now that maybe I need to like refer her to a pelvic floor person, because yeah, originally I said she's I think she is eight months postpartum, getting back into exercise running.
Jimmy:I suspected a bony injury. She got an MRI and it came back normal, so maybe this maybe I need to refer her out. One thing I wanna bring up, this is just something that you see in the running world is there is a big variety in what postpartum looks like, where you see some of these professional athletes and they've spoke some of them like Kara Goucher has spoken out on like the rush to return to run, and some who actually never get back to running. So you see some people like competing in half marathons, like within the first year postpartum, and then other people who just like, yeah, decide never to get back into running, maybe it's like fear, maybe it's some of these issues we've talked about. But when you see a postpartum runner, how do you talk to them about, is there too fast?
Jimmy:Is there should they be thinking about racing during that first year postpartum? Is it really individual? Yeah. How do you talk to to the runner about that?
Amanda:Absolutely. Yeah. Highly individual. I use myself as an example. With my first son, I had a very easy, smooth, straightforward pregnancy.
Amanda:I ran marathon, half marathon. I got like an age placement in my second semester. Ran all the way through and it was fine. And I returned to half marathon racing when he was five months.
Jimmy:Wow.
Amanda:With my second son, I had a I had a medical complication. I was in exercise jail. I wasn't allowed to even go for a walk or do any form of, like, exercise or anything. So the deconditioning that happened during that time period was extensive. And then he was almost ten pounds, and the delivery was a lot more eventful than my six pound first kiddo.
Amanda:So the postpartum period was night and day different, and I didn't return to half marathon racing until right around the one year mark with him, and that was working my tail off. So same person, pelvic health physical therapist specializing in running, who knows what she's doing, it can just look so so differently. So the first thing I would always ask them is what their goal is because they may have been a feisty little racer prior to getting pregnant, and now they're they 're not necessarily looking to race. They just wanna run, you know. So their their goals are just to have their run serve them because they love it.
Amanda:And they may have their eyes set on a race that they wanna do. So from there, again, we go back to that screening. We first and foremost look at their medical, you know, presentation and how they're doing. You know, the contraindications are really the ones that we would be looking for as physical therapists anyway. So blood pressure stability, making sure they've been cleared by their birth provider.
Amanda:And then we run them through that screening funnel to see where they are and to see if that goal is attainable. You know, it's when when the eyes are on a race, then we're looking at what's what's our current time period? What's their body been through in the last year or so? And having that conversation with them to see if it is attainable. If they've had an uneventful pregnancy and delivery, and they had a solid training block going for themselves prior to getting pregnant, a lot of them can return to some of their racing goals within that first year as long as they are going steady as she goes.
Amanda:One of the things that I wanted to circle back to, especially, you know, you said your wife experienced those stress fractures. It's actually more common than a lot of people talk about or aware of because in the postpartum period, they are predisposed to REDS or REDS, the relative energy deficiency syndrome, because they are if they are nursing, they are using a lot of caloric power and energy to produce the milk. They oftentimes are not sleeping, so they're more fatiguable. Their mechanics often change as a byproduct of the body changes that we talked about and the fatigability. We know they're not just sleepy, tired, fatiguable.
Amanda:Their muscles are, like, 25 to 50%, depending on the muscle group, more fatiguable. So those running mechanics can change. And then they're also worried about feeding everybody else except for themselves. So it's often an unintentional under that can put them at a higher risk for the the red ass that can lead to stress fracture as well. So that's something that we wanna keep a close eye on, making sure that we're dosing our running really conservatively, especially as they're getting back addressing the running mechanics and referring to nutrition if we have any suspicions that they could use a little help.
Jimmy:Yeah. That was that was gonna be my next question was where does breastfeeding fit into this? Because how do you when you're dealing with the the postpartum runner, how do you talk to them about this? Do you bring it up, like, just preemptively? Just try to educate them on that?
Jimmy:And if so, what does that look like?
Amanda:Absolutely. So educating them in hydration because that's also a part it's a it's a part of being a person and it's a part of their running and it's also a part of their nursing status as well. So hydration is really key reminding them to eat those high protein fuel snacks throughout the day. If they have to set a little timer reminder, educating them if they've had a really rough night's sleep, and those happen readily, to give themselves some grace during their training. And then the other part of the psychosocial component, and I empathize with this deeply, is that running oftentimes is so special to runners.
