November 29, 2022 • 53 mins
Show Notes
On this episode of the podcast, I chat with Christina Prevett about her work as a physiotherapist in the geriatric and pre and postnatal exercise space as a high level athlete herself. Her recent study, the impact of heavy resistance training on pregnancy and postpartum health outcomes, and what we can do as people who are wanting better outcomes for pregnancy and postpartum and what we can do as clinicians as well, who are working with these athletes.
You're listening to the Resource Doula Podcast, a place where we provide information to help you make informed healthcare decisions for yourself and your family.
Christina’s #1 Tip:
“Your body is strong and your body is resilient. And if pelvic issues come up, we know how to handle them. But that does not mean that your body is not strong and that your body is not resilient. It's just rehab.”
Connect with Christina:
Read her open-access article: Impact of heavy resistance training on pregnancy and postpartum outcomes
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Episode Transcript
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Natalie (00:00):
On today's podcast, I chat with Christina Prevet about
(00:02):
her work as a physiotherapist inthe geriatric and pre and
postnatal exercise space as ahigh level athlete herself.
Her recent study, the impact ofheavy resistance training on
pregnancy and postpartum healthoutcomes, and what we can do as
people who are.
Wanting better outcomes forpregnancy and postpartum and
what we can do as clinicians aswell, who are working with these
(00:27):
athletes and these people.
Christina Preve is a pelvicfloor physiotherapist who has a
passion for helping women withdifferent life transitions,
including postpartum care and.
(00:48):
In 2013, Christina completed herMasters of Physiotherapy and is
currently completing her finalyear of her PhD at the Faculty
of Health Sciences at McMasterUniversity.
She recently published a studylooking at the impacts of heavy
resistance training on pregnancywith a group of international
collaborators, the first toinvestigate the safety of heavy
barbell training on pregnancy.
(01:10):
Christina created strong likeMom during her first
entrepreneurial endeavor, staveoff focusing on postnatal return
to fitness.
Christina teaches five coursesat the Institute of Clinical
Excellence, including clinicalmanagement of the fitness
athlete, pregnancy andpostpartum, where she helps
physiotherapists empower theirpregnant and postpartum athletes
to safely continue strengthtraining.
(01:31):
I'm Natalie, and you'relistening to the Resource Doula
Podcast, a place where weprovide information to help you
make informed healthcaredecisions for yourself and your
family.
Hey Christina, welcome to theshow.
Christina (01:43):
Hi so much for
Natalie (01:46):
You are so welcome.
I'm really, really excited to,to have you on.
You're the first person to comeand talk about heavy lifting on
my podcast so
Christina (01:55):
amazing.
Natalie (01:56):
So, yes.
I wanna jump right in and justask you, how did you start with
the women's health space?
What got you into this world?
Christina (02:04):
Yeah, so I'm actually doing a completely unrelated
PhD.
I'm doing a PhD in heavyresistance training in older
adults, and one of my areas ofexpertise is in geriatrics.
And as a part of my degree, Idid a scoping review about where
physical therapists can beinvolved in health and wellness.
And the perinatal spaceoverwhelmingly came up as an
area that we can help facilitateand remove barriers to exercise
(02:26):
and movement for individuals whoare pregnant and individuals who
are postpartum.
because of that, I dabbled intoit in my own business.
So we started a strong like mompostnatal exercise program, and
that was where I kind of startedtreading into the women's health
space.
I actually was one of thosepeople that said, I'm never
gonna be an internal therapist.
Like, do not wanna do it.
Like that is not something forme that I obviously lied and I
(02:48):
do all that stuff now, but thatwas something that I just didn't
think I wanted to do.
I've learned a lot since thenabout it being a tool and not
identity in the pelvic healthspace, but that's a whole other
soapbox.
And then when I got pregnantwith my daughter, I have a 10
year history of doing CrossFit.
I've competed in power lifting.
(03:09):
I competed nationally in Olympicweightlift.
And then when I got pregnant, Ihad no.
Desire or expectation to not dothat.
And I post a lot on social mediaand the comments that I started
getting were quite interestingabout your baby might die.
Like literally somebody saidthat to me in my second
(03:30):
pregnancy.
I want to see your pelvic floorbiofeedback numbers, thinking
that I was gonna spontaneouslyprolapse, just like the things.
As a person who is very educatedand informed in this space, it,
it even made me pause, you know,it made me think, you know, am I
doing the right thing?
(03:50):
And the thought then to otherindividuals who don't have the
same knowledge and backgroundthat I did, it was just really
disheartening to me.
I thought there was a lot offear spiraling that was going
on.
And therefore I started reallydiving into the research in this
space.
Not conducting research at thetime, but really starting to
synthesize and bring togetherwhat research we do have.
(04:12):
And I started teaching a coursearound pregnant postpartum
CrossFit with an emphasis onbarbell training, return to
gymnastics and return toendurance within kinda the
CrossFit sphere.
And then I was just getting sofrustrated thinking, you know,
we have all.
These individuals, you know, yousee them all the time.
People who are in CrossFit gymsevery single day, and not just
(04:34):
elite athletes like the mom whois exercising for health, who
really enjoys lifting weights,who are being told all of these
myths, like, don't hold yourbreath ever again postpartum or
pregnant.
Don't lift more than 20 poundsor giving, they're getting these
sheets from their doctors.
and it's hard because therewasn't any research on it and
(04:55):
because of that, like, you know,we can't even have a really
well-informed or evidenceinformed rebuttal and cause of
that.
Um, I reached out to MargieDavenport and a group of
international collaborators andwe started with a
cross-sectional survey that waskind of trying to get a picture
of.
Individuals who are liftingbefore pregnancy, what their
(05:15):
modifications changes, theirkind of the way that they
modified during their pregnancy,and then what that did for their
fetal outcomes, deliveryoutcomes, and then kind of got
an idea about.
Postpartum, pelvic floor,physical therapy needs.
And when they started returningto things after baby, if they
did at all.
And that just gave a lot ofinformation.
(05:36):
And, and now I'm, I'm kind of alittle bit known as like, that
pelvic PT that's gonna get youto lift heavy, who's, uh, okay
with that?
And I'm just like, overjoyed byhaving that type of, of
reputation.
And so it's been a reallyexciting journey from, from that
standpoint.
Natalie (05:52):
That's amazing.
Yeah.
I've like just the little thatI've known you and followed you
online.
I'm just constantly like, oh mygosh.
Okay.
I need to rethink that.
Okay.
What is she saying, What can we,what can we
Christina (06:03):
I do that myself.
Natalie (06:06):
Yeah, and it's, it's really interesting because my
background is Pilates and likeno history of going to a gym,
quote unquote gym and liftingheavy weights.
I totally thought that liftingheavy was dumb When I taught
Pilates, like I told peoplelike, you don't need that which
now I'm like, oh my gosh, Ican't believe I had that
(06:26):
mindset.
Um, which.
You know, I mean, it's good toevolve and change and, and learn
new things, but now obviously Iencourage heavy lifting.
Um, but I don't know as muchabout the CrossFit background
because that's not my world.
And so, um, I want to kind oftalk about, I, I read your paper
and it's amazing.
I want you to know it's great.
(06:47):
And I'll link it in the shownotes too so everybody can, um,
go and read it if they sodesire.
I have a lot of nerds who listento this podcast as well.
Um, The, like, the thing thatstood out to me most, I guess
from the very beginning wastalking about the Alva Maneuver,
because that's a huge one thateverybody in the pelvic health
(07:07):
space is like, don't alva whenyou're pregnant.
Don't Alva when you're lifting.
And especially don't do it inpostpartum.
So, um, It like, according toyour, your research, it looked
like there weren't anydifferences in their pregnancy,
labor, or delivery outcomes forthose who did Alva during
pregnancy while they werelifting, um, and those who
didn't.
(07:27):
So can you talk about that alittle bit and, and what does it
look like to Alva and is thatokay?
I have a lot of questions aboutthis, but is that considered
like managing yourInterabdominal pressure?
Well,
Christina (07:40):
Yeah.
Okay, so let's try and impactthis a little bit.
Let's start with the definitionof a Valsalva.
The hard part that comes intothe pelvic health space is that
when we are looking forsomething like a prolapse, which
is a movement of one or more ofthe walls of the vaginal canal
towards the opening because ofshifting of abdominal contents,
(08:01):
we use the Valsalva in order toassess that.
So we ask individuals to beardown, and we call that term in
the obstetrics and gynecologicalspaces as the VE selva.
Therefore, right, we.
That movement is quote unquotebad.
I would argue that it isn't, butin general, it is seen in that
(08:23):
way and that there's a lot ofreframing that has to happen
around the prolapse space aswell.
And then when we use it instrength and conditioning, it
refers to bracing.
And unfortunately, sometimes theway that females are told to
brace is to inhale, feel theirbelly full of air, and then
they're down.
(08:43):
And for individuals with malepelvis that are a bit narrow,
pelvic floor dysfunctions arenot as high in recreationally or
elite level athletes who aremale.
That that isn't going to causeany problems.
The problem is when we are usingthat, that term to refer to
bearing down from a strength andconditioning perspective because
(09:05):
it can lead to increased, uh,instance of things like uh,
urinary incontinence.
But really when we're talkingabout bracing from a a, like
that Valsalva strength andconditioning bracing
perspective, we really aretalking about this, this con co
contraction of all the musclesaround the core canister,
including the internal externaloblique rec, modi, you know, our
(09:27):
chest wall diaphragm and ourpelvic floor.
And when we ve Salva, we see.
Kind of a synchronous activationof all of the muscles around the
core canister, that this acts asa protective mechanism.
It increases our force transferbecause it increases stiffness
around the spine.
So by increasing stiffnessacross the spine, we protect
(09:49):
ourselves from injury.
We also increase our performanceor capacity by allowing us to
exert more force against ouraxial skeletons so that we can
lift more load in, in whateverway we're doing that.
And in that realm, Valsalvaisn't bad.
Valsalva is something thatallows us to be stronger, and it
(10:11):
is something that we do verynaturally.
Over 80% of our one rent max andkind of tie in my geriatric
space.
You know, if your client isusing their hands to get up out
of a chair, their one rat max isless than their body weight,
which means that they'reValsalva.
Every time they get up from achair, because that's the only
(10:32):
way they're gonna be able to doit.
Bringing this back to thepregnant and postpartum space,
if we are actively encouragingindividuals to decondition, and
we may not conceptualize it thatway, but by discouraging or
creating fear aroundstrengthening and movement and
pregnancy and postpartum, we areunintentionally deconditioning.
(10:53):
This group of individuals, thentheir 80% of their one at max
may become their car seatbecause we have told them now
for the next nine months thatthey should not be doing any
type of heavy load theirstrength.
Is gonna come down incombination with the
physiological changes thathappen during pregnancy and then
in the postpartum space.
(11:15):
We just expect them to be ableto baby wear immediately after
delivery.
We have a, if you're in theUnited States, a lot of times
you're having six to 12 weeks ofunpaid leave, and then you're
going to full-time work as aphysical therapist.
