Returning to running postnatal – guidelines for medical, health and fitness professionals managing this population

Research (PDF Available) · March 2019with 8,415 Reads 
How we measure 'reads'
A 'read' is counted each time someone views a publication summary (such as the title, abstract, and list of authors), clicks on a figure, or views or downloads the full-text. Learn more
DOI: 10.13140/RG.2.2.35256.90880/2
Cite this publication
Abstract
There is an absence of guidelines and evidence-based publications to guide post-natal women back to high impact exercise. Pelvic health conditions are common following pregnancy and delivery and often create a barrier to exercise. Symptoms of pelvic floor dysfunction significantly impact upon a woman's quality of life. High impact exercise, such as running, is understood to predispose women to symptoms of pelvic floor dysfunction amongst other musculoskeletal injuries if they are not ready for it. These proposed guidelines aim to offer evidence-based recommendations and advice to returning to running post-natal in order to prevent pelvic floor dysfunction or injury.
Figures - uploaded by Grainne Donnelly
Author content
All content in this area was uploaded by Grainne Donnelly
Content may be subject to copyright.
1
Author’s - Tom Goom, Gráinne Donnelly and Emma Brockwell
Published March 2019
Tom Goom is Clinical Lead at The Physio Rooms and a specialist in the management of
running injury. He has published research on tendinopathy and presents in the UK and
internationally on a number of running related topics. His website running-physio.com has
gained a worldwide audience with over 6 million page views.
Gráinne Donnelly is an Advanced Physiotherapist and Team Lead for pelvic health
physiotherapy in both NHS and private sector in N. Ireland. She is a full member of Pelvic
Obstetric and Gynaecological Physiotherapy and is currently completing a Masters in
Advancing Practice. She is the co-founder of Spark Cancer Rehabilitation, a non-profit
cancer rehabilitation service in N. Ireland. She is passionate about improving the quality
and consistency of information to guide women back to normal life after having a baby.
Emma Brockwell is a Women’s Health Physiotherapist. She specialises in postnatal
rehabilitation and is passionate that all women return to postnatal exercise safely and
effectively. She actively campaigns for improvements in women’s health care co-founding
Pelvic Roar, a pelvic health campaign group. She has written for Women’s Running and
Women’s Health Magazine and runs her own walk/run club, aimed at educating and
encouraging women of all ages to walk and run without pelvic floor dysfunction.
Returning to running postnatal guidelines for medical,
health and fitness professionals managing this population
1
Officially endorsed by:
2
We are very grateful to all the individuals listed below for their invaluable feedback, input,
dissemination and advice to help create this guideline and, in turn, help women to return to
the sport that they love:
Stuart Butler (England Athletics Physiotherapist & Medical Lead)
Claire Callaghan (Women’s Health Physiotherapist & Running Workshop Lead)
Victoria Liu (Women’s Health Physiotherapist & creator of The Bulletproof Runner)
Tom Gray (Physiotherapist, lecturer and runner. Cover photo source)
Myra Robson (Senior Women's Health Physiotherapist, Lewisham and Greenwich NHS
Trust)
Mr Patrick Campbell (Consultant Urgynaecologist, Belfast Health and Social Care Trust)
Elaine Miller (Pelvic Health Physiotherapist and stand-up comedian)
Teresa Cook (POGP post-graduate tutor)
Dr Juliette McGratten (Health Expert, Author, Blogger, Lead Physical Champion for
Public Health England (NW), 261 Fearless Women’s Health Lead and Master Coach
Antony Lo (The PhysioDetective, Australia)
Marika Hart (Women’s Health Physiotherapist and founder of Herasphere, Australia)
Maeve Whelan (Milltown Physiotherapy, Dublin, Ireland)
Helen Keeble (Pelvic Health Physiotherapist & Womens Health Tutor)
Cinny Cusack (Physiotherapy Manager, Rotunda Hospital, Dublin)
Niamh Kenny (Senior Physiotherapist, Rotunda Hospital & Cityphysio, Dublin)
Suzanne Carney (Senior Physiotherapist, Ireland)
Siobhan O’Donovan (Specialist Physiotherapist and founder of Posture Matters)
Chloe Hamilton (Musculoskeletal Team Lead Physiotherapist, WHSCT, N. Ireland)
Joanne O’Neill (Clinical Specialist Musculoskeletal Physiotherapist, WHSCT, N. Ireland)
Sarah Haag (Doctor of Physical Therapy, Entropy Physiotherapy & Wellness, USA)
3
Foreward
There are currently no national/international guidelines that standardise practice and provide
a framework to support health professionals working with women who wish to return to
running after having a baby. Musculoskeletal pain, urinary incontinence, abdominal
separation (Blyholder et al. 2016) and pelvic organ prolapse (POP) are prevalent conditions
amongst postnatal runners. Awareness and understanding of the importance of optimal
postnatal recovery in the prevention and management of these “common but not normal”
conditions is increasing.
These guidelines have been created by the dedicated work of Tom Goom, Gráinne Donnelly
and Emma Brockwell who have a passion in increasing awareness about the importance of
safe and timely return to running postnatal. The evidence base for returning to running in
the postnatal period, as well as returning to exercise in general, is limited. This document is
based on the best available evidence alongside experienced clinical opinion. It is designed
to assist clinical reasoning rather than replace it. It does not provide a prescriptive approach.
Instead, the advice will need to be adapted to suit each individual’s needs.
Our vision is that these guidelines will assist health professionals to develop services for
their population of postnatal women and that they will provide the starting point for the
development of professionally-accredited, standardised, research-informed guidelines. We
will review and update these guidelines in 1 year and continue to format them for ease of
use by non-health professionals, professionals with no specialised training in postnatal care
and the general public.
We envisage that the guideline, as it stands, will sit within the public domain and therefore
be accessible to the public and all professionals that may come into contact with postnatal
women e.g. fitness professionals, midwives etc. It is not our intention that patients, fitness
instructors, medical professionals or non-pelvic health physiotherapists should carry out all
of the recommended tests in this guide but instead use it to be informed and aware of
important signs or symptoms suggesting lack of readiness, and signpost to an appropriate
health professional to assist with assessment and rehabilitation e.g. Specialist
Physiotherapist, General Practitioner (GPs), Urogyanecological Consultant.
4
The scope of this guideline is to provide an overview of considerations for the postnatal
woman returning to exercise. It is not within the scope of this document to discuss each
consideration in detail. We recognise the potential for this guideline to be applied to women
post-gynaecological surgeries or those presenting with pelvic health issues not related to
pregnancy, however this is not the intended target population and the research has not been
considered in this context.
It is advisable that these guidelines are read in their entirety to understand the rationale and
evidence behind the recommendations. The evidence has been evaluated using the Royal
College of Obstetrician’s and Gynaecologist’s (RCOG) classification outlined in a recent
Green Top Guideline (Jauniaux et al. 2018):
Classification of evidence levels table:
Level
Evidence
1++
High-quality meta-analyses, systematic reviews of randomised controlled
trials or randomised controlled trials with a very low risk of bias
1+
Well-conducted meta-analyses, systematic reviews of randomised controlled
trials or randomised controlled trials with a low risk of bias
1-
Meta-analyses, systematic reviews of randomised controlled trials or
randomised controlled trials with a high risk of bias
2++
High-quality systematic reviews of case-control or cohort studies or high
quality case-control or cohort studies with a very low risk of confounding,
bias or change and a high probability that the relationship is causal
2+
Well-conducted case-control or cohort studies with a low risk of
confounding, bias or chance and a moderate probability that the relationship
is causal
2-
Case-control or cohort studies with a high risk of confounding, bias or
chance and a significant risk that the relationship is not causal
3
Non-analytical studies; e.g. case reports, case series
4
Expert opinion/Formal consensus from guideline development group
We welcome any feedback and discussion surrounding the guidelines, particularly regarding
any evidence base that we may have overlooked. Please email grainne@absolute.physio
or physiomum@hotmail.co.uk with any feedback.
5
Contents Table (i of ii)
Content
Page Number(s)
Author Biographies and Foreword
1
Professional Acknowledgements
2
Foreword
3-4
Background
7-8
Guidance for GPs, medical, nursing and allied health professionals
caring for this population
9-11
Guidance for patients and non-clinical persons in evaluating readiness
to return to running following pregnancy
12
Guidance for musculoskeletal and pelvic health physiotherapists
caring for this population
13-15
Key Point Summary 1
15
Load and impact management assessment
16
Strength testing
17
Key Point Summary 2
17
Additional factors for consideration:
18-23
Weight
18
Fitness
18
Breathing
18
Psychological status
18
Diastasis Recti
19
Scar mobilisation
20
Breastfeeding
20
Supportive Clothing
21
Sleep
22
(RED-S)
22-23
Key Point Summary 3
23
Goals
23
Return to running
24-25
Running with a buggy
26-27
Key Point Summary 4
27
6
Contents Table (ii of ii)
Summary of Evidence-based recommendations
28
Moving forward further guideline development
28-29
References
30-37
Appendix 1 - Flow chart of considerations guiding return to running
postnatal
38
Appendix 2 - Example of exercise progression for the early postnatal
period
39
Appendix 3 - Return to running 12 weeks postnatal and beyond
40
7
Background
Common postnatal pelvic health issues such as urinary incontinence are understood to
create a barrier to exercise (Nygaard et al. 2005). Engagement in regular physical activity is
a public health priority due to the established health benefits that it provides. Considering
the points listed above, the authors of these guidelines believe that a framework is required
which supports health professionals in providing appropriate advice to women following
delivery and returning to exercise. The present authors also recognise and consider that,
due to increasing pressures within the National Health Service (NHS), postnatal checks by
GPs are not always standard practice across the UK. In addition, GPs have highlighted that
they are not provided with adequate training in this area so, where it does occur, the
postnatal check may simply involve subjective evaluation and advice. Variations also exist
in the amount of antenatal and postnatal care provided throughout the UK.