Amanda:We have a very special connection. Everyone loves their sport, but running, it lights up our brain with endorphins. It makes us feel great. Especially for women, their running group may be their primary social support, and they miss them, and they wanna be back with them yesterday. So they may be motivated to go harder than their body is necessarily ready for because they are seeking that that social support, and they miss their friends and they miss that thing that makes them feel like them.
Amanda:So just I think just opening it up with that and and asking them how they're doing emotionally. You know, postpartum depression is highly, you know, neurochemical experience. It's not just the feelings. It's all of these changes that are physiologically happening inside them. So, you know, one of the one of the nice things about pelvic therapy is we're behind a closed door.
Amanda:And if that's a conversation that we need to have for thirty minutes, then we're going to have it. So I always just say, you know, I know I felt like I wanted to go hard sooner than my body was capable for with of doing. How are you feeling? Where do you feel like you're at there? And then from there, we can use that conversation to recommend perhaps some counseling or some therapeutic support for them if we're recognizing some of those signs because, you know, a lot of runners too are trained that they deal with their stress by running and the more stress life pours on, the harder they run.
Amanda:Yep. And that's gonna put anybody at risk for a stress fracture, but particularly this population.
Jimmy:With the breastfeeding mother, is there a rule of thumb for calories, extra calories they should be consuming during that time?
Amanda:There is and it's escaping my brain. It is in our paper in British Journal of Sports Medicine. There is a recommended increase per day of energetic consumption.
Jimmy:I can think back to my wife's first our first child, and she was trying to get back to running fairly quickly, and was up to running something like 40 thirty, forty miles a week, and breastfeeding, and the two of those, the amount of calories she was burning, I just I think you would have to be extremely intentional to be able to meet those demands. For the mom, for the for the breastfeeding mom though, is there if are there things they can look out for? Maybe like drop in milk production or things like that that they should be paying attention to to make sure, maybe without tracking calories, but to ensure that they are hitting those goals and they don't slip into lower energy availability or reds?
Amanda:Yeah. Interestingly, a lot of them are sort of mood mood type symptoms. So feeling irritable, feeling malaise, so kind of not feeling well. Sometimes it can present as like a flu ish type fatigue, brain fog, irritability is a big one. And then sloggy on the run.
Amanda:I mean, think any runner can recognize too that feeling of feeling just kind of sloggy when you're exercising and then decrease in milk consumption. And sometimes if they're not pumping, that looks like irritability in the baby. If they're getting less during their nursing sessions, they can get a little bit fussier. They're crying more. They're wanting to nurse more and latch more and those kinds of things.
Jimmy:So the child is not getting the nutrients and showing that in that irritability. Yeah.
Amanda:So you
Jimmy:can look out for that. You can look out for the the mood stuff you mentioned. Do you I guess, personally with your patients, are you typically, like, referring out to a dietitian if they're trying to get back to serious running and breastfeeding and running it? Yeah. Like, running at a high level?
Amanda:Yeah. For those that I feel that I that I'm just in their history history or getting a sense that they're they're they're producing more work than they are taking in, I do recommend that. And somebody that specializes in athletes as well, just depending on your environment in your area, you know, just a typical dietitian may not quite know what to do with the the motivated postpartum athlete in front of you too. And the beauty of the internet is such now that sometimes you can get a consult with a talented one from from telehealth medicine as well.
Jimmy:Yeah, I'll plug Rebecca McConville, who I refer a lot of my patients to. She's in Kansas City. She's been on the podcast, but she's great. If anyone's interested, you can go back and listen to that podcast that I did with her.
Amanda:That's fantastic. And is she does she see people across state lines?
Jimmy:She does. Yeah. So she's worked with, I guess, people I've worked with all the way from California to the East Coast here. Yeah. Really good.
Jimmy:I found her through yeah. Like she works closely if you know Chris Johnson and Nathan Carlson. She's kind of like works with them. But yeah, she's great. She was Yeah, I think it's helpful to have all these people in your network to refer to someone like you when this stuff is over my head, I can't treat this, I need to send them out to you, the nutrition aspect, send them out to there.
Jimmy:I think early in my career, this is very overwhelming to try to refer out to folks. And I think, yeah, I think it makes a lot of help to helps a lot to think we're all a team, we're in this together and you can't do it all for one person.
