Introduction

Dr. Rachel Moore // #ICEPelvic // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, #ICEPelvic Division Leader Rachel Moore discusses reintroducing exercise early to the postpartum athlete, including modified CrossFit workouts, gymnastics, core training, and impact training.

Take a listen to learn how to better serve this population of patients & athletes.

If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

EPISODE TRANSCRIPTION

00:00 INTRO

Hey everyone, Alan here. Before we get into today's episode, I'd like to take a moment to introduce our show sponsor Jane. If you don't know about Jane, Jane is an all-in-one practice management software with features like online booking, scheduling, documentation, and a PCI-compliant payment solution. The time that you spend with your patients and clients is very valuable, and filling out forms during their appointment time can quickly take away from the time that you all have together. That's why the team at Jane has designed online intake forms that your patients can complete from the comfort of their own homes. And to help them remember to fill out their forms, Jane has your back with a friendly email reminder sent 24 hours before their appointment. This means they arrive ready to start their appointment, and you can arrive ready to help. Jane's online intake forms are fully customizable to ensure you're collecting everything you need ahead of time, whether that's getting a credit card on file, insurance billing details, or a signed consent form. You can build out your intake forms from scratch or use templates from Jane's template library and customize it further to meet your practice needs. If you're interested in learning more, head on over to jane.app slash guide. Use the code ICEPT1MO at sign up to receive a one-month grace period on your new account. Thanks everyone. Enjoy today's episode of the PT on ICE Daily Show.

01:22 RACHEL MOORE

Good morning PT on ICE Daily Show. My name is Dr. Rachel Moore. I am on faculty with the pelvic division here at ICE, and I am coming at you live from a different space than I normally am today. I was in San Antonio this weekend with Christina Prevot at a pelvic course, and it was a blast. It was so much fun. We met so many amazing people. We always love our weekends out on the road. So if you are interested in jumping into one of our upcoming live cohorts, we've got Scottsdale, Arizona coming up September 23rd and 24th. That is our live course. It'll be myself and Alexis Morgan. And then September 30th and October 1st, we actually have a course in Canada. Christina Prevot will be leading that one. So if you are north of the border and you're interested in jumping into one of our live pelvic courses, great opportunity to do that coming up. We also have our pregnancy and postpartum newsletter. If you're interested in learning about all things pelvic, staying up to date on everything pelvic, it's a great way to get resources sent directly to your inbox. And you can find that link on the website. So you might hear my baby screaming in the background because he's eating. My mother-in-law is feeding him, so just ignore the baby.

02:46 MODIFYING CROSSFIT WORKOUTS

I'm here to talk to you guys this morning about modifying workouts for the postpartum athlete, particularly in that early stage. So what I wanted to do is kind of break down one workout and talk about how somebody at four weeks, eight weeks or 12 weeks for the same athlete, maybe we would modify that workout. Modifying workouts can be confusing because there's no set standard of at this point you do this, at this point you do this. So kind of across the board, it's going to be very individualized depending on the athlete in front of you. This is something we dive into a ton in our online cohort and we have an entire assignment where we break down different types or the programming and talk about ways to modify it for a particular athlete. But just to kind of give you a little glimpse of what that looks like and just chit chat about it this morning, there are a few factors that we're going to really heavily consider when we're trying to decide what we want to do for a postpartum athlete. And before we dive into those, I want to talk about why.