Eye lift people's limbs.
Those limbs are oftentimes,Light and we are doing that on a
(11:35):
deconditioned person.
And that's where, you know, as Iwas, I was thinking about this
and reflecting on where ourrecommendations were, it didn't
really make a ton of sense tome.
And the Valsalva duringpregnancy piece is important,
where the theoretical constructscome from because we didn't have
any information on it up untilthe last couple of years.
(11:57):
Theoretical constructs arearound that.
We see a transient increase inblood pressure when we val salva
up to about 200 millimeterssystolic millimeters.
Mercury, stoically, gestationalhypertensions.
Preeclampsia in pregnancy aresomething that are extremely
relevant and something that aremonitored very closely.
Heightened sustained bloodpressure is very different than
(12:20):
transient increases anddecreases in blood pressure that
occur with resistance training.
But something that needed to beevaluated was number one.
Number two is that we do have anincrease in pressure, which
causes an increase of work onthe pelvic floor.
This is the big pelvic healthone that we think, okay, our
pelvic floor is already strangeduring pregnancy.
(12:41):
Let's not strain.
More, and I am totally was inthat camp, right?
I still tend to, to bias towardsexhaling on exertion.
I'm now transitioning intoexploring different ways of
breathing and seeing what feelsgood for the pelvis of the
person that I'm working with,but, What I think is happening
(13:03):
and where our theoretical partsmight be wrong, is that for
individuals who are alreadytrain resistance trained, their
bodies are already trained toAlva, and so that progressive
overload is happening duringpregnancy and their body is
adapting as.
Baby starts to grow and, andchanges start to exas or start
to increase in change asindividuals go through the first
(13:24):
or third trimester.
So the body is, I think,adapting and therefore we don't
have to be as fearful around theVal Salva piece.
Now we have, I know, I'm so longwinded.
I'm sorry.
Last piece, like on the researchside, on the research side of
things from Valsalva, we nowhave three studies that have
investigated Valsalva in apregnant person.
(13:47):
One, we, uh, two of them havelooked at resistance training,
one with a 10 max leg press,another one with an incline
bench press, and they werelooking at maternal and fetal
healthcare outcomes and seeingif there was any changes in
ultrasound or anything thatwould.
Would indicate fetal distress orsomething negative happening to
(14:08):
mom.
What we recognize and what thefindings of those two, those
were not my studies.
Those two, um, previous studieswere that there didn't seem to
be any abnormalities in fetalheart rate.
Pregnant and non-pregnantpersons responded to Val Salva
the exact same way, andtherefore it appears from just a
cardiovascular perspective in ahealthy pregnancy, free of
(14:29):
complications.
Valsalva is okay from, from thecirculatory, like the transient
increase in blood pressure.
With that perspective from thepelvic floor perspective, both
of these studies were not donein individuals who were
standing.
With external load on theirbody.
So we couldn't really evaluatepelvic floor outcomes.
But the way we tend to, to tipour toes into the, the pregnant
(14:53):
space is that we make sure babyis fine first, and then we can
start exploring and, and youknow, kind of dabbling into
different areas.
And our study was looking at, wedid a subgroup analysis about
individuals who said that theycontinued to Valsalva during
their pregnancy and those thatdidn't, and we did not see an
increase in pelvic floordysfunction postpartum from the
(15:15):
34% of individuals in our cohortWho answered that question?
That they continued to Valsalvaversus didn't.
The one thing to kind of bringthis full circle is that that is
not saying that Valsalva isprotected.
That is not saying, you know, itis saying that it is net
neutral.
I've seen it.
I've had to kind of, you know,that's not really what my study
(15:36):
said.
Um, it didn't say that there wasan increase in risk.
That doesn't mean that it'sprotective.
It.
I will interpret that as it isnet neutral and what we, we
think and what we know is thatmany of the predictors for
pelvic floor dysfunction, Theyoccur during labor and delivery.
(15:58):
These are obstetrical factorsand oftentimes are completely
outside of mom's control.
Um, not all the time, but, but alot of the time.
And so we don't need to becreating shame around what a
person did during pregnancy,what they didn't do, what they
decided was good for their bodyand what wasn't good for their.
(16:18):
Everybody's pregnancy is goingto be different, and we don't
have any research to supportthat.
The exercise that you choose todo during pregnancy is going to
set you off for bad long-termoutcomes from a pelvic floor
perspective, and, and that'skind of what I really want this,
I wanted this study to highlightis to just add to the body of
(16:41):
literature showing.
It's okay to lift more than 20pounds.
I was pregnant with my second,my daughter was 25 pounds.
If I would've gotten thatrecommendation, imagine how
harmful that is.
Oh, I'm potentially harming mybody or my unborn child in order
to not have my child lose hermind at the park.
Cause I have to carry her outcuz she wants to still play.
(17:02):
You know, like those situationsthat moms get into all the time
and, and yeah, we just, we justhave a, a.
a communication change that Ithink needs to happen.
Natalie (17:13):
I, I agree.
There's so much fear just notonly in the exercise during
pregnancy space, but also justpregnancy in general.
Women's health in general.
There's such a lack of researchand information and.
Good information and educationthat, yeah, people just end up
being scared of things and thenthat, what I've seen I guess in
(17:34):
my, my years of working withpregnant people is it tends
towards I'm just not gonna move.
Like it's safer for me to notmove than to try something new
or continue what I've been doingbecause I don't know.
Christina (17:47):
Yeah, and, and that's even being challenged, right?
When we look at a systematicreview that.
Put individuals on bedrestversus pelvic rest.
So bedrest don't do anythingexcept go to the bathroom, get
food, come back to bed versuspelvic rest.
Don't have any penetrativeintercourse, any speculate
exams, et cetera.
(18:07):
But continue with activities ofdaily living and lower intensity
exercise.
Individuals who are put onbedrest have worse obstetrical
outcomes, and, and thatintuitively makes sense.
Again, you're deconditioningthat person.
It makes labor a lot harder ifyou've lost 30% of your fitness
(18:28):
than if you haven't.
I'm not saying that your laborwill be shorter if you're
fitter.
That's another misnomer thatcomes into the space all the
time.
But what I'm saying is it takesa lot of exertion to, to deliver
a baby in whatever way that youdeliver, and your body needs to
be ready for that.
Natalie (18:47):
Yeah.
I know you probably heard thelabor is a marathon kind of
analogy, but I like to call it aSpartan race.
More so in the
Christina (18:54):
Yeah.
I love that.
Yeah, I love that.
Natalie (18:58):
know what obstacle you're going to encounter, and
you have to have the strategiesand the tools to overcome those
obstacles.
And if we're left weaker,Typical or that what, what we
were before pregnancy, thenwe're going to have struggles,
right?
And, and
Christina (19:16):
Yeah.
Natalie (19:17):
finish that race in a different way than we
anticipated.
Christina (19:20):
Yeah, absolutely.
Absolutely.
So our study tried to look at abunch of different outcomes that
tried to put all those mythsaround pregnancy.
And one of my theories, becauseI see it so often in barbell
athletes, is that they tend tobe on the hyper side of things.
And therefore, you know,especially for elite level
(19:41):
athletes, I think they may bepotentially more at risk for
delivery VST section becausethey are very good at performing
the bear down, but closing theirspans.
And as we know with labor anddelivery, Is going to be
counterintuitive or counter toprogress.
And um, so we were looking atthat, but, but we saw actually
(20:02):
less rates of C-section comparedto within where 13 of
individuals in our surveydelivered via C-section versus
our current standard, which is,
Natalie (20:12):
yeah.
Yeah.
That's incredible.
I was looking at that and onlyfour people had gestational
diabetes.
Is that correct?
Christina (20:19):
yeah.
Natalie (20:20):
That's amazing.
Christina (20:22):
And, and we have this aerobic literature, right, where
individuals who areparticipating in aerobic uh,
training before pregnancy areless likely to develop
gestational diabetes and arebetter able to manage
gestational diabetes once it hasoccurred in pregnancy, if there
is genetic predispositions andthings.
But we didn't really have anaccumulation of anything within
resistance training just becauseour, our literature is so sparse
(20:45):
within that space and.
But, so yeah, it's a reallyencouraging finding for us to
show, and it just makes so muchintuitive sense, right?
We know that resistance traininghelps specifically with ostial
diabetes because our muscles areso metabolically active that
they're gonna be drawing all ofthat blood sugar out of our, our
(21:05):
blood to be able to fuel thatrecovery.
And so it just, it, it does makesense that it is true within
pregnancy, but we hadn'tevaluated it in, in that cohort
of individuals.
And so, and then we saw very lowrates of gestational
hypertension in preeclampsia aswell, which is also wonderful.
And then, um, very low rates ofperinatal mood disorders.
(21:27):
And again, that's a another.
Big health piece, like there's alot of potential confounding
there because individuals whoare lifting heavy prior to
pregnancy probably had a lot ofthose healthy lifestyle factors
in place before they gotpregnant.
And so it's, it's important torecognize that this is
cross-sectional data and we canmake inferences and we can use
this as potential justificationfor more longitudinal or, or
(21:51):
going forward perspective datacollection.
Um, but we can't.
You know, resistance trainingis, is protected against all
these things.
We, we can start, you know, itstarts to, to hint that there
could be a relationship there,but we still have a of work to
do in research to try and reallydelineate some of those
relationships and what themagnitude of.
Natalie (22:12):
Yeah, yeah, no, the outcomes were impressive.
I was really encouraged,especially about the, the
postpartum prolapse too.
I don't remember the number, butit was very low.
Christina (22:23):
13% had subjective symptoms.
So, and we said heaviness or abalding or a feeling like a golf
ball is in the vaginal opening.
That was kind of our, ourmarkers for subjective
complaints.
So important to note, similar toLaurie Forner study on lifting
and, and prolapse.
She was looking subjectively,she didn't do objective exams
cuz it was a cross-sectionalsurvey, but our study kind of
(22:45):
collaborates with what she saw.
Um, with respect to, toincidence of prolapse symptoms.
And again, that's a big.
Fear a spiral that a lot ofindividuals have.
Um, I always joke that withprolapse, we, our training has
done us a disservice becauseevery anatomy textbook makes us
feel like our, our vaginal canalis this hollow tube that is like
(23:08):
collab.
And if I look at an internalexam, I'm just gonna stick right
through to see the cervix.
And I was like, that is not how.
Our vaginas are.
And um, so we have thisassumption that, you know, that
moving and shifting it's smoothmuscle.
Like we're just seeing thatmovement happen and, and yet we
can heighten and sensitize somany pelvises about that.
(23:29):
And so one of my.
Things I really encourage, um,allied Health and, um,
obstetrical and, and individualsin the birth provider space is
to tell them what is, what isnormal to feel down there after
a vaginal birth, like a descentof the bladder, a slight descent
of the ba bladder is normal.
When we look at the naturalhistory of vaginal birth, we are
(23:51):
gonna have more AP movementlike.