Amanda:That's exactly right. I think early in our career, we're working so hard on establishing ourselves and we don't quite know like, are we going to lose trust if we're making a referral or am I going to get that patient back? And I think the longer we all do this, we realize that the patients are going to come and the patient is better off when they're getting all of their individual needs served. So recognizing where gaps are and if you have a gap and you want to fill it, you can take pelvic health level one and get your assessment skills.
Jimmy:If we go back to this this postpartum runner for a second, and it seems like there's just so much involved here and there's a lot of things we wanna be just like pay attention to to help this process go as smoothly as possible. Make sure we're avoiding bone stress injury or other injuries, making sure we're not slipping into that low energy availability state. You mentioned postpartum depression. How common is that?
Amanda:I think that the statistics are up around fifty to sixty percent to varying degrees now. I think it's underreported. I think a lot of people go through it and it's not necessarily labeled or diagnosed. I think that people are starting to share a lot more. I think that athletes and, you know, people in the entertainment industry being more forthcoming has removed some of the shame and stigma around it.
Amanda:But, yeah, it's it's pretty common. I mean, when you think too about what happens, I mean, these drastic body changes, this lack of sleep, and these new pressures on being a parent, I think a lot of us are gonna feel that sense of stress.
Jimmy:Yeah. Watching my wife go through it and just like, yeah, returning to work rather quickly in The US, it's like we don't get like we do in other places. My wife has been back to work, think every time at three months, and trying to nurse while she's a she's a PA and sees patients, so she's trying to nurse in between or sorry, pump in between patients and then making sure she's maintaining her milks, all this stuff you guys have to worry about that it seems like a very, very stressful time. And so is there something again, if I could tie it back to somebody like me, my setting like mine, should I be screening for this with my postpartum runners?
Amanda:Yes. I think you're if you're seeing someone, especially within the first five months, your suspicion that they are experiencing it should just automatically be high. Yeah. And I think it's worthwhile. And, you know, clinicians tend to be just really caring people anyway.
Amanda:So it's worthwhile just to ask, how are you doing? How how are you feeling, you know, with this lack of sleep? Are you and there's there's screening questionnaires that can be given as well that touch on, you know, are you feeling are you feeling like you are your life is not worth living? I mean, touches on some of those deeper questions. One of the questions is, do you feel like your your child and your family would be better off without you?
Amanda:You know? So they get at some of the the deeper ones. But it can even be as as far as just, are you not interested in the things that you used to be? And so when a runner comes in and they're, you know, they they might have these goals, but they they seem a little bit less interested, I dig a little deeper and ask, is it because life has changed and your your time is being distributed in other ways? Or is it because you're just not interested in the things that used to bring you joy anymore?
Amanda:So that's where we can just sort of ask a little bit further on on the topic too. But those malaisey, less interested
Jimmy:Sorry. I was gonna say maybe something like the the PHQ, that little questionnaire. I think it's nine questions. Something like that. Is there is there something maybe that you're aware of that's specific to postpartum or the PHQ would probably be sufficient?
Amanda:Yeah. There's a postpartum screening questionnaire that can be administered.
Jimmy:Yeah. I'll find that. We'll put it in the show notes. We've covered a lot of ground here getting these runners back. If we look at the evidence out there, so your papers were all consensus statements trying to distill from experts what we know about this and what we can do.
Jimmy:Are there current gaps in this in the literature here that you think we need to we need to pursue and study more?
Amanda:One thing that's been really fascinating to watch is within the last five years or so, a lot more lab studies are being done on the running mechanics and the behavior of the pelvic floor muscles. So there are, you know, people running kinematic and kinetic tests. There are people looking at EMG of the pelvic floor during running. And then there's a lot of different types of survey related study happening on athletes as to what their behaviors were and what the outcomes were. So something really fascinating.
Amanda:There was a study done because it's very hard to get past an IRB with pregnant patients. It's, you know, it's obviously for for many legal reasons, hard to study that that patient population. So one interesting thing that several teams, especially in Canada, are doing is they are finding postpartum people, and they are surveying them for what they did when they were pregnant. Like, how heavy did you lift? How far did you run?
Amanda:What were you know, and then looking at the outcomes to see how safe were those behaviors, how, you know, what were your symptoms and correlating and they're finding that a lot of people, as long as that pregnancy is medically safe and stable, are able to continue on with their exercises as they desire. So in terms of gaps, I think it's more getting really specific on the different sports. So guidelines for soccer recently came out in conjunction with FIFA. There was a whole team that worked on those. Guidelines for running are coming out and for lifting.