04:09 GETTING ATHLETES BACK INTO THE GYM

Why do we care about getting an athlete back in the gym, maybe at that three to four week mark rather than waiting until six weeks or even later? Why are we really emphasizing and why do we promote here at ICE getting our athletes back? For a lot of women, the gym is their community and it is their mental health support system. And so postpartum in and of itself can be an incredibly lonely time, especially if you don't have a village around you and especially if you feel like you're isolated from a village that you maybe have. So if we can find ways to get these women into their boxes back at the gym, maybe bringing baby along in their car seat or stroller or if there's child care, great. But bringing baby along, finding ways to modify the stimulus appropriate for somebody that's at that three, four week postpartum mark, we feel that that is incredibly advantageous for mom from both a physical health standpoint. So what are the factors we're going to look at when we're deciding what workouts need to be modified and how to modify them? For one, we want to know what mom did before she was postpartum. So did she work out in pregnancy? What did she do prior to getting pregnant? Had she been a CrossFitter for years when she found out she was pregnant? What was her previous level of strength and did that maintain throughout pregnancy or did she take a long time off and see this big deconditioning response? Method of delivery is another thing that matters really heavily. Some issues with their anterior core wall, but we typically expect to see that somebody who's had a vaginal delivery is going to have potentially more struggles with pelvic floor dysfunction with things like heavy lifting and running and that are going to challenge that anterior core wall. Again, that's not a hard and fast rule. That's not saying it's the only way. We see that overlap, but that's kind of the things that we can expect to see based on the type of delivery. We also need to know about the type of delivery that we expect to see. Especially if they're breastfeeding, we need to make sure we're having the discussion with them about making sure that they're getting enough calories in to support their body and help that not only postpartum healing that is occurring naturally, but also that recovery from being in the gym. We also really want to think about mirroring the stimulus of the workout. So we're not going to do the same things that somebody who is not postpartum, four weeks postpartum is doing, but we want to think about what the intended stimulus of that workout is and try to find ways that we can match that intended stimulus, whether that's muscle groups that are being hit, whether it's cardiovascular versus more muscular strength or what kind of factors we're shooting for and prioritizing in that workout. We want to preserve that with our modifications. So let's break down an athlete and a workout and let's talk about how we would how I would scale this athlete at four weeks postpartum, eight weeks postpartum and 12 weeks postpartum. So our athlete, we're going to call her Suzy. Suzy is a CrossFitter. She's been doing CrossFit for seven years. She just had her first baby. She exercised during her pregnancy until 38 weeks and then she just kind of felt like she wanted to rush. She was feeling like, meh, I'm not really wanting to push fitness right now. I'm just going to kind of take it easy. Her previous lifts, her one rep max back squat was 215 pounds pre-pregnancy. Her one rep max deadlift was 275 pounds pre-pregnancy. Her strict press pre-pregnancy was 95 pounds. And from a gymnastics standpoint, she was able to do kipping pull-ups, bar muscle-ups, chest to bars, and she was able to do double-enders and workouts. So an athlete that has pretty decent experience in CrossFit. It isn't brand new to this and continued to exercise during her pregnancy, had a vaginal delivery. How would we modify a workout for her at four weeks? So we're going to take a workout. It's going to be the same throughout just for the sake of not being confusing. And it's hard to kind of conceptualize and listen. So our workout, the RX version of this workout is five rounds for time, 40 double-enders, three wall walks, 15 toes to bar, and 20 double kettlebell deadlifts. At four weeks postpartum, how are we going to modify for Suzy? So we're going to maybe keep that same stimulus of five rounds. We could also decrease that, but for this exercise, we'll keep that same stimulus of five rounds for time. Instead of 40 double-enders, four weeks postpartum is pretty dang early to start doing that impact. So instead of just doing something like calf raises that would work her calves, but maybe not tax her cardiovascular system, I'm going to have Suzy do a 30 second either bike, row or ski, whatever feels the most comfortable at a comfortable pace. So she's not going breakneck. She's not going to like an eight, nine out of 10 RPE. She's just moving and getting her heart rate up for 30 seconds. Instead of wall walks, we're going to do a 30 second, 30 second, 30 second workout. So swapping the three wall walks out for 12 elevated plank shoulder taps, really focusing on that core connection piece. So focusing on that hollow body, maintaining that core brace, making sure that she's not pushing down into the basement and doing plank shoulder taps to an elevated surface that is challenging for her, but does not feel uncomfortable in any way. Instead of toes to bar, thinking about what the components of that toes to bar are with that lap pressed down and core component piece. I'm going to have her hook a band up to the rig and face away from it. She's going to hold a isometric lap pressed down. So she's going to engage her lats. If you're watching, you can see, but facing away from the rig, hands are in the van, pressing down, standing in that hollow body position, focusing on maintaining that core brace. Focusing on maintaining that core engagement. And I'm going to have her do knee marches. So we're going to swap out those 15 toes to bar for 15 standing knee marches with isometric lap pressed down to mimic that pressing with the knee raise. We could also, if we're thinking about flipping this, preserving grip or reintroducing grip, have her hold an active hang for 30 seconds as well. Those are two options for the same athlete. And you could also alternate from round to round. So maybe one round, we're doing that lap pressed down knee raise. And then that second round, we're doing that active hang and we're alternating between those two. And then finally, instead of the 20 double kettlebell deadlifts, we can even just take bodyweight good mornings. These get sneaky on you if you haven't worked your hammies in a while. So putting hands behind the neck, nice flat neutral spine, hinging forward and coming back up. So her workout again, five rounds for time, 30 seconds on a cardio machine bike rower ski, 12 elevated plank shoulder taps focusing on maintaining that core engagement, either 15 standing marches with isometric lap press downs or 30 seconds of an active hang or whatever amount of time she was able to maintain. And then 20 bodyweight good mornings. That would be the workout for somebody who is four weeks postpartum. She's showing up to the gym. She's hitting a similar intended stimulus. She's moving. She's in class with her friends and she's getting a workout in. Let's take this same athlete, same workout and pretend we have fast forwarded for whatever reason she's now eight weeks postpartum. At eight weeks post, five rounds for time, 40 toe taps or line hops. So we are introducing impact at this point. We can absolutely have maybe began this earlier at about that six week point. So introducing that impact 45 times is a high volume. So if this was something where we wanted to work on single unders, we could maybe cut that rep scheme to 15 or 20 and then still have her do those five rounds focusing on that less volume as we're introducing impact. So two options there from that impact standpoint instead of three full wall walks, maybe we're having her do three modified wall walks. So if you've done the crossfit open and you did a scale division with the wall walk, you start out on the floor, press up on your hands, feet go on the wall and you go hand behind, hand behind, hand forward, hand forward, come all the way back down. The chest hits the floor again. to start working on that core engagement, that active shoulder and getting up on the wall. Alternatively, she can work on a wall walk as high as she can go. So two options there as well. Instead of toes to bar, we're going to say that she's been working on her hangs, she's building that grip strength, she's got that hip swing down. We're going to swap that out for hanging knee raises and maybe 15 is too high volume so we can do 10 hanging knee raises, working on that good kip swing, pressing down as she brings her knees up and really pulling through the bar to get into that arch position. And then finally for the double kettlebell deadlift, we're going to let her send that and she's just going to choose a weight that she's able to hang on to that is an appropriate stimulus for her that she's not feeling any heaviness, pain or leakage. So for this athlete at eight weeks postpartum, five rounds for time, either 40 toe taps or line hops or decreasing that rep scheme and adding in single unders to work on that impact with the rope swing. Three modified wall walks or walking up as high as she can. Ten hanging knee raises and 20 double kettlebell deadlifts at a lighter weight. Let's take this athlete, hit the fast forward button and now we're 12 weeks postpartum. Same workout, same athlete. Five rounds for time. We're going to let her play with double unders.