Before when you were liftingduring, um, pre-pregnancy, or if
you're Nelly Paris, your firstpregnancy, you're not gonna feel
a lot of up and down movementthere.
But because of this stretchinjury from a vaginal birth, you
are gonna feel more pelvicmovement.
And that is.
Normal.
But a lot of individuals canlink that to something that is
(24:13):
pathological or something thatis wrong and something that they
are trying to avoid.
So they start to lift and theystart feeling very sensitized
saying, I'm feeling theseprolapse symptoms and you know,
we have to start teasing thatapart.
Like, is that prolapse symptoms?
Is that fatigue of your pelvicfloor?
Cause those muscles are gonna bethe weakest across your system,
(24:35):
or is that normal movement aftera vaginal.
Natalie (24:40):
Hmm.
That's really fascinating.
I think that's, that's somethingthat like pro providers,
practitioners need to be moreaware of, like you said.
And then also empowering womento do their own assessment on
themselves and figure out like,what did I feel before?
What do I feel now?
And comparing that, am I stillstrong?
(25:01):
Am I leaking?
You know, all of the, all of theself assessment questions can be
helpful.
Um, okay.
Why isn't this space morestudied?
It bothers me,
Christina (25:16):
Yeah, that's a great question.
Well, the first thing, and thereason why we did a
cross-sectional survey isbecause, Have to, when you're
doing research, you have to gothrough an ethics board.
So when you're going through anethics board, and this is just
due diligence within theresearch space, anytime you're
doing a study, you have to makesure that.
(25:40):
When you're dealing with apregnant person, the risks are
already elevated, right?
Because our adverse outcomes aresomething that are really
devastating, right?
If we had a fetal loss or amaternal complication or
something that led to a birthdefect, whatever it may be, like
it, the risk is very low, but,but the risk is there and the
risk is very high.
(26:01):
Versus other, you know, exerciseprograms where we're thinking
maybe a musculoskeletal injuryor like an exacerbation may.
The adverse event that we'relooking at.
So that's number one.
So we tend to, to tread veryslowly and that's why we did a
cross-sectional survey becausethe, the last, like really the
research that we have inresistance training is around,
(26:23):
you know, lifting 20 to 30pounds.
So it makes sense that this iswhere the recommendation comes
from.
You know, the resistance studiesthat we do have, this was the
load that individuals werelifting.
There was no adverse events tothat.
We don't know anything abovethat threshold.
So the threshold that we aregonna give people is don't lift
more than 20 or 30 pounds.
Right?
It's like this bad case oftelephone that happens.
(26:45):
And so we went to the, we wentto our ethics board and said,
People are doing it.
We wanna see if people are doingit anyway because our next step,
which they are, right, they are.
But we have to have thatjustification.
But now we haven't.
So we can say, you know, I knowthat this is something that is
(27:05):
riskier or something that hasnot been evaluated, but based on
our study, we got almost 700female.
Who lifted heavy during theirpregnancy.
So there is a cohort ofindividuals who are, who are
self-selecting that this is anexercise modality that they
enjoy and wanna continue doing.
Let's do more research in thisarea and, and research is a long
(27:27):
game.
You know, it took us, we did across sectional survey that was
open for 12 weeks.
It still took us 18 months toget it from start of project to
finish.
And I think a lot of people whoare our clinicians or consumers
of research who have never beenin that space, it, it's hard to
truly.
Appreciate that.
You know, it is such a long gameand so I'm hoping that this is,
(27:50):
is step one.
I have so many different ideasaround where we can go next from
this study, and I think in theCrossFit space, in the aerobic
space, in the return to runningspace, like we now have a lot of
cross-sectional data that isstarting to describe what is
happening.
We need interventional studiesnow we need, you know,
(28:12):
longitudinal data.
It's expensive.
It takes a lot of time.
And so I think we're having moreindividuals interested.
This study, we pub I knew thatthe study was needed.
All of us did in, in ourresearch group.
I cannot even believe the uptakeof our paper.
It was just unbelievable.
It just, it just showed.
(28:34):
How much this was needed.
You know, I'm still gettingmessages at people asking me for
it because they had thisinteraction or, or this happened
and it's open access, which iswonderful because then you can,
you can access it for, fromanywhere, anyone, even if you're
not involved in, um, a collegeor a university, and.
Yeah, so we're getting there.
(28:55):
It just, the more people who areasking for this research, the
more people who are pushing itin clinical practice, it comes
into the research space, informsour projects, and then vice
versa.
Natalie (29:05):
Oh yeah.
A door.
It's like the first little stepinto this whole world where we
really need more research, we,we need more information.
And I, I bet in the next 10years, like you probably have
your theories about this, but inthe next 10 years we're gonna
see like a bunch of studies anda bunch of change in not only
(29:25):
like pelvic PT practice, butrecommendations from
practitioners, generalobstetrics and all of that.
Christina (29:33):
Oh, I hope so.
And, and I think, you know, theway exercise, even recreational
exercise has changed withrespect to high intensity.
CrossFit was one of thosemethodologies where at first,
Every clinician, what are youdoing those kicking pullups for?
Like, you're just gonna hurtyourself.
(29:53):
That CrossFit stuff, it'sreckless.
And now that it's changed fornow, a lot of allied health
providers are coming alongsideCrossFit and saying, you know,
this high intensity stuff, it'shelpful.
You can get really fit.
You wanna make sure thatcoaching is there.
You're doing it progressing, youknow, we call it mechanics,
consistency, intensity, masterall those basics and
(30:15):
fundamentals.
Then build that consistency upand you can add that high
intensity, start putting it intoworkouts.
But now we have, you know, likethe burn body bootcamps and the
orange theories that are allreally kind of spinoffs of this
high intensity paradigm.
That's so needed.
You know, we have high intensityinterval training research for
individuals in ICU who have hadstrokes.
You were actively in cancertreatment.
(30:37):
You know, like that intensitymatters and that intensity is
helpful across the lifespan, andthat's, I think, gonna come and
be true in the pregnantpostpartum space too.
Natalie (30:48):
I'm so
Christina (30:48):
When your body is ready for.
Natalie (30:50):
Yes.
Yeah.
Um, okay.
I'm gonna kind of go go back topelvic PT and specifically the
internal exam.
Um, what does that look like foran athlete, for someone who has
been lifting heavy prior topregnancy, during pregnancy, and
then in postpartum?
What does that look like?
Do you do things different thanthe general population?
Christina (31:11):
Yeah.
So yes and no.
So we will do a supineassessment where we are doing
external, um, palpation, makingsure there's no pain points,
doing an external check of whatthey're doing from cough sneeze,
looking for basically the rangeof motion of the pelvic floor.
What.
Their keel looks like, or whatthey think a keel is, a bear
(31:33):
down to look at their movement.
We will add in a brace insupine.
So we will say, you know, do a,like, pretend you have a Mac
squat on your back braces ifyou're about to, to squat that
weight or pick that weight offthe floor, see what happens.
And then our internal checks areall the exact same.
The demands of our, you know,our, especially our lifters, I
(31:57):
am more likely going to see theminstead of being able to isolate
the pelvic flora, they're gonnakick on everything, right?
They're gonna kick on theirglutes, their addicts, their
abdominal wall.
They're gonna stop breathing,and they're gonna do a keel and.
That makes a lot of sense,right?
Because when I am MaxDeadlifting, I'm not just trying
to turn on my pelvic floor.
I'm trying to turn on everythingwith as much recruitment as
(32:19):
possible.
And so that for them is verysport specific.
It is absolutely helpful forthem to be able to, to tease
apart and isolate those muscles.
And we're starting to get someresearch on using pelvic floor
muscle training for athleticincontinence, which is
individuals who are leakingspecific to sport and outside of
activities of daily living.
And then we'll do the standingassessment as well.
(32:41):
So we can get individuals instanding, going through that
same sequence and looking atexternal checking In standing,
we can do it in the bottom ofthe squat, which tends to be a
point where individuals areleaking.
So go through a pelvic floorcontraction, whatever that means
for you, a bear down, a coffer,sneeze, and a brace.
Again, whatever that means foryou.
(33:02):
And then we can do that with,uh, a digital assessment as
well, getting them to see someof those movements.
And that's where we live ourlife.
You know, we live our life instanding.
Our supine assessment, do notget me wrong, we have tons of
evidence for it.
It is extremely helpful.
It gives us our baseline, but weneed to get people off the
table.
Oh my gosh, six to eight weeksof transfers of dominance
(33:23):
training just makes me wannablow my brains out.
Like that is not.
and individuals don't wanna dothat.
Like eagles are boring.
Like they are useful and that iswhere we start.
But then we integrate that intofunction as fast as we can.
Right?
Like that is the goal is yes.
Get them doing that Pelvic fourcontraction.
We have grade A level oneevidence for using it against
(33:46):
pelvic four dysfunction.
There's a whole, right nowthere's a lot of people on
social media being like, stopdoing keels.
I was like, stop telling them tostop doing keels.
That is not, Gosh, the socialmedia space can be so annoying
sometimes.
But
Natalie (34:01):
Overgeneralization for sure.
Christina (34:02):
yes, it's teach it.
Teach the coordination of it,make sure the prerequisites
strength is there, and thenintegrate it into function.
Like that's our steps.
And that should be the first twosessions that we're doing that
not, you know, week 12
Natalie (34:18):
Yeah.
Agreed.
Yeah.
And
Christina (34:21):
and then,
Natalie (34:21):
up and up and carrying their babies around the house
anyways.
Going up and downstairs andlifting the car seat and getting
in and out of the car.
Like normal
Christina (34:29):
was doing a 50 pound carry with my toddler baby
wearing my son because mytoddler lost it in the park and
she didn't wanna leave.
So I was like, Maya, you canwalk with me, or Mommy can pick
you up.
And she didn't wanna walk.
So off I went, you know, I thinkit was three weeks postpartum.
It just is what it's, you dowhat you have to do.
And then from the, the pelvicside of things, we also, um,
(34:53):
really strongly advocate forcoaching first.
So if you were seeingindividuals who are lifting or
leaking with lifting, then yougotta see them lift.
And if you don't have theequipment in your, your, your
clinic.
I, I think you should get theequipment number one, but number
two, if you don't have it rightnow, then you should be video
getting their videos and, andseeing what's happening.
(35:15):
Like are there any deviations intheir movements?
What does their bracing sequencelook like?
What does it look like when theyput a weightlifting belt on?
Does that change the way thatthey brace?
Because that can lead toleaking.
Like what is their thresholdwhen they leak?
If they are deadlifting 2 85,are they fine?
And then when they bump up to 295, now they aren't.
All of those things are gonna beso, so important for assessing a
(35:38):
person who enjoys lifting andexperiencing symptoms with
lifting, um, to really createthat bridge from like what we
are seeing in our internalevaluations and then what is
happening in the gym, and thencreating that bridge for them,
for them to get back to thosemovements.
Natalie (35:55):
Awesome.
Yeah, that should be thestandard.
That's what I think.
Christina (35:59):
A hundred percent.