Amanda:So getting sport specific to show, you know, what the occurrence rates are for different symptoms or injuries and what sorts of activities people are able to do safely can help guide our expectations on the person in front of us.
Jimmy:Is that is that postpartum or during pregnancy or both?
Amanda:It's both.
Jimmy:Both. Awesome. Yeah.
Amanda:Yeah. Yeah.
Jimmy:So are there common myths you see that you're, like, constantly having to, like, say, oh, that's not really a thing here.
Amanda:Oh, yes. You know, running is not safe during pregnancy. You are going to put the pregnancy at risk. You're going to injure yourself. Certainly, certainly anyone can injure themselves.
Amanda:And if your your gait mechanics are falling apart, injury can occur. But labeling a whole condition and blaming the pregnancy is not yet evidence based. Another big myth is that you have to wait three months till postpartum. We know that that is gray area and that some people are able to start earlier and some people really need to wait even further on afterwards. And lifting was a is a big one.
Amanda:Christina Previtt up in Canada has done a lot of work to help dispel some of the myths around lifting heavy, like CrossFit type lifting during pregnancy. You know, as long as people are not doing big Valsalva movements and they're using clean mechanics and whatnot, a lot of them are able to lift pretty heavy, pretty deep into that pregnancy, and don't have adverse outcomes on themselves or baby.
Jimmy:Nice. Alright. So three misspelled there. So running is safe, can be safe, most likely is safe, lifting is safe, Three months is arbitrary. Doesn't matter.
Jimmy:It depends on the individual. Awesome. No. I love it. So Amanda, as we're wrapping up here, are there any let's say, so we talked about the myths there.
Jimmy:Any like common things you see therapists like me doing wrong and that I could do better?
Amanda:That's a good question. I would think one of the things that I just educate orthopedic colleagues on is if you're working with a patient who has low back pain, hip pain, IT band type symptoms, and you're following your normal course of action and they are being compliant. I hate the word compliant sometimes, but they're doing the thing. They're working hard. They're being earnest about their rehabilitation process and they're not improving.
Amanda:There's a high probability that the pelvic floor muscles are implicated and can be driving some of the symptoms. So just know that that that is more common than you might be aware of. The other thing is that the statistics around stress urinary incontinence in athletes, there's multiple papers that have shown anywhere from fifty percent to eighty percent, and that's even in athletes that have never been pregnant. So when you're thinking about your clinical day, let's just use an easy number like 10.
Jimmy:Mhmm.
Amanda:If you saw ten, like teenage and beyond athletic people that came into your clinic, six to eight of them are experiencing stress urinary incontinence. And so by screening, you can help pick up on that and refer them because it's not just about the leakage. If the leakage is occurring, there is some sort of functional issue with the pelvic floor. It may be that they're too weak, and it may be that they're too tight. So don't miss that.
Jimmy:Got it. And alright. Dumb question. But leaking for anyone, is it normal? Can it be normal?
Jimmy:Or is this typically, like, abnormal and fixable?
Amanda:It is common, but not normal. And it is fixable.
Jimmy:Awesome. Alright. So I have that pesky patient not getting better, IT band, hip related, whatever. I'm gonna think about referring to you. Can I just start with those five questions you mentioned and start there and say, something up here that can kind of give the red flag to say, alright, go see Amanda?
Jimmy:Awesome. Alright. Love it. Easy, simple. Amanda, anything else you would like to touch on before I let you continue on with your day?
Amanda:I think that we covered a lot of things. If people have any other additional questions, I'm always, always available. And I would just say that there's always hope, and you can do the thing that you love. And we're just here to help you do that thing in a way that is helping your body in the most optimal way.
Jimmy:Awesome. And then for the listeners out there, where can they learn more about you? Where can they hear yeah. Where can they learn more about you, I guess?
Amanda:Absolutely. I have a website, amanda oleson d p t dot com, and I'm active on Instagram with educational videos. And I present literature and evidence and those kinds of things, and that's at doctor Amanda Olson. Those are the two primary places, and, you know, they can certainly email me. Amandaolsondpt@gmail.com.
Jimmy:Awesome. Well, Amanda, I thank you so much for your time. It's been a great chat and, yeah, we will talk soon.
Amanda:Thank you so much for having me.
Jimmy:That's it for today on the Physio Insights podcast presented by Runeasi. Would you like to share an interesting case, insight, or have a thought about the podcast? Comment below, and don't forget to follow us for more episodes.