A review of exercise guidelines highlighted the lack of focus, clarity and consistency for
postnatal return to exercise (Evenson et al. 2014):
UK guidelines (RCOG 2006) recommend that a medical caregiver should be
consulted before resuming pre-pregnancy physical activity.
Norwegian guidelines (Strømme et al. 2000) state that women can generally start
exercising after 6 weeks but that self-perception forms an important indicator for what
type of exercise to engage in.
Australian guidelines (SMA 2009) caution against activities that cause high
gravitational load on the pelvic floor e.g. running/aerobics
All of the above guidelines refer to consideration of the mode of delivery with C/S
requiring more time to recover.
No guidelines considered normal deliveries which required stitches (following
perineal tears or episiotomy) however a more recent publication (Bø et al. 2017)
highlighted that operative delivery requires further recovery and consideration prior
to return to exercise.
It was identified that the 6-week postnatal check is too long to wait for postnatal
women to resume or begin a low intensity physical activity program including walking,
pelvic floor and abdominal muscle exercises (Evenson et al. 2014).
8
It is the consensus of the present authors that evaluation by a health professional must take
account of patient perceived symptoms regarding safety of exercise in order to provide best
practice in supporting women back to running in the postnatal period. It is the responsibility
of all health professionals to ensure that they are working within their personal scope of
practice, however physiotherapists are well placed to evaluate fitness levels and abilities to
support a return to exercise for such women. Using the combined skillsets of
musculoskeletal / sports physiotherapists alongside specialist pelvic health physiotherapists
will ensure that a comprehensive evaluation of the postnatal woman can be achieved.
After having a baby, the pelvic floor is weak and injured in most women and may need
instruction and supervision to be able to perform a correct pelvic floor muscle contraction,
especially in those women who did not train these muscles before birth (Bø et al. 2017).
High-impact activity, such as running, is associated with a sudden rise in intra-abdominal
pressure (Leitner et al. 2016). It has also been reported that ground reaction forces of
between 1.6 and 2.5 times bodyweight can occur when running at a moderate speed of 11
Kilometers/hour (Gottschall and Kram 2005). Presently, it is unknown if or how much of this
is absorbed through the lower limb on impact and therefore it is assumed that some, if not
all, of those forces are also transmitted to the pelvic floor. This highlights the importance of
strength and speed of contraction in the pelvic floor muscles in order to carry out their role
in pelvic organ support and continence during high impact activities (Leitner et al. 2016). It
also helps reason why weak, less co-ordinated muscles in postnatal women may not
achieve the level of function needed to maintain these roles and highlights the importance
and indication for adequate rehabilitation. The evidence supporting individualised pelvic floor
rehabilitation for the management of urinary incontinence (, 2003; Dumoulin et al. 2018;
Price et al. 2010), POP (Hagen et al. 2013), sexual dysfunction (Brækken et al. 2015) and
the prevention of POP (Hagen et al. 2016) is well established.
Evaluating readiness to return to running following pregnancy
Evidence-Based Recommendation 1: Postnatal women can benefit from
individualised assessment and guided pelvic floor rehabilitation for the
prevention and management of pelvic organ prolapse, the management of
urinary incontinence and for improved sexual function. Level 1+
9
Guidance for GPs, medical, nursing and allied health professionals
caring for this population
Running is a high impact sport placing a lot of demand on the body. In a recent systematic
review investigating urinary incontinence in female athletes (De Mattos Lorenco et al. 2018),
high impact exercise was found to have a 4.59 fold increased risk of pelvic floor dysfunction
compared to low impact exercise. Postnatal women need adequate time to heal and regain
strength, particularly in the abdominal and pelvic floor muscles after pregnancy and delivery.
It is understood that the levator hiatus area widens during pregnancy and increases
significantly after vaginal delivery. In most women following vaginal delivery, it is thought to
return to a similar area by 12-months postnatal as to that seen immediately after caesarean
delivery. However it is does not return to prenatal size (Stær-Jensen et al. 2015). Recovery
of the levator ani muscle and associated connective tissue and nerves is generally
maximized by 4-6 months postnatal and is considered to be a reflection of levator hiatus
area recovery (Shek et al. 2010, Stær-Jensen et al. 2015).
Bladder neck mobility increases after vaginal delivery and, while the support to the bladder
neck can improve postnatal, mobility remains higher than when measured at 37 weeks
gestation (Toozs-Hobson et al. 2008, Stær-Jensen et al. 2015).
Following caesarean section delivery, consideration should also be given to the healing and
remodeling of the uterine scar. It has been shown by ultrasound investigations that the
uterine scar thickness is still increased at 6-weeks postnatal suggesting that the process of
scar remodeling after caesarean delivery extends beyond the traditionally accepted period
(Hamer et al. 2007). This is further supported by the understanding that abdominal fascia
has only regained 51%-59% of its original tensile strength by 6-weeks post caesearean
section and 73%-93% of its original tensile strength at 6-7 months postnatal. (Ceydeli et al.
2005).
10
We therefore recommend that a low impact exercise timeline is followed within the first 3
months of the postnatal period (see Appendix 2), followed by a return to running between 3-
6 months postnatal, at the earliest, (see Appendix 3). In addition to this every postnatal
mother, regardless of delivery mode, should be offered the opportunity to receive a pelvic
health assessment (from 6-weeks postnatal) with a specialist physiotherapist to
comprehensively assess the abdominal wall and pelvic floor including vaginal +/- anorectal
examination as indicated. As previously mentioned, the high level evidence supporting
pelvic floor rehabilitation for the management of all types of urinary incontinence (Dumoulin
et al. 2018), the prevention and management of pelvic organ prolapse (Hagen et al. 2013;
Hagen et al. 2016) and for improved sexual function (Brækken et al. 2015) is well
established. A screen for signs and symptoms of pelvic floor dysfunction (refer to Table 1,
p10) alongside risk factors (refer to Table 2, p11) will assist identification of issues needing
to be addressed and highlight the importance of getting a pelvic health assessment and
professionally guided rehabilitation (refer to evidence-based recommendation 1). A
validated tool such as the Australian Pelvic Floor Questionnaire can provide a useful screen
for pelvic floor dysfunction.
Evidence-Based Recommendation 2: Return to running is not advisable
prior to 3 months postnatal or beyond this if any symptoms of pelvic
floor dysfunction are identified prior to, or after attempting, return to
running. Level 4
Table 1: Key signs/symptoms of pelvic floor and/or abdominal wall dysfunction
Urinary and/or faecal incontinence
Urinary and/or faecal urgency that is difficult to defer
Heaviness/pressure/bulge/dragging in the pelvic area
Pain with intercourse
Obstructive defecation
Pendular abdomen, separated abdominal muscles and/or decreased abdominal
strength and function
Musculoskeletal lumbopelvic pain
11
The increased awareness of pelvic health issues and the importance of adequate postnatal
recovery has been identified recently in the NHS 10 year plan (see page 49 section 3.17 at
https://www.longtermplan.nhs.uk/wp-content/uploads/2019/01/nhs-long-term-plan.pdf)
however local resources and pathways may not be adequately in place as yet. It is predicted
that the provision of postnatal services will develop and expand over the coming years in
light of the NHS long term plan. The development and design of recommended services will
inform local pathways regarding who should refer into physiotherapy services or carry out
pelvic health screening questionnaires.
Other considerations for medical, nursing and allied health professions caring for the
postnatal population are outlined on pages 16-20 Additional factors for consideration” and
may highlight further issues that they can address.
Table 2: Risk factors for potential issues returning to running
Less than 3 months postnatal
Pre-existing hypermobility conditions (e.g. Ehlers-Danlos)
Breastfeeding
Pre-existing pelvic floor dysfunction or lumbopelvic dysfunction
Psychological issues which may predispose a postnatal mother to inappropriate
intensity and/or duration of running as a coping strategy
Obesity
Caesarian Section or perineal scarring
Relative Energy Deficiency in Sport (Red-S)
12
Guidance for patients and non-clinical persons in evaluating readiness
to return to running following pregnancy
Running is a high impact sport placing a lot of demand on your body. To be run ready, your
body needs time to heal and regain its strength after having a baby. For this reason we
recommend following an initial low impact exercises timeline (see Appendix 2) followed by
return to running between 3-6 months postnatal (see Appendix 3). It is recommended that
all women, regardless of how they deliver, seek out a pelvic health assessment with a
specialist physiotherapist to evaluate strength, function and co-ordination of the abdominal
and pelvic floor muscles which are often impacted by pregnancy and delivery.
The importance of getting referral to a pelvic health physiotherapist is further highlighted if
any of the following signs and symptoms are experienced prior to, or after attempting, return
to running:
Heaviness/ dragging in the pelvic area (can be associated with prolapse)
Leaking urine or inability to control bowel movements
Pendular abdomen or noticeable gap along the midline of your abdominal wall.
(This may indicate Diastasis Rectus Abdominis (DRA))
Pelvic or lower back pain
Ongoing or increased blood loss beyond 8 weeks postnatal that is not linked to
your monthly cycle
13
Guidance for musculoskeletal and pelvic health physiotherapists caring
for this population
The objective measures described in this section are to be used by clinicians within their
scope of practice. It is recommended that pelvic health and musculoskeletal
physiotherapists work together in their evaluation of postnatal women looking to return to
running.