Natalie (36:00):
you mentioned weightlifting belts, and I
didn't ask you that question Iwas going to.
Um, so why would someone chooseto use one for one question?
When is it contraindicated andlike, what's the purpose or the
goal?
There were 45 people.
In your study that used themduring pregnancy?
Um, up to like 18 weeks, Ithink, if I read that correctly.
Christina (36:20):
Yes.
Natalie (36:21):
Can you talk about that
Christina (36:23):
Um, in the first trimester, I generally do not
have any contraindications toexercise that I would advise my
clients unless there was apregnant complication or
something that we were workingaround.
Um, it's gonna be how sick areyou feeling and what is your
fatigue doing, and what doesyour rebound fatigue look like
after exercise?
And the rebound fatigue is gonnabe relevant throughout
(36:43):
pregnancy.
You know, you do it heavyworkout, you feel a bit tired
when you're in day to day.
When you're pregnant, you likefive x that and that's what your
rebound fatigue feels like whenyou go really high intensity.
And, and if that, if you'redoing your exercise and you're
able to go home and just kind ofrest and relax and you wanna hit
that intensity, that's totallyfine.
(37:03):
If you are working out in themorning and it's making it so
that you feel like you can'tparent or do your job, then
we're gonna have to scale atintensity back.
From the weightlifting beltperspective in the first
trimester, I generally don'tmake any recommendation.
If people want to use it, theycan.
If they don't wanna use it, theydon't have to.
Baby is really far in theposterior aspect of the pelvis.
It is not like there is nodirect compression on uterine
(37:26):
wall, on baby themselves.
Um, Until further along, and somost of my clients, I don't
really need to make arecommendation because they
start feeling real cringy aboutit around weeks 10 to week 14,
and then they just ditch it, andthat's totally fine.
Um, and so that, that's kind ofgenerally where the
(37:47):
recommendation is.
Individuals will useweightlifting belts because
we'll get a 10% increase in, uh,EMG activation of the spinal or
para of spinal muscles in thespine, um, which allows us to
feel more supported through thespine and allows us to lift more
weight.
So there is a performanceadvantage to using a weight
lifting belt in the sports ofCrossFit.
(38:08):
Weight lifting and Olympicweightlifting.
They're also legal aids to beable to use in competition.
And because they give us aperformance advantage, we want
to be utilizing them.
So therefore it's something thatwe want to be encouraging if we
can.
It is also a time whenindividuals can be experiencing
(38:29):
more pelvic four symptoms iswhen they use a belt.
So a couple of kind of standardthings that we talk about with
the weight lifting belt.
Number one is that we shouldn'tbe using it for all sets.
It is for a top set, theheaviest load that we are
utilizing for my postpartumclients.
I ask them, are you using thebelt because it makes you feel.
(38:50):
Better at your top sets or areyou using it as a crutch because
we haven't built up thefoundation yet that you need in
order to be exposing yourself tothese loads and, and truly
reflecting on, are you ready forthose loads just yet?
If you feel like you need to useone at eight or 10 weeks
postpartum, it might be morebecause we need to build more of
the foundations and your core isyour weak point, not your quad.
(39:12):
Um, and, and we need to work onthe weak point across the, the
system.
And then when we utilize it,the, the problem where leaking
can happen is that individualschange their bracing strategy.
So the way that I'll teach aValsalva is I get them to bring.
Take a big breath and thencontract their belly like
(39:32):
somebody was gonna give them alittle punch to the stomach, or
your toddler was about to jumpon your belly.
And everyone knows that feeling,right?
Like you start to tighten up.
That's what you wanna beexperiencing.
So that'll create a nice, um,closed canister.
Allow for increase in EMGactivation throughout the entire
system.
When you put a weightliftingbelt on, that should not change.
(39:54):
What some people will do is thatthey will be told to actively
push out against the belts, andthat's where, especially
postpartum, when you have moreof that movement down there, it
feels like you're pushing in themiddle of a balloon and.
You know, your, your ribcage isabove, so that's not where that
extra energy or pressure isgonna go.
It's gonna go down towards thepelvic floor and people are
gonna feel potentiallysymptomatic there.
(40:16):
And so the idea is that itreally should just be an extra
proprioceptive little bit ofsupport.
It should not be something thatyou are utilizing as a crutch.
Your body needs to be ready forit, and then it's gonna help
give you that performance a.
Natalie (40:31):
I don't think I've ever heard somebody explain it that
way before, and that makes waymore sense than what I've heard
from other people, andespecially since that's not my
wheelhouse.
That Thank you for, for goingover that.
I appreciate it.
Christina (40:43):
Yeah, you're welcome.
The last thing probably aboutthe weightlifting belt is that
the general recommendations thatwe wanna give is that the
weightlifting belt shouldmaintain the same size all the
way around.
Ideally, you'll see some whereit'll be very narrow as it goes
across the sides of the ribs,and then very wide in the back,
but that's gonna distribute thatforce unequally.
(41:04):
So we really want to be thinkingthat it is going to go like
around that ring of your bellyand and distributing that load
very evenly across.
All sides of that canister.
So things that if individualsare asking, you know, what belt
should I be utilizing?
One, we want it to beconsistent, um, with all the way
around.
And then the second thing isthat different sports will have
(41:26):
different rules around whatweight lifting belts are legal
versus not.
And so it's important for theathlete to check.
With that as well.
Like a power lifting federationwill only have specific brands
and are only gonna allowleather, like thicker lever or
prong belts versus CrossFit andweight lifting, which has a
(41:46):
little bit more flexibility andmost will use a cloth belt, a
lot more cinching and pressureand stability and all thick
leather belt than in the clothprong belts.
And, but that can be a way thatyou go from not using belt, you
use the cloth.
Then use the leather if you'retrying to progress an athlete
back to power lifting, forexample, and they need to use
(42:09):
that leather belt.
Natalie (42:10):
Okay.
Okay, gotcha.
Makes a
Christina (42:12):
Mm-hmm.
Natalie (42:12):
of sense.
Something I was gonna ask you, Idon't, I didn't see pushing
times for outcomes in yourstudy.
Was that included,
Christina (42:22):
Yes.
So we have like 60 pages ofsupplementary tables.
Did you take a look?
Natalie (42:28):
Yes.
I started, I didn't get throughall of them.
Christina (42:31):
Yeah, so we had some around like length of second
stage of labor, um, that wasthere.
I'm not sure if it was in thesubgroup analysis, but we did
ask that question.
Nothing really remarkable cameout that would be outside of the
norm.
Um, but yeah, nothinglengthened.
Nothing shortened.
Natalie (42:50):
Okay, cool.
Yeah, I'm curious cuz I'm like,okay, if these individuals are
doing Alva, if they're usingdifferent bracing techniques,
how does that translate topushing a baby out or not
Christina (43:00):
From a birth prep perspective, you know, for my
athletes, I'm getting themdoing, I, I call them birth prep
workouts, where it is mandatorythat they do them.
It is in their programming everyweek, and it's all about down
training.
So it's around learning.
You know, sometimes pelvichealth can only talk about open.
GLAD is pushing, but evencoached open, GLAD is pushing,
(43:20):
ends up being a combination ofopen and closed just because of
performance and, and what'shappening in the moment.
You.
And so we need athletes to beaware of, we need everyone to be
aware of both, I shouldn't justsay athletes.
We need everybody to be aware ofboth.
And working on that relaxationcan really help with the labor
and delivery process.
(43:40):
And you know, I've had a lot ofathletes who have had second
babies and they say, oh yeah,the first time I was absolutely
fighting myself.
I could, like, the experiencewas just so different knowing
that I had to, to have thatrelaxation.
Natalie (43:55):
Interesting.
Christina (43:55):
And that's where I think even our perennial
massaging, where we're, we'reapplying that stretch, if a
person's goal is an unmedicateddelivery, applying that stretch
is very similar to that ring offire feeling and then being able
to relax that pelvic force.
So again, getting our athletes,you know, there is a, a bigger
trend towards unmedicated ortrying for an unmedicated
(44:16):
delivery.
Applying that stretch and thenworking on some of that
relaxation and open and closedpushing strategies can be
helpful.
Um, and then on the flip side,you know, we have some research
saying that an epidural maylengthen the second stage of
labor.
I don't know if that's alwaystrue.
You know, like, especially ifyou have an athlete that's
really fighting their ownprogression, that epidural may
(44:38):
actually get their body torelax.
And, and so I've had clients toowho.
Said, you know, I was reallyfighting until I got that
epidural, and then I felt likemy body relaxed and I went from
three centimeters to eightcentimeters in like no time.
Natalie (44:51):
Yeah.
Yeah.
Christina (44:51):
So, so we have to,
Natalie (44:53):
in practice.
Yeah.
Christina (44:55):
yeah.
So we have to take all of thisdata as things that are, are
trends, but then obviously applyour clinical reasoning and then
be able to modify and, and adaptto the person that's in front of
us.
And that's really the truedefinition of evidence informed.
Natalie (45:09):
Yeah, reading the person, not the studies.
Only
Christina (45:12):
Right, that trium it, right?
Natalie (45:16):
Okay, So I wanna kind of wrap up with what are your
favorite resources, books,accounts that you recommend
following?
For someone who really wants tolearn more, do more research,
dive into this world,
Christina (45:31):
So I'm gonna have to shamelessly self plug some of
these things.
Um, so I teach cliniciansthrough the Institute of
Clinical Excellence.
I teach two courses.
I teach our eight week onlinecourse.
Um, that goes all the way frompreconception with the female
athlete or, or a person whowants to move their body all the
way through pregnantmodifications, labor and
(45:52):
delivery for trimester, and thenreturn to exercise postpartum.
We also have a two day livecourse where we focus a lot on
lab.
We teach the basics of theinternal assessment and then
teach how to bridge that into.
Return to intensity and exerciseand movement, we get, you know,
we get the information in theinternal exam and then we're
(46:14):
able to move that to returningto tipping pullups and returning
to handstand pushups andreturning to heavy squatting and
deadlifting.
And so I teach those two courseswith, um, Alexis Morgan and our
team, and we teach that throughthe Institute of Clinical
Excellence for clinic.
And then for athletes who arelistening to the podcast, I run
a company called The BarbellMamas, so I do programming.
(46:38):
For pregnant CrossFitters,weightlifters, power lifters,
postpartum CrossFit,weightlifters power lifters,
that take into considerationsome of the pelvic floor, uh,
factors in both of those timesin a person's life and have
created filters for return.
So for pregnant modifications,we help individuals stay moving.
In a way that makes them feelsupported and then postpartum,
(47:00):
we really try to use thatpostpartum programming to bridge
them back to their communities.
So get them back into theCrossFit gyms, get them back
into their Weightlift clubs, getthem back into movement, and so,
you know, We are not fearful ofpelvic floor issues coming up,
especially for individuals whoare high intensity athletes
because they're pushing theirboundaries.
And until you know where thoseboundaries are, you're really
(47:21):
not gonna know where those linesare.
So these athletes are gonna bethe ones who are going to.