12:27 INTRODUCING IMPACT

So these 12 weeks postpartum, let's say we've been working on impact. Eight weeks we did some single unders or some line hops. That's four weeks of time to have built up the stimulus of maintaining or responding to that impact. So instead of setting a set number for her, I'm going to give her a time domain. I want you to spend about 30 seconds of effort working on your double under. Doesn't mean it has to be breakneck speed. Maybe she's getting two to three, getting into that pelvic recovery position, resting and then picking the rope back up. This is giving her time within that workout to work on the skills that we are hoping to get back to while progressing along in that impact. We're going to swap out wall walks. Maybe not three wall walks, maybe just two. She may be able to do three, but if not, then we are going to drop that number down to two. We can always scale volume with movements. Same thing for toes to bar. So maybe she's back to toes to bar. She's able to hang on to four or five and then she starts feeling some fatigue, hops down from the bar, jumps back up for that second set. Again, this is five rounds, so that cumulative volume does add up. So instead of 15 toes to bar, maybe we're dropping her down to eight toes to bar instead. And then finally, that double kettlebell deadlift, we're going to let her send it and we're going to think, okay, at eight weeks she may have done a certain weight. She's probably at a little bit heavier weight at this point. Maintaining able to breathe, not having leakage, not having heaviness, not having pain, but choosing a weight that feels great for her. Double kettlebell deadlifts are an incredibly functional thing if you're a mom, constantly picking up diaper bags and car seats and kiddos and all the things. So one workout, one person, three different timelines. There are options even within each timeline for this athlete. There is no one right answer when it comes to modifying a workout for an athlete. We need to consider the stimulus of the workout. We need to consider this athlete's history. We need to consider this athlete's recovery and we need to consider the athlete's goals. So when we take all of these things into account, this is kind of a day by day process starting out, but eventually we want to get to the point where our athletes understand how to make these modifications themselves and they feel comfortable. Okay, I can press the gas on this or maybe I need to take a step back on this. At the end of the day, our job is to help them figure this out as we are actively working towards getting back to doing all the things that it is that they want to do. I hope that makes sense. I know it's kind of hard without like, I'm a whiteboard person. So I hope you guys learned something this morning. This is an area that we cover in our online cohort. So if you are looking to learn more about modifying workouts for the postpartum athletes from a programming standpoint especially, hop into our online cohorts, come hang out with us live on the road. We've got tons of courses coming up between September to December and hopefully we'll see you guys soon. Bye!

18:02 OUTRO

Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.