A quick reference guide to evaluate fitness to return to running postnatal can be found in
Appendix 1.
Criteria for return
(i) Err on the side of caution due to risk of pelvic floor dysfunction.
(ii) Combine time-based criteria with specific signs, symptoms, tests and recognised
risk factors (refer to Table 2, p11).
Time based criteria
Aim for a return to running between 3-6 months postpartum providing the individual has
passed the criteria listed below which will be discussed in greater detail throughout the
document. Refer to Evidence-Based Recommendations 1 and 2 for further understanding.
Assessment of pelvic health
Return to running is not advisable if any of the following subjective or objective issues are
identified during screening:
Subjective symptoms:
Urinary and/or faecal incontinence prior to or during commencement of running
Pressure/bulge/dragging in the vagina prior to or during commencement of running.
Ongoing or onset of vaginal bleeding, not related to menstrual cycle, during or after
attempted low impact or high impact exercise (refer back to care provider).
Musculoskeletal (MSK) pain e.g. pelvic pain prior to or during commencement of
running.
14
Objective measures:
Until future research informs the efficacy of hypotheses suggesting reflexive recruitment
of pelvic floor activity is stimulated during higher impact activities (Leitner et al. 2016) the
consensus of this guide is that running is less advisable if there is lower than grade 3
Modified Oxford Manual Muscle Testing (MOMMT) score during digital vaginal (Laycock
and Jerwood 2001) or ano-rectal examination. Testing in both crook lying and functional
positions, e.g. standing, is recommended to get a true indication of pelvic floor function
and pelvic organ support. (NB-See further guidance below regarding GH+PB in order to
assist overall clinical reasoning regardless of strength grade).
Reduced pelvic floor muscle endurance. Recommended baseline in standing:
10x fast reps
8-12 reps of 6-8 second maximum voluntary contraction
60 seconds submaximal 30-50% contraction
GH+PB ≥7cm on Valsalva
Regardless of MOMMT score, it is advisable that the evaluation of the risk of developing
pelvic organ prolapse (POP) should be carried out via the GH+PB component of the
POP-Q Assessment (Bump et al. 1996; Reimers et al. 2018) considering that 7cm
length on valsalva is highly predictive of apical support loss (Khunda et al. 2012). If POP
or significant apical loss is identified, a vaginal pessary should be considered to reduce
the worsening of fascial support and facilitate return to running.
Women who present with <grade 3 MOMMT score without identifiable compromise in
their fascial support (i.e. GH+PB <7cm) may be considered appropriate for graded return
to running if no other signs or symptoms are present during load impact testing (p16).
Similarly, women presenting with ≥grade 3 MOMMT score who demonstrate significant
apical loss or ballooning at the hiatal area (GH+PB 7cm) should have fascial support
deficits addressed via a pessary or other support devices prior to return to running.
Education regarding the identified risk of POP if the fascial support is not addressed
should be provided.
Evidence of incontinence during examination
15
NOTE: The identification of any of these issues should indicate referral to (or ongoing
care by) a pelvic health physiotherapist. Lack of progress with conservative
management or any identified concerns related to pelvic floor dysfunction should
indicate liaison with the GP and referral into local continence and/or urogynecology
pathways. Local referral pathways will vary they are likely to include options such
as GP referral, direct referrals from physiotherapists and self-referral. The health
professional needs to understand the pathway for women under their care.
Key Point Summary 1:
(i)
Every mother should have the option to access a pelvic health assessment.
(ii)
Subjective symptoms suggesting pelvic floor dysfunction should be identified
(iii)
Pelvic floor strength, endurance and co-ordination should be evaluated
(iv)
The presence and risk of pelvic organ prolapse should be evaluated
(v)
The presence of postnatal pelvic or lower back pain should be evaluated
(vi)
Lack of progress with conservative measures or identified concern related to
pelvic floor dysfunction indicates referral into urogynaecology pathways
16
Load and impact management assessment
In order to successfully complete this assessment, the postnatal mother needs to achieve
the following without pain, heaviness, dragging or incontinence:
Walking 30 minutes
Single leg balance 10 seconds
Single leg squat 10 repetitions each side
Jog on the spot 1 minute
Forward bounds 10 repetitions
Hop in place 10 repetitions each leg
Single leg ‘running man’: opposite arm and hip flexion/extension (bent knee) 10
repetitions each side
Video analysis, similar to methods currently used in running gait analysis, may offer
clinicians a platform to evaluate signs of failed lumbopelvic or abdominal load transfer as
well as a method of measuring progress between sessions.
Load impact management tests may be repeated after steps have been taken to manage
any identified pelvic health issues e.g. retest with a pessary or continence aid such as
Contiform and/or sportswear/products aimed at supporting the pelvic floor and lumbopelvic
area (Okayama et al. 2019) such as EVB Sportswear (Sheridan et al. 2015). If symptoms
are reduced these can be used to assist the return to impact activities.
Consideration of the risk of Relative Energy Deficiency in Sport (RED-S), a more
comprehensive term for what was previously referred to as the Female Athlete Triad
Syndrome (Mountjoy et al. 2014), is important during this stage of assessment and
progression. It describes the impairment of bodily functions due to excess energy
expenditure without adequate replacement as a result of excessive activity or other lifestyle
factors. Postnatal women with RED-S are at increased risk of stress fractures (Mountjoy et
al. 2014), pelvic floor dysfunction (Carvalhais et al. 2018) and fertility issues. See more about
RED-S on p22.
17
Strength testing
In order to ensure key muscle groups are prepared for running, each of the following
movements should be performed with the number of repetitions counted to fatigue. Aim for
20 repetitions of each test.
Single leg calf raise
Single leg bridge
Single leg sit to stand
Side lying abduction
Assessing the strength of all key hip muscles; abductors, adductors, flexors, extensors and
rotators is also recommended (Chumanov et al. 2012). This can be done isometrically and
measured with a hand held dynamometer where available.
NOTE: Weakness in these areas of strength testing should not be considered a barrier
for return to running but instead identify where strength work can be directed.
Key Point Summary 2:
(i)
Evaluate load management through a series of specified tests
(ii)
Specified tests should be achieved without heaviness, dragging or incontinence
(iii)
Video analysis may offer additional benefit to load management testing
(iv)
Assess strength of key muscle groups (calf, quads, hamstrings, glutes,
abdomen)
Evidence-Based Recommendation 3: The assessment of pelvic health,
load impact management, and strength testing described in this section is
based on expert clinical consensus drawing from the best available
evidence. No studies specific to the postnatal population have been carried
out to evaluate readiness to return to exercise. Level 4
18
Additional factors for consideration
The following factors must also be taken into consideration as part of the postnatal
evaluation:
Weight - Being overweight increases the load on pelvic floor. Women are considered at a
higher risk of pelvic floor related symptoms if they have a BMI >30 (Pomian 2016). In
keeping with an increased risk for musculoskeletal injuries (Nielsen et al. 2013), it is
recommended that weight management is addressed in women with BMI>30 prior to return
to running. It is acknowledged that exercise is an important component of weight loss and
therefore low risk forms of exercise are advisable until BMI is within targeted range. Refer
to NICE guidance (2010) on “Weight Management before, during and after pregnancy” and
Appendix 2 for low impact exercise options.
Fitness - Encourage safe and appropriate early postnatal fitness work. Refer to Appendix
2 for an example of suggested exercise progression.
It must be noted that assessment and rehabilitation plans will vary depending on individual
birth experience and issues.
Breathing Encourage a slow pace on initial return to running such that would allow the
individual to maintain a conversation. Analysis of breathing pattern is recommended as part
of the postnatal evaluation in order to ensure optimal breathing strategies are restored
including synergy between diaphragm, abdominals and pelvic floor.
Psychological status - screening for Postnatal Depression (PND) (e.g. using the Edinburgh
Depression Scale) is appropriate as part of the assessment of readiness for sport (e.g.
attitudes to training, evidence of previous exercise addiction). PND is experienced by
approximately 20% of mothers (Camacho and Shields 2018). Where running is important
for mental wellbeing it is important to advise on alternative coping strategies (such as
relaxation, mindfulness, counselling) alongside supervised exercise opportunities e.g. local
community ‘couch to 5km’, Park Run, or health trust initiatives for suitable active living in
partnership with local gym instructors).
19
Diastasis Rectus Abdominis (DRA) Screening / management for DRA, the separation
of the outer most abdominal muscles (see figure 1), is recommended by a suitably qualified
professional, e.g. pelvic health or musculoskeletal physiotherapist with experience in DRA.
DRA can impact upon the function of the abdominal wall, particularly rectus abdominus
function and rotational torque (Hills et al. 2018). There is a paucity of evidence for the impact
of running with DRA. The relationship between DRA and pelvic floor dysfunction continues
to be debated with no conclusive outcome from the limited research base, however, a recent
systematic review confirmed that there is a weak correlation between DRA and pelvic organ
prolapse (Benjamin et al. 2018).
The expert consensus from specialist pelvic health physiotherapists is that running prior to
regaining functional control of the abdominal wall (in order to manage IAP and load transfer)
may be counter-productive and result in overloading or compensatory strategies in the pelvic
floor. Until such time that research informs us otherwise, the current authors suggest that
DRA should be considered in terms of potential risk for pelvic floor dysfunction.