You know, start jumping orrunning and they're gonna be
like, oh, body went too far.
That's okay.
We're gonna take that down alittle bit.
Just like we're not afraid ofpain.
Pain is a signal.
Our pelvic force issues are asignal of where our body
readiness is.
And so, okay, you'reexperiencing leaking with this
(47:42):
squat, here's how I want you tomodify it.
And so we have different filtersfor that.
And the idea.
You know, we always say this,that it's bad advice, you know,
to wait six weeks and thenlisten to your body.
And I've kind of reallyreflected on that.
I'm not being very nice sayingthat.
I want you to listen to yourbody, but I want to tell you
what to listen for.
You know, I want to tell you,you know, what your guideposts
(48:05):
are because you're not gonnaknow, especially if you've never
done this before.
Natalie (48:10):
Huh.
Christina (48:11):
What, what you're listening for and you're, you're
an athlete.
You've been very in tune to yourbody, but your, your.
Feels and looks a little bitdifferent now.
And, and that's okay.
So we just, we just wanna helpguide you on that journey.
And so the Barb Mamas isdefinitely, um, one where, where
we talk a.
Natalie (48:29):
Awesome.
Awesome.
Okay, last two questions that Iask every single guest, The
first one is if you could boileverything down to one.
Like your number one piece ofadvice for our listeners, what
do everyone to know?
Christina (48:44):
Okay.
My piece of advice is that yourbody is strong and your body is
resilient.
And if pelvic issues come up, weknow how to handle them.
But that does not mean that yourbody is not strong and that your
body is not resilient.
It's just.
Natalie (49:03):
Preach it.
I love it.
Last question.
What is your favorite wellnesshabit that you incorporate into
your daily life?
Christina (49:14):
Hmm.
Lifting heavy weights.
my husband and I live together.
Yeah.
My husband and I live togetherand so it's kind of two for one
because it's my connection timewith him and you know, having
two little kids.
It takes a big toll on yourrelationship too.
And so it's a way that weconnect together and we, we
(49:35):
compete together in the CrossFitspace.
We've competed together inweight lifting and power
lifting, and that's justsomething that we've always done
together.
And so, I'm just that personthat is just in love with
fitness in every stretch of theimagination.
I like go to bed thinking aboutit.
I just have found something thatI just love doing.
It just sets my soul on fire.
So that is definitely mywellness habit that I, you
(49:59):
would, any physician would haveto give me very good reasons for
me to stop lifting weights,
Natalie (50:06):
And you would probably be able to argue them
intelligently, so it wouldn'tmatter that way.
Christina (50:11):
Yeah, they would have to come, they would have to do a
tent with me for a little bit,for me to be okay with it.
Natalie (50:17):
That's awesome.
I love it.
Well, thank you so much forbeing here today and, and
spending your time and energywith me.
I, I super appreciate it.
Christina (50:25):
you're so, thank you for having me, and thank you to
your listeners for chiming intothis.
Natalie (50:30):
My top takeaway from my conversation with Christina was
there are so many different waysto approach fitness during
pregnancy and postpartum, butheavy resistance training has so
many benefits, and I wasparticularly interested in the
topic of the Alva maneuverduring pregnancy because this is
something that historically thepeople in the pelvic health
(50:53):
space, Recommend avoiding, andso it was really encouraging and
good to hear that doing Alvaproperly while pregnant,
especially if you've beenlifting prior to pregnancy, does
not result in any adverseoutcomes for pregnancy,
postpartum, or during labor andbirth as well.
It's not necessarily protective,but, it showed no adverse
(51:17):
outcome.
There are so many things thatstill need to be researched, but
we are making progress, and ifyou are an athlete who lifts
heavy and enjoys lifting heavy,you should definitely follow
Christina.
I also love how she brought inthe concept of we do not need to
be fearful of postpartum pelvicfloor issues or even during
(51:38):
pregnancy because it's just likepain.
We're not scared of pain.
It's a signal and it tells uswhat we need to know and we
adjust accordingly.
So that should be encouragingfor all of you as well.
I have linked all of theresources she mentioned as well
as her sites and social pagesfor you to follow in the show
notes for this episode.
So please go read her study andplease remember that what you
(52:01):
hear on this podcast is notmedical advice, but remember to
always do your own research andtalk to your provider before
making important decisions aboutyour healthcare.
If you found this podcasthelpful, please consider leaving
a five star review in yourfavorite podcast app Or sharing
it with a friend.
Thanks so much for listening.
I'll catch you next time.
On today's podcast, I chat with Christina Prevet about
(00:02):
her work as a physiotherapist inthe geriatric and pre and
postnatal exercise space as ahigh level athlete herself.
Her recent study, the impact ofheavy resistance training on
pregnancy and postpartum healthoutcomes, and what we can do as
people who are.
Wanting better outcomes forpregnancy and postpartum and
what we can do as clinicians aswell, who are working with these
(00:27):
athletes and these people.
Christina Preve is a pelvicfloor physiotherapist who has a
passion for helping women withdifferent life transitions,
including postpartum care and.
(00:48):
In 2013, Christina completed herMasters of Physiotherapy and is
currently completing her finalyear of her PhD at the Faculty
of Health Sciences at McMasterUniversity.
She recently published a studylooking at the impacts of heavy
resistance training on pregnancywith a group of international
collaborators, the first toinvestigate the safety of heavy
barbell training on pregnancy.
(01:10):
Christina created strong likeMom during her first
entrepreneurial endeavor, staveoff focusing on postnatal return
to fitness.
Christina teaches five coursesat the Institute of Clinical
Excellence, including clinicalmanagement of the fitness
athlete, pregnancy andpostpartum, where she helps
physiotherapists empower theirpregnant and postpartum athletes
to safely continue strengthtraining.
(01:31):
I'm Natalie, and you'relistening to the Resource Doula
Podcast, a place where weprovide information to help you
make informed healthcaredecisions for yourself and your
family.
Hey Christina, welcome to theshow.
Christina (01:43):
Hi so much for
Natalie (01:46):
You are so welcome.
I'm really, really excited to,to have you on.
You're the first person to comeand talk about heavy lifting on
my podcast so
Christina (01:55):
amazing.
Natalie (01:56):
So, yes.
I wanna jump right in and justask you, how did you start with
the women's health space?
What got you into this world?
Christina (02:04):
Yeah, so I'm actually doing a completely unrelated
PhD.
I'm doing a PhD in heavyresistance training in older
adults, and one of my areas ofexpertise is in geriatrics.
And as a part of my degree, Idid a scoping review about where
physical therapists can beinvolved in health and wellness.
And the perinatal spaceoverwhelmingly came up as an
area that we can help facilitateand remove barriers to exercise
(02:26):
and movement for individuals whoare pregnant and individuals who
are postpartum.
because of that, I dabbled intoit in my own business.
So we started a strong like mompostnatal exercise program, and
that was where I kind of startedtreading into the women's health
space.
I actually was one of thosepeople that said, I'm never
gonna be an internal therapist.
Like, do not wanna do it.
Like that is not something forme that I obviously lied and I
(02:48):
do all that stuff now, but thatwas something that I just didn't
think I wanted to do.
I've learned a lot since thenabout it being a tool and not
identity in the pelvic healthspace, but that's a whole other
soapbox.
And then when I got pregnantwith my daughter, I have a 10
year history of doing CrossFit.
I've competed in power lifting.
(03:09):
I competed nationally in Olympicweightlift.
And then when I got pregnant, Ihad no.
Desire or expectation to not dothat.
And I post a lot on social mediaand the comments that I started
getting were quite interestingabout your baby might die.
Like literally somebody saidthat to me in my second
(03:30):
pregnancy.
I want to see your pelvic floorbiofeedback numbers, thinking
that I was gonna spontaneouslyprolapse, just like the things.
As a person who is very educatedand informed in this space, it,
it even made me pause, you know,it made me think, you know, am I
doing the right thing?
(03:50):
And the thought then to otherindividuals who don't have the
same knowledge and backgroundthat I did, it was just really
disheartening to me.
I thought there was a lot offear spiraling that was going
on.
And therefore I started reallydiving into the research in this
space.
Not conducting research at thetime, but really starting to
synthesize and bring togetherwhat research we do have.
(04:12):
And I started teaching a coursearound pregnant postpartum
CrossFit with an emphasis onbarbell training, return to
gymnastics and return toendurance within kinda the
CrossFit sphere.
And then I was just getting sofrustrated thinking, you know,
we have all.
These individuals, you know, yousee them all the time.
People who are in CrossFit gymsevery single day, and not just
(04:34):
elite athletes like the mom whois exercising for health, who
really enjoys lifting weights,who are being told all of these
myths, like, don't hold yourbreath ever again postpartum or
pregnant.
Don't lift more than 20 poundsor giving, they're getting these
sheets from their doctors.
and it's hard because therewasn't any research on it and
(04:55):
because of that, like, you know,we can't even have a really
well-informed or evidenceinformed rebuttal and cause of
that.
Um, I reached out to MargieDavenport and a group of
international collaborators andwe started with a
cross-sectional survey that waskind of trying to get a picture
of.
Individuals who are liftingbefore pregnancy, what their
(05:15):
modifications changes, theirkind of the way that they
modified during their pregnancy,and then what that did for their
fetal outcomes, deliveryoutcomes, and then kind of got
an idea about.
Postpartum, pelvic floor,physical therapy needs.
And when they started returningto things after baby, if they
did at all.
And that just gave a lot ofinformation.
(05:36):
And, and now I'm, I'm kind of alittle bit known as like, that
pelvic PT that's gonna get youto lift heavy, who's, uh, okay
with that?
And I'm just like, overjoyed byhaving that type of, of
reputation.
And so it's been a reallyexciting journey from, from that
standpoint.
Natalie (05:52):
That's amazing.
Yeah.
I've like just the little thatI've known you and followed you
online.
I'm just constantly like, oh mygosh.
Okay.
I need to rethink that.
Okay.
What is she saying, What can we,what can we
Christina (06:03):
I do that myself.
Natalie (06:06):
Yeah, and it's, it's really interesting because my
background is Pilates and likeno history of going to a gym,
quote unquote gym and liftingheavy weights.
I totally thought that liftingheavy was dumb When I taught
Pilates, like I told peoplelike, you don't need that which
now I'm like, oh my gosh, Ican't believe I had that
(06:26):
mindset.
Um, which.
You know, I mean, it's good toevolve and change and, and learn
new things, but now obviously Iencourage heavy lifting.
Um, but I don't know as muchabout the CrossFit background
because that's not my world.
And so, um, I want to kind oftalk about, I, I read your paper
and it's amazing.
I want you to know it's great.
(06:47):
And I'll link it in the shownotes too so everybody can, um,
go and read it if they sodesire.
I have a lot of nerds who listento this podcast as well.
Um, The, like, the thing thatstood out to me most, I guess
from the very beginning wastalking about the Alva Maneuver,
because that's a huge one thateverybody in the pelvic health
(07:07):
space is like, don't alva whenyou're pregnant.