Whilst it is not within the scope of this document to advise on the comprehensive
assessment and rehabilitation of DRA, the overall aim is to focus on strategies that optimise
IAP management and load transfer across the abdominal wall. A mother can return to
running with a diastasis if it is functional, i.e. abdominal muscle separation is present but the
mother has strategies to control IAP and transfer load across the abdominal wall.
Failed load transfer can be indicated by abdominal doming/sinking at the midline, lateral
shift of the trunk or significant rib flare during load transfer tests such as active SLR to 30
degrees, resisted trunk rotation or chin to chest.
Figure 1 Diastasis Rectus Abdominis
20
Scar mobilisation consideration of scar mobility and the need for scar mobilisation
should be given regardless of mode of delivery. Both c-section and perineal scars can
result in pain and restriction. A healing wound results in alteration of tissue dynamics due
to modifications to the mechanical tension compared to that of the adjacent region
(Tomasek et al. 2002). This may impact on the function of adjacent muscles and
structures. When considering the abdominopelvic location of a c-section, the surgical scar
resulting from a Pfannenstiel incision may affect different organs and systems. The
digestive, urinary, reproductive and locomotive systems can potentially be affected by a
scar in such a location (Comesaña et al. 2017). Proposed benefits of scar mobilisation
include reducing inflammation, fibrosis, and improving tissue remodeling (Benjamin et al.
2008; Bouffard et al. 2008). It is therefore recommended as good practice to assess and
implement advice and guidance regarding scar mobilisation.
Breastfeeding The World Health Organisation (WHO) advises women to breastfeed for
at least the first 6 months postnatal and up 2 years (WHO 2016). It is likely that women
embarking on return to running are still breastfeeding. It is recognised that breastfeeding
prolongs the presence of a hormonally altered environment in the postnatal mother with
lower levels of oestrogen and the possibility for slightly raised levels of relaxin to continue.
Theories that higher relaxin levels postnatal increase the risk of joint laxity and potential
injury have not been proven (Marnach et al. 2003; Schauberger et al. 1996). It is not fully
understood why some breastfeeding women may have increased joint laxity compared to
baseline however it is recognised that the overall environment of hormones during this
period of time and up to 3 months following weaning may influence joint laxity. This, in
turn, may increase the mother’s risk of developing injury or dysfunction, including pelvic
floor dysfunction or pelvic organ prolapse. It is important to establish whether any pre-
existing joint mobility existed prior to pregnancy and whether the environment that
breastfeeding creates is significantly exacerbating this.
It is recommended that consideration of breastfeeding status is given to a postnatal mother
throughout the process of her evaluation for return to running. Education should be
provided about timing of feeds around running, to ensure that the breasts are not overly
full or likely to become uncomfortably full during the run (ACOG, 2002). It is also important
to consider hydration and the degree of exertion when a mother returns to running, in
21
order to reduce potential impact upon the supply of milk. Women should be advised that
moderate to vigorous exercise during lactation does not affect the quantity or composition
of breast milk or impact infant growth (Cary and Quinn 2001; Davies et al. 2003; ACOG
2015). It is essential that postnatal mothers feel supported in their choice to continue
feeding by offering solutions and advice to support continued breastfeeding while returning
to running.
Supportive clothing - Women may benefit from wearing a personally fitted sports bra
that offers support rather than compression (McGhee et al. 2013) as this provides
significantly increased breast and bra comfort compared with a standard encapsulation
sport bra during exercise (McGhee et al. 2010). High breast support has been suggested
to be more beneficial in female runners and should be considered when fitting (Milligan et
al. 2015). Personal fitting of sports bras is not common practice among female runners
with most opting for off the shelf sizes however its merit is acknowledged for this
population and health professionals are advised to increase awareness of the importance
of getting professionally fitted (Brown et al. 2014).
Advice should be provided on the importance of supportive footwear. It should be noted
that shoe size can alter permanently with pregnancy and footwear previously worn should
not be presumed to be the correct fit.
Sportswear and clothing aimed at supporting the pelvic floor and lumbopelvic area is
gaining increased awareness and understanding for the benefits that they may offer.
Okayama et al. (2019) demonstrated that wearing supportive underwear was almost as
effective as pelvic floor muscle training in reducing stress urinary incontinence in women at
the end of a 6-week trial period. Ongoing high-quality studies are required to evaluate how
each intervention compares beyond 6-weeks and also specifically in relation to high impact
exercise, however, the outcome of this trial suggests that supportive
underwear/sportswear may have a role alongside pelvic floor rehabilitation in the
management of pelvic floor dysfunction and postnatal return to exercise. Studies
investigating the protective and preventative benefits of such products are also welcomed.
22
Sleep Sleep is key for recovery from both physical and psychological stress and is
frequently restricted in the post-partum period and beyond. Sleep deprivation in athletes is
associated with increased injury risk (Milewski et al. 2014), lower general health and
increased stress (Biggins et al. 2017). Sleep loss is also thought to reduce muscle protein
synthesis and impair maximal muscle strength (Knowles et al. 2018). Current research
recommends 7 to 9 hours of sleep per night (Bonnar et al. 2018). Day-time naps can be
used to extend sleep and reduce the effects of sleep deprivation (Bird 2013). These can
be timed to coincide with the infant’s sleep schedule. It can be challenging to increase
sleep time so it’s important to optimise sleep quality by creating a relaxing routine to
prepare for sleep. This includes reducing stimulation from ‘screen time’, creating a cool,
comfortable sleep environment and avoiding consumption of alcohol or caffeine (Bird
2013).
Relative Energy Deficiency in Sport (RED-S) previously referred to as the Female
Athlete Triad Syndrome it refers to impaired physiological functioning caused by relative
energy deficiency including impairments of metabolic rate, menstrual function, bone
health, immunity, protein synthesis and cardiovascular health (Mountjoy et al. 2014;
Mountjoy et al. 2015). To simplify, it is the impairment of bodily functions due to excess
energy expenditure without adequate replacement as a result of excessive activity or other
lifestyle factors. The daily demands, physiological effects of breastfeeding and social
pressure to return to pre-pregnancy figure/fitness can predispose a postnatal woman to
compromised nutrition, poor sleep, excessive exercise and unrealistic expectations which
may impact upon the impairments described above. The impact on psychological
wellbeing along with the risk of compromised bone health (Mountjoy et al. 2014), pelvic
23
floor dysfunction (Carvalhais et al. 2018) and fertility that can occur in the presence of
RED-S is an important consideration in the postnatal screening of a woman returning to
running and something that care providers should be mindful of. Bone density is already
understood to be at risk in the female population as they age and therefore the long-term
implications or future impact of RED-S, including whether it is reversible, must be
considered at this stage of a woman’s life. Education should be provided to women with
identifiable risks or signs or RED-S to increase awareness and understanding of this
poorly understood condition.
Implementing a Post-partum Plan
Focus on ‘What you CAN do?’
GOALS:
1. Improve physical and mental wellbeing.
2. Education - importance of postnatal rehab and graded return to running
3. Improve pelvic floor and abdominal function
4. Build strength and fitness
5. Facilitate safe return to sport
Key Point Summary 3:
(i)
Consideration of weight, fitness, breathing, psychological status, DRA, scar mobility,
sleep, breastfeeding status, supportive wear and the risk of RED-S is recommended
to provide a holistic approach to the return to running evaluation and address the
common issues that this population can encounter.
(ii)
Prescribed rehabilitation will vary depending on individual presentation and needs.
24
Return to running
If a woman is 3 months+ postnatal and is able to pass the tests detailed in this guide it is
appropriate to jointly plan a programme that will allow a graded return to running. Key
considerations in planning this return are discussed below and summarised in Appendix 3.
New and upcoming hypotheses regarding a reflexive initiation of pelvic floor activation that
is encouraged during higher impact activity is raising interest and indications for further
research (Leitner et al. 2016). Graded return to running following adequate postnatal pelvic
floor and abdominal muscle recovery is promoted and encouraged by this guide in order to
achieve such potential benefits as well as meet public health recommendations surrounding
the importance and benefits of physical activity. At present there is very limited research to
guide us in planning this return. The consensus of the present authors is that returning to
sport is a process of balancing risk and reward for the individual. Addressing risk factors and
planning a gradual progression can reduce risk, while including cross-training recovery
strategies (especially sleep) can maximise the rewards.
It is sensible to start small, often with around 1 to 2 minutes of running at an easy pace.
Setting short-term goals, such as reaching a target distance, can be helpful alongside long
term goals such as competing in a race. These goals will influence training progression.
For more challenging performance goals, for example completing a key race in a certain
time, it can be helpful for the woman to work with a local running coach.
Risk factors for injury need to be identified and addressed and, when present, a more
cautious return to running with a lower starting point and graded progression is
25
recommended. For example, obesity is thought to be a risk factor for running injury and
recent research reports lower injury risk when starting with a total of 3 Kilometers per week
when compared to 6 Kilometers (Bertelsen et al. 2018).
For run-training progression, building training volume (e.g. running distance/time) prior to
increasing training intensity is recommended. Expert consensus of the present authors
advises that a total weekly running distance/time should not be increased by more than
around 10% per week. However, it should be noted that when starting with very low training
volume (such as running just a few minutes) a 10% increase may be prohibitively slow.
Consider the relative increase (i.e. in percentage) and the absolute increase (i.e. in
distance/time). A higher relative increase may be manageable when the absolute increase
is small. For example progressing from 1 minute to 2 minutes is a high relative increase of
100% but the absolute increase is small, only an additional minute.
Including walk breaks can be helpful to reduce fatigue initially and can be gradually reduced
and removed. A ‘couch to 5km’ programme can be helpful as this usually includes walk
breaks and builds gradually towards 5km of running within around 9 weeks. Programmes
vary but the NHS couch to 5km starts with 3 runs in week 1 beginning with a brisk 5 minute
walk then alternating 1 minute of running with 90 seconds of walking for a total of 20 minutes.
Postnatal women should be advised about the key individual signs that they need to monitor
during their return to running. This includes a realistic discussion on what is acceptable and
should be expected, as well as any indicators that training needs to be reduced, modified or
stopped. Heaviness, dragging, incontinence or moderate to severe pain may suggest
excessive training distance or intensity. Mild musculoskeletal pain (0-3/10 on a pain scale)
which settles quickly after a run with no pain lasting into the next day is often acceptable
and has been used as a guide in management of tendinopathy and other conditions
(Silbernagel et al. 2007). However decisions should be made based on the individual and
the nature and cause of their symptoms.
26
Running with a buggy
The general advice given to women regarding buggy-running focuses on the baby’s
health. It is advised that if considering running with a buggy that the buggy in one that is
designed for this function i.e. that it has a five-point harness for the baby, fixed front
wheels, hand-operated brakes, rear wheel suspension, pneumatic tyres, 3 wheels and a
wrist strap. Buggy companies advise that buggy- running should not commence until baby
is between 6-9 months old to protect the baby’s neck and spine. The research on the
physical, physiological and biomechanical effects of running with a buggy on the postnatal
mother is limited and variable. The studies are often small. According to Wall-Scheffer
(2015), buggy running can be included in the list of ‘challenging human locomotor regimes’
O’Sullivan (2015) found that running with a buggy leads to minor changes in trunk, pelvis
and hip kinematics with no significant changes at the knee and ankle. Due to these
changes in kinematics the authors suggest that flexibility work for the spine, pelvis, hips
and gluteal strengthening exercises may be recommended for the runner.
Alcantara and Wall-Scheffer (2017) found that running while pushing a buggy had an
increased energy cost when compared with running independently. They investigated 3
different types of buggy pushing methods: Push / Chase, 1 handed buggy-running and 2
Buggy running, 6 months postnatal. Picture source Tom Gray.
27
handed buggy-running. Whilst finding that speed and stride length are decreased when
running with a buggy, they found that the 2 handed method resulted in a speed and stride
length most similar to non-buggy running.
The authors of these guidelines recommend that women do not consider running with a
buggy until their baby is at least 6-9 months old (as per manufacturers guidelines). Further,
that when they do start buggy-running, the buggy is designed for running and the woman
commences slowly, in a graded fashion, initially using the 2 handed technique. A strength
and stretch program for spine, pelvis, and hips should also be advised.
Key Point Summary 4:
(i)
Once a woman is 12 weeks postnatal and passing the tests recommended in
these guidelines plan as graded return to running
(ii)
Agree a manageable starting point with short and long term goals
(iii)
Progress training gradually and adapt it to individual needs and risk factors
(iv)
Monitor the response to running and modify where needed
(v)
Consider buggy running as an option, not before the baby is 6-9 months old,
starting slowly with a 2 handed technique
Evidence-Based Recommendation 4: The recommendations for
considering additional factors in a woman’s postnatal evaluation such as
weight, breathing, psychological status, DRA, breast health/feeding, RED-S
and running with a buggy are made by considered expert consensus based
on the best available evidence. There is a paucity of research investigating
these factors specific to the postnatal population and running. Level 4
28
Summary of Evidence-Based Recommendations
Moving forward: further guideline development
Further development of this guide will aim to extend guidance to the pregnant and post-
gynecological surgery populations. The potential benefits of exercise and weight training
during pregnancy in order to optimise the return to postnatal running without complications
are beginning to be recognised (Blyholder et al. 2016). Links to comprehensive guides on
the specific components highlighted within this document will increase the overall
understanding and implementation of service improvements to this population This should
be combined with systematic grading of the strength of the research in order to provide
greater clarification to health professionals. There is a significant need for high-quality
research studying return to exercise for the postnatal population in order to inform future
updates of this guide. Prospective cohort studies would provide insight into the determinants
of common problems (PND, weight complaints and musculoskeletal issues including pelvic
floor dysfunction) from a prevention viewpoint. Randomised controlled trials would provide
Recommendation
Level of Evidence
1. Postnatal women can benefit from individualised
assessment and guided pelvic floor rehabilitation
for the prevention and management of pelvic organ
prolapse, the management of urinary incontinence
and for improved sexual function.
Level 1+ - Well-conducted
randomised controlled
trials or randomised
controlled trials with a low
risk of bias
2. Return to running is not advisable prior to 3 months
postnatal or beyond this if any symptoms of pelvic
floor dysfunction are identified prior to, or after
attempting, return to running.
4 Expert opinion
3. Assess pelvic health, load impact management and
strength testing in order to evaluate readiness to
return to running postnatal
4 Expert opinion
4. Consider additional factors in a woman’s postnatal
evaluation such as weight, fitness, breathing,
psychological status, DRA, breast support and
feeding, RED-S and running with a buggy
4 Expert opinion
29
insight into the most effective treatment regimens for women with these problems. Further
investigation and clarification to understand newer hypotheses in stress urinary incontinence
about the reflexive response of the pelvic floor to load as well as the potential caudal
displacement of the pelvic floor during high impact as a purposeful eccentric response
(Leitner et al. 2016; Leitner et al. 2017) is indicated. The present authors hope that you find
this document a useful starting point until future, more comprehensive editions are available.
30
References
ACOG (2002) Exercise during pregnancy and the postpartum period. ACOG Committee
Opinion No. 267. Obstet Gynecol. 99(1), 171173.
Alcantara R. and Wall-Scheffler C. (2017) Stroller running: Energetic and kinematic
changes across pushing methods. PLoS ONE 12(7) [Accessed online 24/02/19 e0180575.
https://doi.org/10.1371/journal. pone.0180575].
Benjamin, D.R., Frawley, H.C., Shields, N., van de Water, A.T.M. and Taylor, N.F. (2018)
Relationship between diastasis rectus abdominis muscle (DRAM) and musculoskeletal
dusfunctions, pain and quality of life: a systematic review. Physiotherapy, in pres.
[www.document]. URL https://doi.org/10.1016/j.physio.2018.07.002.
Bertelsen, M., Hansen, M., Rasmussen, S. and Nielsen, R. (2018). THE START-TO-RUN
DISTANCE AND RUNNING-RELATED INJURY AMONG OBESE NOVICE RUNNERS: A
RANDOMIZED TRIAL. International Journal of Sports Physical Therapy 13(6), 943-955.
Biggins, M., Cahalan, R., Comyns, T., Purtill, H. and O’Sullivan, K. (2017). Poor sleep is
related to lower general health, increased stress and increased confusion in elite Gaelic
athletes. The Physician and Sports Medicine, 46(1), 14-20.
Bird, S. (2013). Sleep, Recovery, and Athletic Performance. Strength and Conditioning
Journal 35(5), 43-47.
Blyholder L., Chumanov, E., Carr, K. and Heiderscheit, B. (2016) Exercise Behaviours and
Health Conditions of Runners After Childbirth. Sports Health 9(1).
Bonnar, D., Bartel, K., Kakoschke, N. and Lang, C. (2018). Sleep Interventions Designed
to Improve Athletic Performance and Recovery: A Systematic Review of Current
Approaches. Sports Medicine 48(3), 683-703.
Bø, K. (2003) Is there still a place for physiotherapy in the treatment of female
incontinence? EAU Update Series 1(3), 145-153.
31
Bø, K. Talseth T, Holme I.(1999) Single blind, randomised controlled trial of pelvic floor
exercises, electrical stimulation, vaginal cones, and no treatment in management of genuine
stress incontinence in women. BMJ, 318-487.
Bø, K. Artal, R., Barakat, R., Brown, W. J., Davies, G. A. L., Dooley, M., Evenson, K. R.,
Haakstad, L. A. H., Kayser, B., Kinnunen, T. I., Larsénm K., Mottola, M. F., Nygaard, I., van
Poppel, M., Stuge, B., Khan, K. M. (2017) Exercise and pregnancy in recreational and elite
athletes: 2016/17 evidence summary from the IOC Expert Group Meeting, Lausanne. Part
3-exercise in the postpartum period. Br J Sports Med 51(21), 1516-1525.
Brækken, I. H., Majida, M., Ellström Engh, M. and Bø, K. (2015). Can Pelvic Floor Muscle
Training Improve Sexual Function in Women with Pelvic Organ Prolapse? A Randomized
Controlled Trial. The Journal of Sexual Medicine, 12(2), 470480.
Brown, N., Burbage, J.L., Brasher, A, and Scurr, J. (2014) An investigation into breast
support and sports bra use in female runners of the 2012 London Marathon. Journal of
Sports Sciences 32(9).
Bump, R.C., Mattiasson, A., Bø, K. Brubaker, L.P., DeLancey, J.O.L., Klarskov, P., ShuU,
B.L. and Smith, A.R.B. (1996) The standardization of terminology of female pelvic organ
and pelvic floor dysfunction. Am J Obstet Gynecol 175(1), 10-17.
Carvalhais, A., Araújo, J., Jorge, R.N. and , K. (2018) Urinary incontinence and
disordered eating in female elite athletes. J Sci Med Sport [Accessed online 24/02/19
https://doi.org/10.1016/j.jsams.2018.07.008].