Don't Alva when you're lifting.
And especially don't do it inpostpartum.
So, um, It like, according toyour, your research, it looked
like there weren't anydifferences in their pregnancy,
labor, or delivery outcomes forthose who did Alva during
pregnancy while they werelifting, um, and those who
didn't.
(07:27):
So can you talk about that alittle bit and, and what does it
look like to Alva and is thatokay?
I have a lot of questions aboutthis, but is that considered
like managing yourInterabdominal pressure?
Well,
Christina (07:40):
Yeah.
Okay, so let's try and impactthis a little bit.
Let's start with the definitionof a Valsalva.
The hard part that comes intothe pelvic health space is that
when we are looking forsomething like a prolapse, which
is a movement of one or more ofthe walls of the vaginal canal
towards the opening because ofshifting of abdominal contents,
(08:01):
we use the Valsalva in order toassess that.
So we ask individuals to beardown, and we call that term in
the obstetrics and gynecologicalspaces as the VE selva.
Therefore, right, we.
That movement is quote unquotebad.
I would argue that it isn't, butin general, it is seen in that
(08:23):
way and that there's a lot ofreframing that has to happen
around the prolapse space aswell.
And then when we use it instrength and conditioning, it
refers to bracing.
And unfortunately, sometimes theway that females are told to
brace is to inhale, feel theirbelly full of air, and then
they're down.
(08:43):
And for individuals with malepelvis that are a bit narrow,
pelvic floor dysfunctions arenot as high in recreationally or
elite level athletes who aremale.
That that isn't going to causeany problems.
The problem is when we are usingthat, that term to refer to
bearing down from a strength andconditioning perspective because
(09:05):
it can lead to increased, uh,instance of things like uh,
urinary incontinence.
But really when we're talkingabout bracing from a a, like
that Valsalva strength andconditioning bracing
perspective, we really aretalking about this, this con co
contraction of all the musclesaround the core canister,
including the internal externaloblique rec, modi, you know, our
(09:27):
chest wall diaphragm and ourpelvic floor.
And when we ve Salva, we see.
Kind of a synchronous activationof all of the muscles around the
core canister, that this acts asa protective mechanism.
It increases our force transferbecause it increases stiffness
around the spine.
So by increasing stiffnessacross the spine, we protect
(09:49):
ourselves from injury.
We also increase our performanceor capacity by allowing us to
exert more force against ouraxial skeletons so that we can
lift more load in, in whateverway we're doing that.
And in that realm, Valsalvaisn't bad.
Valsalva is something thatallows us to be stronger, and it
(10:11):
is something that we do verynaturally.
Over 80% of our one rent max andkind of tie in my geriatric
space.
You know, if your client isusing their hands to get up out
of a chair, their one rat max isless than their body weight,
which means that they'reValsalva.
Every time they get up from achair, because that's the only
(10:32):
way they're gonna be able to doit.
Bringing this back to thepregnant and postpartum space,
if we are actively encouragingindividuals to decondition, and
we may not conceptualize it thatway, but by discouraging or
creating fear aroundstrengthening and movement and
pregnancy and postpartum, we areunintentionally deconditioning.
(10:53):
This group of individuals, thentheir 80% of their one at max
may become their car seatbecause we have told them now
for the next nine months thatthey should not be doing any
type of heavy load theirstrength.
Is gonna come down incombination with the
physiological changes thathappen during pregnancy and then
in the postpartum space.
(11:15):
We just expect them to be ableto baby wear immediately after
delivery.
We have a, if you're in theUnited States, a lot of times
you're having six to 12 weeks ofunpaid leave, and then you're
going to full-time work as aphysical therapist.
Eye lift people's limbs.
Those limbs are oftentimes,Light and we are doing that on a
(11:35):
deconditioned person.
And that's where, you know, as Iwas, I was thinking about this
and reflecting on where ourrecommendations were, it didn't
really make a ton of sense tome.
And the Valsalva duringpregnancy piece is important,
where the theoretical constructscome from because we didn't have
any information on it up untilthe last couple of years.
(11:57):
Theoretical constructs arearound that.
We see a transient increase inblood pressure when we val salva
up to about 200 millimeterssystolic millimeters.
Mercury, stoically, gestationalhypertensions.
Preeclampsia in pregnancy aresomething that are extremely
relevant and something that aremonitored very closely.
Heightened sustained bloodpressure is very different than
(12:20):
transient increases anddecreases in blood pressure that
occur with resistance training.
But something that needed to beevaluated was number one.
Number two is that we do have anincrease in pressure, which
causes an increase of work onthe pelvic floor.
This is the big pelvic healthone that we think, okay, our
pelvic floor is already strangeduring pregnancy.
(12:41):
Let's not strain.
More, and I am totally was inthat camp, right?
I still tend to, to bias towardsexhaling on exertion.
I'm now transitioning intoexploring different ways of
breathing and seeing what feelsgood for the pelvis of the
person that I'm working with,but, What I think is happening
(13:03):
and where our theoretical partsmight be wrong, is that for
individuals who are alreadytrain resistance trained, their
bodies are already trained toAlva, and so that progressive
overload is happening duringpregnancy and their body is
adapting as.
Baby starts to grow and, andchanges start to exas or start
to increase in change asindividuals go through the first
(13:24):
or third trimester.
So the body is, I think,adapting and therefore we don't
have to be as fearful around theVal Salva piece.
Now we have, I know, I'm so longwinded.
I'm sorry.
Last piece, like on the researchside, on the research side of
things from Valsalva, we nowhave three studies that have
investigated Valsalva in apregnant person.
(13:47):
One, we, uh, two of them havelooked at resistance training,
one with a 10 max leg press,another one with an incline
bench press, and they werelooking at maternal and fetal
healthcare outcomes and seeingif there was any changes in
ultrasound or anything thatwould.
Would indicate fetal distress orsomething negative happening to
(14:08):
mom.
What we recognize and what thefindings of those two, those
were not my studies.
Those two, um, previous studieswere that there didn't seem to
be any abnormalities in fetalheart rate.
Pregnant and non-pregnantpersons responded to Val Salva
the exact same way, andtherefore it appears from just a
cardiovascular perspective in ahealthy pregnancy, free of
(14:29):
complications.
Valsalva is okay from, from thecirculatory, like the transient
increase in blood pressure.
With that perspective from thepelvic floor perspective, both
of these studies were not donein individuals who were
standing.
With external load on theirbody.
So we couldn't really evaluatepelvic floor outcomes.
But the way we tend to, to tipour toes into the, the pregnant
(14:53):
space is that we make sure babyis fine first, and then we can
start exploring and, and youknow, kind of dabbling into
different areas.
And our study was looking at, wedid a subgroup analysis about
individuals who said that theycontinued to Valsalva during
their pregnancy and those thatdidn't, and we did not see an
increase in pelvic floordysfunction postpartum from the
(15:15):
34% of individuals in our cohortWho answered that question?
That they continued to Valsalvaversus didn't.
The one thing to kind of bringthis full circle is that that is
not saying that Valsalva isprotected.
That is not saying, you know, itis saying that it is net
neutral.
I've seen it.
I've had to kind of, you know,that's not really what my study
(15:36):
said.
Um, it didn't say that there wasan increase in risk.
That doesn't mean that it'sprotective.
It.
I will interpret that as it isnet neutral and what we, we
think and what we know is thatmany of the predictors for
pelvic floor dysfunction, Theyoccur during labor and delivery.
(15:58):
These are obstetrical factorsand oftentimes are completely
outside of mom's control.
Um, not all the time, but, but alot of the time.
And so we don't need to becreating shame around what a
person did during pregnancy,what they didn't do, what they
decided was good for their bodyand what wasn't good for their.
(16:18):
Everybody's pregnancy is goingto be different, and we don't
have any research to supportthat.
The exercise that you choose todo during pregnancy is going to
set you off for bad long-termoutcomes from a pelvic floor
perspective, and, and that'skind of what I really want this,
I wanted this study to highlightis to just add to the body of
(16:41):
literature showing.
It's okay to lift more than 20pounds.
I was pregnant with my second,my daughter was 25 pounds.
If I would've gotten thatrecommendation, imagine how
harmful that is.
Oh, I'm potentially harming mybody or my unborn child in order
to not have my child lose hermind at the park.
Cause I have to carry her outcuz she wants to still play.
(17:02):
You know, like those situationsthat moms get into all the time
and, and yeah, we just, we justhave a, a.
a communication change that Ithink needs to happen.
Natalie (17:13):
I, I agree.
There's so much fear just notonly in the exercise during
pregnancy space, but also justpregnancy in general.
Women's health in general.
There's such a lack of researchand information and.
Good information and educationthat, yeah, people just end up
being scared of things and thenthat, what I've seen I guess in
(17:34):
my, my years of working withpregnant people is it tends
towards I'm just not gonna move.
Like it's safer for me to notmove than to try something new
or continue what I've been doingbecause I don't know.
Christina (17:47):
Yeah, and, and that's even being challenged, right?
When we look at a systematicreview that.
Put individuals on bedrestversus pelvic rest.
So bedrest don't do anythingexcept go to the bathroom, get
food, come back to bed versuspelvic rest.
Don't have any penetrativeintercourse, any speculate
exams, et cetera.
(18:07):
But continue with activities ofdaily living and lower intensity
exercise.
Individuals who are put onbedrest have worse obstetrical
outcomes, and, and thatintuitively makes sense.
Again, you're deconditioningthat person.
It makes labor a lot harder ifyou've lost 30% of your fitness
(18:28):
than if you haven't.
I'm not saying that your laborwill be shorter if you're
fitter.
That's another misnomer thatcomes into the space all the
time.
But what I'm saying is it takesa lot of exertion to, to deliver
a baby in whatever way that youdeliver, and your body needs to
be ready for that.
Natalie (18:47):
Yeah.
I know you probably heard thelabor is a marathon kind of
analogy, but I like to call it aSpartan race.
More so in the
Christina (18:54):
Yeah.
I love that.
Yeah, I love that.
Natalie (18:58):
know what obstacle you're going to encounter, and
you have to have the strategiesand the tools to overcome those
obstacles.
And if we're left weaker,Typical or that what, what we
were before pregnancy, thenwe're going to have struggles,
right?
And, and
Christina (19:16):
Yeah.
Natalie (19:17):
finish that race in a different way than we
anticipated.
Christina (19:20):
Yeah, absolutely.
Absolutely.
So our study tried to look at abunch of different outcomes that
tried to put all those mythsaround pregnancy.
And one of my theories, becauseI see it so often in barbell
athletes, is that they tend tobe on the hyper side of things.
And therefore, you know,especially for elite level
(19:41):
athletes, I think they may bepotentially more at risk for
delivery VST section becausethey are very good at performing
the bear down, but closing theirspans.
And as we know with labor anddelivery, Is going to be
counterintuitive or counter toprogress.
And um, so we were looking atthat, but, but we saw actually
(20:02):
less rates of C-section comparedto within where 13 of
individuals in our surveydelivered via C-section versus
our current standard, which is,
Natalie (20:12):
yeah.