Camacho, E. M. and Shields, G. E. (2018) Cost-effectiveness of interventions for perinatal
anxiety and/or depression: a systematic review. BMJ Open 8:e022022. [Accessed online
24/02/19] doi: 10.1136/bmjopen-2018-022022.
Cary, G.B. and Quinn, T.J. (2001) Exercise and lactation are they compatible? Can J App
Physio 26, 55-75.
32
Ceydeli, A., Rucinski, J. and Wise, L. (2005) Finding the best abdominal closure: an
evidence-based review of the literature. Curr Surg 62, 2205.
Chumanov ES1, Wille CM, Michalski MP, Heiderscheit BC.(2012) Changes in muscle
activation patterns when running step rate is increased. Gait Posture. 2012 Jun;36(2), 231-
235.
Comesaña, C. A., Vicente, M.P.S., Ferreira, T. D., Varela, M.M.P., Quintáns, M.M.P.Q.
and Pilat, A. (2017) Effect of myofascial induction therapy on post- c-section scars, more
than one and a half years old. Pilot study. Journal of Bodywork and Movement Therapies
21(1),197204.
Davies G., Wolfe L., Mottola M. and MacKinnon C. (2003) Joint SOGC/CSEP Clinical
Practice Guideline: Exercise in pregnancy and the postpartum period. Can J Appl Physiol
28(3), 330341.
De Mattos Lourenco T, Matsuoka P, Baracat C, Haddad J (2018) Urinary incontinence in
female athletes: a systematic review. International Urogynecology Journal
Dumoulin, C., Cacciari, L. and Hay-Smith, E.C. (2018) Pelvic floor muscle training versus no
treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database
of Systematic Reviews Issue 10 [Accessed online 24/02/19] doi:
10.1002/14651858.CD005654.pub4.
Evenson, K. R., Mottola, M. F., Owe, K. M., Rousham, E. K. and Brown, W. (2014) Summary
of International Guidelines for Physical Activity Following Pregnancy Obstet Gynecol Surv.
69(7): 407414.
Gottschall, J.S. and Kram, R. (2005) Ground reaction forces during downhill and uphill
running. Journal of Biomechanics 38, 445-452.
Hagen, S., Stark, D., Glazener, C., Dickson, S., Barry, S., Elders, A., Frawley, H., Galea,
M.P., Logan, J., McDonald, A., McPherson, G., Moore, K.H., Norrie, J., Walker, A. and
33
Wilson, D. (2014) Individualised pelvic floor muscle training in women with pelvic organ
prolapse: a multicenter randomised controlled trial. The Lancet 282(9919), 796-806.
Hagen, S., Glazener, C., McClurg, D., Macarthur, C., Elders, A., Herbison, P., Wilson, D.,
Toozs-Hobson, P., Hemming, C., Hay-Smith, J., Collins, M., Dickson, S. and Logan J.
(2017) Pelvic floor muscle training for secondary prevention of pelvic organ prolapse
(PREVPROL): a multicenter randomized controlled trial. The Lancet 389(10 067), 393-402.
Hamar, B.D., Saber, S.B., Cackovic, M., Magloire, L.K., Pettker, C.M., Abdel-Razeq,
S.S., Rosenberg, V.A., Buhimschi, I.A. and Buhimschi, C.S. (2007) Ultrasound evaluation
of the uterine scar after cesarean delivery: a randomized controlled trial of one- and two-
layer closure. Obstet Gynecol 110, 80813.
Hills, N. F., Graham, R. B., and McLean, L. (2018) Comparison of trunk muscle function
between women with and without diastasis recti abdominis at 1 year postpartum. Physical
Therapy 98(10), 891-901.
Hu, H., Meijer, O. G., Hodges, P. W., Bruijn, S. M., Strijers, R. L., Nanayakkara, P. W. and
van Dieën, J.H. (2012) Understanding the Active Straight Leg Raise (ASLR): An
electromyographic study in healthy subjects. Manual therapy 17 (6), 531-537.
Jauniaux, E.R.M., Alfirevic, Z., Bhide, A.G., Belfort, M.A., Burton, G.J., Collins, S.L., Dornan,
S., Jurkovic, D., Kayem, G., Kingdom, J., Silver, R. and Sentilhes, L. on behalf of the Royal
College of Obstetricians and Gynaecologists (2018) RCOG Greentop Guideline No. 27a:
Placenta Praevia and Placenta Accreta: Diagnosis and Management. BJOG 126(1), e1-e48.
Khunda, A., Shek, K. and Dietz, P. (2012) Can ballooning of the levator hiatus be determined
clinically? ICS 206(3), 246.e1246.e4.
Knowles, O., Drinkwater, E., Urwin, C., Lamon, S. and Aisbett, B. (2018). Inadequate
sleep and muscle strength: Implications for resistance training. Journal of Science and
Medicine in Sport 21(9), 959-968.
34
Laycock, J. and Jerwood, D. (2001) Pelvic floor muscle assessment: the PERFECT
scheme. Physiotherapy 87, 631-642.
Leitner, M., Moser, H., Eichelberger, P., Kuhn, A. and Radlinger, L. (2016) Evaluation of
pelvic floor muscle activity during running in continence and incontinence women: An
exploratory study. Neurourol Urodynam 9999, 17.
Leitner, M., Moser, H., Eichelberger, P., Kuhn, A., Baeyens, J.-P. and Radlinger, L.
(2017). Evaluation of pelvic floor kinematics in continent and incontinent women during
running: An exploratory study. Neurourology and Urodynamics, 37(2), 609618.
Marnach, M. L., Ramin, K. D., Ramsey, P. S., Song, S. W., Stensland, J. J. and An, K. N.
(2003) Chatacterization of the relationship between joint laxity and maternal hormones in
pregnancy. Obstetrics & Gynaeocology 101(2), 331-335.
McGhee, D.E. and Steele, J.R. (2010) Breast elevation and compression decrease exercise-
induced breast discomfort. Med Sci Sports Exerc 42:13331338.
McGhee, D.E., Steele, J.R., Zealey, W.J. and Takacs, G.J. (2013) Bra-breast forces
generated in women with large breasts while standing and during treadmill running:
implications for sports bra design. Appl Ergon 44(1) 112-118.
Milewski, M., Skaggs, D., Bishop, G., Pace, J., Ibrahim, D., Wren, T. and Barzdukas, A.
(2014). Chronic Lack of Sleep is Associated With Increased Sports Injuries in Adolescent
Athletes. Journal of Pediatric Orthopaedics 34(2), 129-133.
Milligan, A., Mills, C., Corbett, J. and Scurr, J. (2015) The influence of breast support on
torso, pelvis and arm kinematics during a five kilometer treadmill run. Journal of Human
Movement Science 42, 246260.
Mountjoy, M., Sundgot-Borgen,, J., Burke,, L., Carter, S., Constantini, N., Lebrun, C.,
Meyer, N., Sherman, R., Steffen, K., Budgett, R., Ljungqvist, A. (2014) The IOC consensus
statement: beyond the Female Athlete TriadRelative Energy Deficiency in Sport (RED-
S) Br J Sports Med 48, 491497. doi:10.1136/bjsports-2014-093502.
35
Mountjoy, M., Sundgot-Borgen, J., Burke, L., Carter, S., Constantini, N., Lebrun, C., Meyer,
N., Sherman, R., Steffen, K., Budgett, R., Ljungqvist, A. and Ackerman, K. (2015) The IOC
relative energy deficiency in sport clinical assessment tool (RED-S CAT). Br J Sports Med
Published Online First [13th December 2018] doi: 10.1136/bjsports-2015-094873.
Nielsen, R., O., Buist, I., Parner E. T., Nohr, E. A., Sørensen, H., Lind, M., PhD, and
Rasmussen, S. (2013) Predictors of Running-Related Injuries Among 930 Novice Runners
A 1-Year Prospective Follow-up Study The Orthopaedic Journal of Sports Medicine 1(1).
Nygaard, I., Girst, T., Fultx, N. H., et al. (2005) Is Urinary Incontinence a Barrier to Exercise
in Women? Obstetrics & Gynaecology 106(2), 307-314.
Okayama, H., Ninomiya, S., Naito, K., Endos, Y. and Morikawa, S. (2019) Effects of wearing
supportive underwear versus pelvic floor muscle training or no treatment in women with
symptoms of stress urinary incontinence: an assessor-blinded randomized control trial. Int
Urogynecol J [Accessed online 24/02/19] https://doi.org/10.1007/s00192-018-03855-z
O'Sullivan R., Kiernan D. and Malone A. (2015) Run kinematics with and without a jogging
stroller. Gait Posture Jan 43:220-224.
Pomian, A., Lisik, W., Kosieradzki, M. and Barcz, E. (2016) Obesity and Pelvic Floor
Disorders: A Review of the Literature. Med Sci Monit 22, 1880-1886.
Price, N., Dawood, R. and Jackson, S.R. (2010) Pelvic floor exercise for urinary
incontinence: A systematic literature review. Maturitas 67(4), 309-315.
Reimers, C., Siafarikas, F., Stær-Jensen, J., Cvancarova, S., Bø, K. and Engh, M.E. (2018)
Risk factors for anatomic pelvic organ prolapse at 6 weeks postpartum: a prospective
observational study. Int Urogynecol J [Accessed online 24/02/19]
https://doi.org/10.1007/s00192-018-3650-2.
Royal College of Obstetricians and Gynaecologists (2006) Exercise in pregnancy RCOG
Statement No. 4 - January 2006.
36
Schauberger, C. W., Rooney, B. L., Goldsmith, L., Shenton, D., Silva, P. D. and Schaper,
A. (1996) Peripheral joint laxity increases in pregnancy but does not correlate with serum
relaxin levels. American Journal of Obstetrics and Gynecology 174(2), 667-671.
Sheridan, S. E., Ghrefa, Z. and Moyna, N. M. (2015) Final Report - Physiological,
metabolioc, perceptual and psychological responses during treadmill running in women with
a history of urinary incontinence: effect of wearing traditional and specially designed sports
briefs. Dublin College University Research Study, School of Health & Human Performance
for publication as part of PHD.
Silbernagel, K., Thomeé, R., Eriksson, B. and Karlsson, J. (2007) Continued Sports
Activity, Using a Pain-Monitoring Model, during Rehabilitation in Patients with Achilles
Tendinopathy. The American Journal of Sports Medicine, 35(6), 897-906.
Sports Medicine Australia (2002) SMA statement: The benefits and risks of exercise during
pregnancy. J Sci Med Sport 5(1), 1119.
Stær-Jensen, J., Siafarikas, F., Hilde, G., Benth, J.Š., Bø, K. and Engh, M.E. (2015)
Postpartum recovery of levator hiatus and bladder neck mobility in relation to pregnancy.
Obstet Gynecol 125, 531539.
Strømme S., Anderssen S., Hjermann I., Sundgot-Borgen J., Mæhlum S., Aadland A. (2000)
Physical activity and health Guidelines [Fysisk aktivitet og helse Anbefalinger] The
Directorate of Health and Social Affairs Accessible at
http://www.helsedirektoratet.no/publikasjoner/fysisk-aktivitet-og-helse-
anbefalinger/Publikasjoner/fysisk-aktivitet-og-helse-anbefalinger.pdf. (Not available in
English).
Tomasek, J.J., Gabbiani, G., Hinz, B., Chaponnier, C. and Brown, R.A. (2002)
Myofibroblasts and the mechano-regulation of connective tissue remodeling. Nat. Rev. Mol.
Cell. Biol. 2(5), 349-363.
Toozs-Hobson, P., Balmforth, J., Cardozo L., Khullar, V. and Athanasiou, S. (2008) The
effect of mode of delivery on pelvic floor functional anatomy. Int urogynecol 19(3):407-16.
37
Wall-Scheffler, C.M. (2015) Optimal movement speeds in human locomotion. Int Comp
Biol 55(6), 1155-1165.
Wolfe L. and Davies G. (2003) Canadian guidelines for exercise in pregnancy. Clin Obstet
Gynecol. 2003;46(2), 488495.
WHO (2016) Infant and young child feeding. Secondary infant and young child feeding.
[Accessed 17/02/2019] http://www.who.int/mediacentre/factsheets/fs342/en/
38
Appendix 1
Flow chart of considerations to guide return to running postnatal
Is the mother at least 3 months postnatal?
Subjective screen and use of validated outcome
measures e.g. Australian pelvic floor questionnaire
Screening not passed?
Screening passed?
Objective Screening:
Pelvic Floor Screen via a Specialist Physio
Abdominal Screen for DRA including functional
dynamic/load tests
Load and impact screening +/- video analysis
Strength testing
BMI <30
Psychological screen for PND
RED-S screen
Additional considerations (breastfeeding/scar
tissue/sleep)
No Continue screen if more than 6
weeks postnatal informing that the
minimum recommended recovery
timeframe before return to running
is 3 months. Refer to example of
early postnatal exercise progression
recommended in Appendix 2.
example exercise progression in
post-natal weeks 6-12
Yes Continue screen informing
about the potential to return to
running if recommended tests are
passed but that the screening may
highlight she isn’t ready yet
Graded return to running
e.g. couch to 5K
Rehabilitation programme to address
dysfunctional areas or signposting to relevant
professionals e.g. physio, GP or Uro-gynae
consultant.
(After signposted intervention)
39
Appendix 2
Example of exercise progression for the early postnatal period (0-3 months)
Week 0 to 2
Pelvic floor muscle exercises (once catheter removed) targeting strength and
endurance functions.
Basic core exercises e.g. pelvic tilt, bent knee drop out, side lying abduction.
Walking (for cardiovascular exercise).
Week 2 to 4
Progress walking/pelvic floor muscle/core rehab.
Consider introduction of squats, lunges and bridging, in line with the functional
requirements of day-to-day life as a new mother.
Week 4 to 6
Introduce low impact exercise e.g. static cycling or cross-trainer taking into account
individual postnatal recovery, mode of delivery and perineal trauma. Recovery should
be such that the new mother is comfortable sitting on a saddle.
Week 6 to 8
scar mobilisation (for either c-section or perineal scar)
power walking
increased duration/intensity of low impact exercise
deadlift techniques beginning at light weights no more than the weight of the baby in a
car seat (15kg) with gradual load progression e.g. barbell only with no weight. This
aims to strengthen and restore strategies for carrying out the normal everyday tasks
required when caring for a newborn and/or older siblings.
resistance work during core and lower limb rehab
Weeks 8 to 12
Introduce swimming (if lochia has stopped and there are no issues with wound
healing).
Spinning (if comfortable sitting on a spinning saddle).
40
Appendix 3
Return to running 12 weeks postnatal and beyond
Graded to return to running e.g. NHS couch to 5km’ plan
Goal specific agree short and long term goals
For challenging goals consider working with a running coach
Risk factors to injury e.g. obesity reduce distance to a couch to 3km rather than 5km
Build training volume (e.g. distance/time ) before intensity
Monitor signs and symptoms and modify program appropriately or signpost to
professional help to address postnatal issues
ResearchGate has not been able to resolve any citations for this publication.
  • Article
    Introduction and hypothesis In our previous single-arm pilot study, we reported that ready-made supportive underwear (shaper) was effective in elevating the bladder neck and reducing urinary incontinence (UI) symptoms. The aim of this study was to determine the effects of wearing a shaper compared with pelvic floor muscle training (PFMT) at home using a training compact disc with music, or no treatment, in an assessor-blinded randomized control trial, on reducing UI symptoms. Methods Participants aged 30–59 years with symptoms of stress urinary incontinence were randomly assigned to three groups: the shaper group, PFMT group, and no treatment group. The UI episodes/week and the Japanese version of the International Consultation on Incontinence Questionnaire Short-Form were compared between the baseline and the 6th or 12th week of the intervention period. Results Eighty-nine women who completed the 12-week intervention period were analyzed. After the 12-week intervention period, the improvement rate in UI symptoms (ratio of the case number in which the UI episodes/week decreased at least 50% from the baseline) was 73.3% (22/30 women) in the shaper group, 74.2% (23/31 women) in the PFMT group, and 25.0% (7/28 women) in the no treatment group. The improvement rate in UI symptoms in the shaper and PFMT groups was significantly higher than that in the no treatment group (both P < 0.001). Conclusions Wearing supportive underwear (shaper) was almost as effective as PFMT at home in reducing UI symptoms.
  • Article
    Background/purpose: High body mass index is associated with an increased risk of running-related injury among novice runners. However, the amount of running participation plays a fundamental explanatory role in regards to running-related injury development. Therefore, the purpose of the present study was to investigate if the risk of running-related injury among obese novice runners (BMI 30-35) was different when the start-to-run distance was 3km per week instead of 6km per week. Hypothesis: A start-to-run distance of 3km per week is associated with 20% fewer running-related injuries and significantly fewer symptoms of overuse injury than a start-to-run distance of 6km per week among obese novice runners. Study design: Randomized trial. Methods: Fifty-six obese novice runners with a body mass index between 30-35 were enrolled and randomized to receive one of the two following Interventions: (i) a 4-week running program with a start-to-run distance of 3km per week including three sessions with 1km running per session (n=29), or (ii) a 4-week running program with a start-to-run distance of 6km per week including three sessions with 2km running per session (reference group, n=27). In both programs, the weekly running distance was increased by 10% each week throughout the follow-up. Results: The intention-to-treat analysis revealed a protective cumulative risk difference of -16.3% (95%CI: -43.8%; 11.3%, p=0.25) after four weeks. Importantly, some participants completed much more running than prescribed (n=5) and some never uploaded any training (n=15). Therefore, a supplementary per-protocol analysis was performed revealing a cumulative risk difference of -31.2% (95%CI: -57.0%; -5.2%, p=0.02) after four weeks. Furthermore, in the per-protocol analysis, the cumulative risk difference of overuse-injury symptoms was -47.8% (95%CI: -81.0%; -14.6%, p=0.01) after four weeks of running. Conclusions: A 3km reduction from 6km per week to 3km per week in the start-to-run distance appears to be associated with fewer running-related injuries and significantly fewer symptoms of overuse injury. Level of evidence: 2b.
  • Article
    Full-text available
    Objectives Anxiety and/or depression during pregnancy or year after childbirth is the most common complication of childbearing. Economic evaluations of interventions for the prevention or treatment of perinatal anxiety and/or depression (PAD) were systematically reviewed with the aim of guiding researchers and commissioners of perinatal mental health services towards potentially cost-effective strategies. Methods Electronic searches were conducted on the MEDLINE, PsycINFO and NHS Economic Evaluation and Health Technology Assessment databases in September 2017 to identify relevant economic evaluations published since January 2000. Two stages of screening were used with prespecified inclusion/exclusion criteria. A data extraction form was designed prior to the literature search to capture key data. A published checklist was used to assess the quality of publications identified. Results Of the 168 non-duplicate citations identified, 8 studies met the inclusion criteria for the review; all but one focussing solely on postnatal depression in mothers. Interventions included prevention (3/8), treatment (3/8) or identification plus treatment (2/8). Two interventions were likely to be cost-effective, both incorporated identification plus treatment. Where the cost per quality-adjusted life year (QALY) gained was reported, interventions ranged from being dominant (cheaper and more effective than usual care) to costing £39 875/QALY. Conclusions Uncertainty and heterogeneity across studies in terms of setting and design make it difficult to make direct comparisons or draw strong conclusions. However, the two interventions incorporating identification plus treatment of perinatal depression were both likely to be cost-effective. Many gaps were identified in the economic evidence, such as the cost-effectiveness of interventions for perinatal anxiety, antenatal depression or interventions for fathers. PROSPERO registration number CRD42016051133.