Yeah.
That's incredible.
I was looking at that and onlyfour people had gestational
diabetes.
Is that correct?
Christina (20:19):
yeah.
Natalie (20:20):
That's amazing.
Christina (20:22):
And, and we have this aerobic literature, right, where
individuals who areparticipating in aerobic uh,
training before pregnancy areless likely to develop
gestational diabetes and arebetter able to manage
gestational diabetes once it hasoccurred in pregnancy, if there
is genetic predispositions andthings.
But we didn't really have anaccumulation of anything within
resistance training just becauseour, our literature is so sparse
(20:45):
within that space and.
But, so yeah, it's a reallyencouraging finding for us to
show, and it just makes so muchintuitive sense, right?
We know that resistance traininghelps specifically with ostial
diabetes because our muscles areso metabolically active that
they're gonna be drawing all ofthat blood sugar out of our, our
(21:05):
blood to be able to fuel thatrecovery.
And so it just, it, it does makesense that it is true within
pregnancy, but we hadn'tevaluated it in, in that cohort
of individuals.
And so, and then we saw very lowrates of gestational
hypertension in preeclampsia aswell, which is also wonderful.
And then, um, very low rates ofperinatal mood disorders.
(21:27):
And again, that's a another.
Big health piece, like there's alot of potential confounding
there because individuals whoare lifting heavy prior to
pregnancy probably had a lot ofthose healthy lifestyle factors
in place before they gotpregnant.
And so it's, it's important torecognize that this is
cross-sectional data and we canmake inferences and we can use
this as potential justificationfor more longitudinal or, or
(21:51):
going forward perspective datacollection.
Um, but we can't.
You know, resistance trainingis, is protected against all
these things.
We, we can start, you know, itstarts to, to hint that there
could be a relationship there,but we still have a of work to
do in research to try and reallydelineate some of those
relationships and what themagnitude of.
Natalie (22:12):
Yeah, yeah, no, the outcomes were impressive.
I was really encouraged,especially about the, the
postpartum prolapse too.
I don't remember the number, butit was very low.
Christina (22:23):
13% had subjective symptoms.
So, and we said heaviness or abalding or a feeling like a golf
ball is in the vaginal opening.
That was kind of our, ourmarkers for subjective
complaints.
So important to note, similar toLaurie Forner study on lifting
and, and prolapse.
She was looking subjectively,she didn't do objective exams
cuz it was a cross-sectionalsurvey, but our study kind of
(22:45):
collaborates with what she saw.
Um, with respect to, toincidence of prolapse symptoms.
And again, that's a big.
Fear a spiral that a lot ofindividuals have.
Um, I always joke that withprolapse, we, our training has
done us a disservice becauseevery anatomy textbook makes us
feel like our, our vaginal canalis this hollow tube that is like
(23:08):
collab.
And if I look at an internalexam, I'm just gonna stick right
through to see the cervix.
And I was like, that is not how.
Our vaginas are.
And um, so we have thisassumption that, you know, that
moving and shifting it's smoothmuscle.
Like we're just seeing thatmovement happen and, and yet we
can heighten and sensitize somany pelvises about that.
(23:29):
And so one of my.
Things I really encourage, um,allied Health and, um,
obstetrical and, and individualsin the birth provider space is
to tell them what is, what isnormal to feel down there after
a vaginal birth, like a descentof the bladder, a slight descent
of the ba bladder is normal.
When we look at the naturalhistory of vaginal birth, we are
(23:51):
gonna have more AP movementlike.
Before when you were liftingduring, um, pre-pregnancy, or if
you're Nelly Paris, your firstpregnancy, you're not gonna feel
a lot of up and down movementthere.
But because of this stretchinjury from a vaginal birth, you
are gonna feel more pelvicmovement.
And that is.
Normal.
But a lot of individuals canlink that to something that is
(24:13):
pathological or something thatis wrong and something that they
are trying to avoid.
So they start to lift and theystart feeling very sensitized
saying, I'm feeling theseprolapse symptoms and you know,
we have to start teasing thatapart.
Like, is that prolapse symptoms?
Is that fatigue of your pelvicfloor?
Cause those muscles are gonna bethe weakest across your system,
(24:35):
or is that normal movement aftera vaginal.
Natalie (24:40):
Hmm.
That's really fascinating.
I think that's, that's somethingthat like pro providers,
practitioners need to be moreaware of, like you said.
And then also empowering womento do their own assessment on
themselves and figure out like,what did I feel before?
What do I feel now?
And comparing that, am I stillstrong?
(25:01):
Am I leaking?
You know, all of the, all of theself assessment questions can be
helpful.
Um, okay.
Why isn't this space morestudied?
It bothers me,
Christina (25:16):
Yeah, that's a great question.
Well, the first thing, and thereason why we did a
cross-sectional survey isbecause, Have to, when you're
doing research, you have to gothrough an ethics board.
So when you're going through anethics board, and this is just
due diligence within theresearch space, anytime you're
doing a study, you have to makesure that.
(25:40):
When you're dealing with apregnant person, the risks are
already elevated, right?
Because our adverse outcomes aresomething that are really
devastating, right?
If we had a fetal loss or amaternal complication or
something that led to a birthdefect, whatever it may be, like
it, the risk is very low, but,but the risk is there and the
risk is very high.
(26:01):
Versus other, you know, exerciseprograms where we're thinking
maybe a musculoskeletal injuryor like an exacerbation may.
The adverse event that we'relooking at.
So that's number one.
So we tend to, to tread veryslowly and that's why we did a
cross-sectional survey becausethe, the last, like really the
research that we have inresistance training is around,
(26:23):
you know, lifting 20 to 30pounds.
So it makes sense that this iswhere the recommendation comes
from.
You know, the resistance studiesthat we do have, this was the
load that individuals werelifting.
There was no adverse events tothat.
We don't know anything abovethat threshold.
So the threshold that we aregonna give people is don't lift
more than 20 or 30 pounds.
Right?
It's like this bad case oftelephone that happens.
(26:45):
And so we went to the, we wentto our ethics board and said,
People are doing it.
We wanna see if people are doingit anyway because our next step,
which they are, right, they are.
But we have to have thatjustification.
But now we haven't.
So we can say, you know, I knowthat this is something that is
(27:05):
riskier or something that hasnot been evaluated, but based on
our study, we got almost 700female.
Who lifted heavy during theirpregnancy.
So there is a cohort ofindividuals who are, who are
self-selecting that this is anexercise modality that they
enjoy and wanna continue doing.
Let's do more research in thisarea and, and research is a long
(27:27):
game.
You know, it took us, we did across sectional survey that was
open for 12 weeks.
It still took us 18 months toget it from start of project to
finish.
And I think a lot of people whoare our clinicians or consumers
of research who have never beenin that space, it, it's hard to
truly.
Appreciate that.
You know, it is such a long gameand so I'm hoping that this is,
(27:50):
is step one.
I have so many different ideasaround where we can go next from
this study, and I think in theCrossFit space, in the aerobic
space, in the return to runningspace, like we now have a lot of
cross-sectional data that isstarting to describe what is
happening.
We need interventional studiesnow we need, you know,
(28:12):
longitudinal data.
It's expensive.
It takes a lot of time.
And so I think we're having moreindividuals interested.
This study, we pub I knew thatthe study was needed.
All of us did in, in ourresearch group.
I cannot even believe the uptakeof our paper.
It was just unbelievable.
It just, it just showed.
(28:34):
How much this was needed.
You know, I'm still gettingmessages at people asking me for
it because they had thisinteraction or, or this happened
and it's open access, which iswonderful because then you can,
you can access it for, fromanywhere, anyone, even if you're
not involved in, um, a collegeor a university, and.
Yeah, so we're getting there.
(28:55):
It just, the more people who areasking for this research, the
more people who are pushing itin clinical practice, it comes
into the research space, informsour projects, and then vice
versa.
Natalie (29:05):
Oh yeah.
A door.
It's like the first little stepinto this whole world where we
really need more research, we,we need more information.
And I, I bet in the next 10years, like you probably have
your theories about this, but inthe next 10 years we're gonna
see like a bunch of studies anda bunch of change in not only
(29:25):
like pelvic PT practice, butrecommendations from
practitioners, generalobstetrics and all of that.
Christina (29:33):
Oh, I hope so.
And, and I think, you know, theway exercise, even recreational
exercise has changed withrespect to high intensity.
CrossFit was one of thosemethodologies where at first,
Every clinician, what are youdoing those kicking pullups for?
Like, you're just gonna hurtyourself.
(29:53):
That CrossFit stuff, it'sreckless.
And now that it's changed fornow, a lot of allied health
providers are coming alongsideCrossFit and saying, you know,
this high intensity stuff, it'shelpful.
You can get really fit.
You wanna make sure thatcoaching is there.
You're doing it progressing, youknow, we call it mechanics,
consistency, intensity, masterall those basics and
(30:15):
fundamentals.
Then build that consistency upand you can add that high
intensity, start putting it intoworkouts.
But now we have, you know, likethe burn body bootcamps and the
orange theories that are allreally kind of spinoffs of this
high intensity paradigm.
That's so needed.
You know, we have high intensityinterval training research for
individuals in ICU who have hadstrokes.
You were actively in cancertreatment.
(30:37):
You know, like that intensitymatters and that intensity is
helpful across the lifespan, andthat's, I think, gonna come and
be true in the pregnantpostpartum space too.
Natalie (30:48):
I'm so
Christina (30:48):
When your body is ready for.
Natalie (30:50):
Yes.
Yeah.
Um, okay.
I'm gonna kind of go go back topelvic PT and specifically the
internal exam.
Um, what does that look like foran athlete, for someone who has
been lifting heavy prior topregnancy, during pregnancy, and
then in postpartum?
What does that look like?
Do you do things different thanthe general population?
Christina (31:11):
Yeah.
So yes and no.
So we will do a supineassessment where we are doing
external, um, palpation, makingsure there's no pain points,
doing an external check of whatthey're doing from cough sneeze,
looking for basically the rangeof motion of the pelvic floor.
What.
Their keel looks like, or whatthey think a keel is, a bear
(31:33):
down to look at their movement.
We will add in a brace insupine.
So we will say, you know, do a,like, pretend you have a Mac
squat on your back braces ifyou're about to, to squat that
weight or pick that weight offthe floor, see what happens.
And then our internal checks areall the exact same.
The demands of our, you know,our, especially our lifters, I
(31:57):
am more likely going to see theminstead of being able to isolate
the pelvic flora, they're gonnakick on everything, right?
They're gonna kick on theirglutes, their addicts, their
abdominal wall.
They're gonna stop breathing,and they're gonna do a keel and.
That makes a lot of sense,right?
Because when I am MaxDeadlifting, I'm not just trying
to turn on my pelvic floor.
I'm trying to turn on everythingwith as much recruitment as
(32:19):
possible.
And so that for them is verysport specific.
It is absolutely helpful forthem to be able to, to tease
apart and isolate those muscles.