  • Article
    Background: Diastasis of the rectus abdominis muscle (DRAM) is common during and after pregnancy. Objectives: To determine the association between: the presence of DRAM and low back pain, lumbo-pelvic pain, incontinence, pelvic organ prolapse, abdominal muscle performance or health-related quality of life; and between DRAM width and severity of these outcomes. Data sources: Six electronic databases (EMBASE, Medline, CINAHL, PUBMED, AMED and PEDro). Study selection: Included studies of all designs with adults with DRAM that assessed low back pain, lumbo-pelvic pain incontinence, pelvic organ prolapse, abdominal performance or health-related quality of life. Study appraisal & synthesis methods: Methodological quality was assessed using the Effective Public Health Practice Project tool. A narrative summary was completed for DRAM presence and presence of the various musculoskeletal dysfunctions, and DRAM width and the severity of these dysfunctions. Results: Twelve studies involving 2242 participants were included. There was no significant association between the presence of DRAM and lumbo-pelvic pain or incontinence. There was a small association between the presence of DRAM and pelvic organ prolapse. DRAM width may be associated with health-related quality of life, abdominal muscle strength and severity of low back pain. Limitations: Quality of studies was weak. There was variability in the methods used to assess DRAM. Conclusion: There is weak evidence that DRAM presence may be associated with pelvic organ prolapse, and DRAM severity with impaired health-related quality of life, impaired abdominal muscle strength and low back pain severity. Systematic Review Registration Number: PROSPERO CRD42017058089.
  • Article
    Objectives: To evaluate the association between urinary incontinence and disordered eating, in elite female athletes. Design: This cross-sectional study included 744 young and healthy Portuguese women: 372 elite athletes and 372 age-matched non-athletes, mean age 21±5.3years. Methods: Data regarding clinical, demographic, and sport practice characteristics were collected by questionnaire. The International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form was applied to identify urinary incontinence. The Eating Disorder Examination Questionnaire was applied to identify disordered eating. Odds ratios with 95% confidence intervals (95% CI) were used to estimate the association between UI and disordered eating. Results: The prevalence of urinary incontinence in athletes and non-athletes was 29.3% and 13.4%, p<0.001, respectively. No difference in prevalence of disordered eating was found between athletes (17.7%) and non-athletes (20.2%), p=0.435. Urinary incontinence was associated with disordered eating only in the athletes. After adjustment for age, type of sport, smoking and alcohol intake, athletes with disordered eating presented increased odds of urinary incontinence of any type over athletes without disordered eating (OR=3.09; 95% CI: 1.74-5.50). Conclusions: Athletes with disordered eating were three times more likely to present urinary incontinence than women without disordered eating. There is a need for further studies to elaborate on mechanisms for this association.
  • Article
    Background: A separation of the abdominal muscles at the linea alba, known as diastasis recti abdominis (DRA), can occur after childbirth. However, the impact of DRA on abdominal muscle function is not clear. Objective: The objective was to determine if differences exist in trunk muscle function and self-reported pain and low back dysfunction between women with and without DRA at 12 to 14 months postpartum and if differences that emerge from the data are associated with the magnitude of the interrectus distance (IRD). Design: This study was a prospective observational case-control study. Methods: Women with (IRD ≥ 2.2 cm; n = 18) and without DRA (IRD < 2.2 cm; n = 22) participated. Maximal trunk flexion, extension, and rotation torque-generating capacity (Newton-meters), The Sit Up test (0-3 points), and the Sitting-Rising Test (0-10 points), and trunk flexion, extension, and lateral flexion endurance (seconds) were measured. Pain and disability were assessed using numerical pain rating scales (0-100) and the Roland Morris Low Back Pain Questionnaire (0-24 points). Women were compared using independent t tests and Mann-Whitney U-Tests. Pearson's product-moment and Spearman's rank correlation coefficients were used to determine associations; α = .05 was used for all tests. Results: Women with DRA demonstrated significantly lower trunk muscle rotation torque and scored lower on the sit-up test than those without DRA. IRD was negatively correlated with both trunk rotation torque (rho = -0.367) and sit-up test score (rho = -0.514). Limitations: The results of this study should not be generalized to women who present with moderate-to-severe IRDs or to multiparous women. Conclusion: The presence of DRA in primiparous women at 1 year postpartum is associated with trunk rotation strength and ability to perform a sit-up.
  • Article
    Introduction and hypothesis: The objective was to identify risk factors for postpartum anatomic pelvic organ prolapse (aPOP) by comparing women with and without aPOP at 6 weeks postpartum with regard to pelvic floor measurements antepartum and obstetrical characteristics. Methods: We carried out a prospective observational cohort study including nulliparous pregnant women in a Norwegian university hospital. Participants underwent clinical examinations, including pelvic organ prolapse quantification system (POP-Q) and transperineal ultrasound at gestational week 21 and at 6 weeks postpartum. Background and obstetrical information was obtained from an electronic questionnaire and from the patient's electronic medical file respectively. Associations were estimated using logistic regression analyses. The dependent variable was aPOP, defined as POP-Q stage ≥2 at 6 weeks postpartum. Independent variables were mid-pregnancy measurements of selected POP-Q variables and levator hiatus area (LHarea), delivery route, and the presence of major levator ani muscle (LAM) injuries at 6 weeks postpartum. Results: A larger LHarea, a more distensible LAM, a longer distance from the meatus urethra to the anus (Gh + Pb) and a more caudal position of the anterior vaginal wall (Ba) at mid-pregnancy were risk factors for aPOP at 6 weeks postpartum, whereas delivery route and the presence of major LAM injuries were not. Conclusion: Prelabor differences in the pelvic floor rather than obstetrical events were risk factors for aPOP at 6 weeks postpartum.
  • Introduction and hypothesis People are increasingly aware of healthy lifestyles. Extenuating practice can injure the pelvic floor. Urinary incontinence (UI) is a prevalent condition in women whether they exercise professionally or not. The most common symptom is stress UI. It is reported in a large variety of sports and may interfere with everyday life or training, leading athletes to change or compromise their performance or risk compromising it. We aimed to assess the prevalence of UI in female athletes and to determine whether the type of sport might also influence UI. Methods A systematic review of the literature was performed by searching PubMed, the Cochrane Library, and LILACS up to 23 January 2017. The search strategy included the keywords pelvic floor disorders, urinary incontinence, athletes, and sports. The inclusion criterion was studies of women who performed any kind of sport with a prevalence of UI. The subjects were female, with no restriction for age, sport modality, or frequency of training. The outcome was prevalence of UI. Results The search identified 385 studies, 22 of which met the methodologic criteria for complete analysis. In this review, 7507 women aged 12 to 69 years were included. Only five studies compared physically active women to controls. Every study included high or moderate impact activities involving jumping, fast running, and rotational movements. In total, 17 sport modalities were analyzed. The prevalence of UI varied from 5.56% in low-impact activity to 80% in trampolining. In athletes, the prevalence of incontinence ranged from 10.88% to 80%, showing that the amount of training influences UI symptoms. High-impact activities showed a 1.9-fold prevalence over medium-impact activities and 4,59-fold prevalence over impact activities. Factors such as hormone use, smoking, or menopausal status could not be assessed since they were not detailed in most of the studies. Conclusion These data suggest that sports practice increases the prevalence of UI and that the type of activity performed by women also has a bearing on the disorder.
  • Article
    Objectives: Inadequate sleep (e.g., an insufficient duration of sleep per night) can reduce physical performance and has been linked to adverse metabolic health outcomes. Resistance exercise is an effective means to maintain and improve physical capacity and metabolic health, however, the outcomes for populations who may perform resistance exercise during periods of inadequate sleep are unknown. The primary aim of this systematic review was to evaluate the effect of sleep deprivation (i.e. no sleep) and sleep restriction (i.e. a reduced sleep duration) on resistance exercise performance. A secondary aim was to explore the effects on hormonal indicators or markers of muscle protein metabolism. Methods: A systematic search of five electronic databases was conducted with terms related to three combined concepts: inadequate sleep; resistance exercise; performance and physiological outcomes. Study quality and biases were assessed using the Effective Public Health Practice Project quality assessment tool. Results: Seventeen studies met the inclusion criteria and were rated as 'moderate' or 'weak' for global quality. Sleep deprivation had little effect on muscle strength during resistance exercise. In contrast, consecutive nights of sleep restriction could reduce the force output of multi-joint, but not single-joint movements. Results were conflicting regarding hormonal responses to resistance training. Conclusion: Inadequate sleep impairs maximal muscle strength in compound movements when performed without specific interventions designed to increase motivation. Strategies to assist groups facing inadequate sleep to effectively perform resistance training may include supplementing their motivation by training in groups or ingesting caffeine; or training prior to prolonged periods of wakefulness.