And we're starting to get someresearch on using pelvic floor
muscle training for athleticincontinence, which is
individuals who are leakingspecific to sport and outside of
activities of daily living.
And then we'll do the standingassessment as well.
(32:41):
So we can get individuals instanding, going through that
same sequence and looking atexternal checking In standing,
we can do it in the bottom ofthe squat, which tends to be a
point where individuals areleaking.
So go through a pelvic floorcontraction, whatever that means
for you, a bear down, a coffer,sneeze, and a brace.
Again, whatever that means foryou.
(33:02):
And then we can do that with,uh, a digital assessment as
well, getting them to see someof those movements.
And that's where we live ourlife.
You know, we live our life instanding.
Our supine assessment, do notget me wrong, we have tons of
evidence for it.
It is extremely helpful.
It gives us our baseline, but weneed to get people off the
table.
Oh my gosh, six to eight weeksof transfers of dominance
(33:23):
training just makes me wannablow my brains out.
Like that is not.
and individuals don't wanna dothat.
Like eagles are boring.
Like they are useful and that iswhere we start.
But then we integrate that intofunction as fast as we can.
Right?
Like that is the goal is yes.
Get them doing that Pelvic fourcontraction.
We have grade A level oneevidence for using it against
(33:46):
pelvic four dysfunction.
There's a whole, right nowthere's a lot of people on
social media being like, stopdoing keels.
I was like, stop telling them tostop doing keels.
That is not, Gosh, the socialmedia space can be so annoying
sometimes.
But
Natalie (34:01):
Overgeneralization for sure.
Christina (34:02):
yes, it's teach it.
Teach the coordination of it,make sure the prerequisites
strength is there, and thenintegrate it into function.
Like that's our steps.
And that should be the first twosessions that we're doing that
not, you know, week 12
Natalie (34:18):
Yeah.
Agreed.
Yeah.
And
Christina (34:21):
and then,
Natalie (34:21):
up and up and carrying their babies around the house
anyways.
Going up and downstairs andlifting the car seat and getting
in and out of the car.
Like normal
Christina (34:29):
was doing a 50 pound carry with my toddler baby
wearing my son because mytoddler lost it in the park and
she didn't wanna leave.
So I was like, Maya, you canwalk with me, or Mommy can pick
you up.
And she didn't wanna walk.
So off I went, you know, I thinkit was three weeks postpartum.
It just is what it's, you dowhat you have to do.
And then from the, the pelvicside of things, we also, um,
(34:53):
really strongly advocate forcoaching first.
So if you were seeingindividuals who are lifting or
leaking with lifting, then yougotta see them lift.
And if you don't have theequipment in your, your, your
clinic.
I, I think you should get theequipment number one, but number
two, if you don't have it rightnow, then you should be video
getting their videos and, andseeing what's happening.
(35:15):
Like are there any deviations intheir movements?
What does their bracing sequencelook like?
What does it look like when theyput a weightlifting belt on?
Does that change the way thatthey brace?
Because that can lead toleaking.
Like what is their thresholdwhen they leak?
If they are deadlifting 2 85,are they fine?
And then when they bump up to 295, now they aren't.
All of those things are gonna beso, so important for assessing a
(35:38):
person who enjoys lifting andexperiencing symptoms with
lifting, um, to really createthat bridge from like what we
are seeing in our internalevaluations and then what is
happening in the gym, and thencreating that bridge for them,
for them to get back to thosemovements.
Natalie (35:55):
Awesome.
Yeah, that should be thestandard.
That's what I think.
Christina (35:59):
A hundred percent.
Natalie (36:00):
you mentioned weightlifting belts, and I
didn't ask you that question Iwas going to.
Um, so why would someone chooseto use one for one question?
When is it contraindicated andlike, what's the purpose or the
goal?
There were 45 people.
In your study that used themduring pregnancy?
Um, up to like 18 weeks, Ithink, if I read that correctly.
Christina (36:20):
Yes.
Natalie (36:21):
Can you talk about that
Christina (36:23):
Um, in the first trimester, I generally do not
have any contraindications toexercise that I would advise my
clients unless there was apregnant complication or
something that we were workingaround.
Um, it's gonna be how sick areyou feeling and what is your
fatigue doing, and what doesyour rebound fatigue look like
after exercise?
And the rebound fatigue is gonnabe relevant throughout
(36:43):
pregnancy.
You know, you do it heavyworkout, you feel a bit tired
when you're in day to day.
When you're pregnant, you likefive x that and that's what your
rebound fatigue feels like whenyou go really high intensity.
And, and if that, if you'redoing your exercise and you're
able to go home and just kind ofrest and relax and you wanna hit
that intensity, that's totallyfine.
(37:03):
If you are working out in themorning and it's making it so
that you feel like you can'tparent or do your job, then
we're gonna have to scale atintensity back.
From the weightlifting beltperspective in the first
trimester, I generally don'tmake any recommendation.
If people want to use it, theycan.
If they don't wanna use it, theydon't have to.
Baby is really far in theposterior aspect of the pelvis.
It is not like there is nodirect compression on uterine
(37:26):
wall, on baby themselves.
Um, Until further along, and somost of my clients, I don't
really need to make arecommendation because they
start feeling real cringy aboutit around weeks 10 to week 14,
and then they just ditch it, andthat's totally fine.
Um, and so that, that's kind ofgenerally where the
(37:47):
recommendation is.
Individuals will useweightlifting belts because
we'll get a 10% increase in, uh,EMG activation of the spinal or
para of spinal muscles in thespine, um, which allows us to
feel more supported through thespine and allows us to lift more
weight.
So there is a performanceadvantage to using a weight
lifting belt in the sports ofCrossFit.
(38:08):
Weight lifting and Olympicweightlifting.
They're also legal aids to beable to use in competition.
And because they give us aperformance advantage, we want
to be utilizing them.
So therefore it's something thatwe want to be encouraging if we
can.
It is also a time whenindividuals can be experiencing
(38:29):
more pelvic four symptoms iswhen they use a belt.
So a couple of kind of standardthings that we talk about with
the weight lifting belt.
Number one is that we shouldn'tbe using it for all sets.
It is for a top set, theheaviest load that we are
utilizing for my postpartumclients.
I ask them, are you using thebelt because it makes you feel.
(38:50):
Better at your top sets or areyou using it as a crutch because
we haven't built up thefoundation yet that you need in
order to be exposing yourself tothese loads and, and truly
reflecting on, are you ready forthose loads just yet?
If you feel like you need to useone at eight or 10 weeks
postpartum, it might be morebecause we need to build more of
the foundations and your core isyour weak point, not your quad.
(39:12):
Um, and, and we need to work onthe weak point across the, the
system.
And then when we utilize it,the, the problem where leaking
can happen is that individualschange their bracing strategy.
So the way that I'll teach aValsalva is I get them to bring.
Take a big breath and thencontract their belly like
(39:32):
somebody was gonna give them alittle punch to the stomach, or
your toddler was about to jumpon your belly.
And everyone knows that feeling,right?
Like you start to tighten up.
That's what you wanna beexperiencing.
So that'll create a nice, um,closed canister.
Allow for increase in EMGactivation throughout the entire
system.
When you put a weightliftingbelt on, that should not change.
(39:54):
What some people will do is thatthey will be told to actively
push out against the belts, andthat's where, especially
postpartum, when you have moreof that movement down there, it
feels like you're pushing in themiddle of a balloon and.
You know, your, your ribcage isabove, so that's not where that
extra energy or pressure isgonna go.
It's gonna go down towards thepelvic floor and people are
gonna feel potentiallysymptomatic there.
(40:16):
And so the idea is that itreally should just be an extra
proprioceptive little bit ofsupport.
It should not be something thatyou are utilizing as a crutch.
Your body needs to be ready forit, and then it's gonna help
give you that performance a.
Natalie (40:31):
I don't think I've ever heard somebody explain it that
way before, and that makes waymore sense than what I've heard
from other people, andespecially since that's not my
wheelhouse.
That Thank you for, for goingover that.
I appreciate it.
Christina (40:43):
Yeah, you're welcome.
The last thing probably aboutthe weightlifting belt is that
the general recommendations thatwe wanna give is that the
weightlifting belt shouldmaintain the same size all the
way around.
Ideally, you'll see some whereit'll be very narrow as it goes
across the sides of the ribs,and then very wide in the back,
but that's gonna distribute thatforce unequally.
(41:04):
So we really want to be thinkingthat it is going to go like
around that ring of your bellyand and distributing that load
very evenly across.
All sides of that canister.
So things that if individualsare asking, you know, what belt
should I be utilizing?
One, we want it to beconsistent, um, with all the way
around.
And then the second thing isthat different sports will have
(41:26):
different rules around whatweight lifting belts are legal
versus not.
And so it's important for theathlete to check.
With that as well.
Like a power lifting federationwill only have specific brands
and are only gonna allowleather, like thicker lever or
prong belts versus CrossFit andweight lifting, which has a
(41:46):
little bit more flexibility andmost will use a cloth belt, a
lot more cinching and pressureand stability and all thick
leather belt than in the clothprong belts.
And, but that can be a way thatyou go from not using belt, you
use the cloth.
Then use the leather if you'retrying to progress an athlete
back to power lifting, forexample, and they need to use
(42:09):
that leather belt.
Natalie (42:10):
Okay.
Okay, gotcha.
Makes a
Christina (42:12):
Mm-hmm.
Natalie (42:12):
of sense.
Something I was gonna ask you, Idon't, I didn't see pushing
times for outcomes in yourstudy.
Was that included,
Christina (42:22):
Yes.
So we have like 60 pages ofsupplementary tables.
Did you take a look?
Natalie (42:28):
Yes.
I started, I didn't get throughall of them.
Christina (42:31):
Yeah, so we had some around like length of second
stage of labor, um, that wasthere.
I'm not sure if it was in thesubgroup analysis, but we did
ask that question.
Nothing really remarkable cameout that would be outside of the
norm.
Um, but yeah, nothinglengthened.
Nothing shortened.
Natalie (42:50):
Okay, cool.
Yeah, I'm curious cuz I'm like,okay, if these individuals are
doing Alva, if they're usingdifferent bracing techniques,
how does that translate topushing a baby out or not
Christina (43:00):
From a birth prep perspective, you know, for my
athletes, I'm getting themdoing, I, I call them birth prep
workouts, where it is mandatorythat they do them.
It is in their programming everyweek, and it's all about down
training.
So it's around learning.
You know, sometimes pelvichealth can only talk about open.
GLAD is pushing, but evencoached open, GLAD is pushing,
(43:20):
ends up being a combination ofopen and closed just because of
performance and, and what'shappening in the moment.
You.
And so we need athletes to beaware of, we need everyone to be
aware of both, I shouldn't justsay athletes.
We need everybody to be aware ofboth.
And working on that relaxationcan really help with the labor
and delivery process.
(43:40):
And you know, I've had a lot ofathletes who have had second
babies and they say, oh yeah,the first time I was absolutely
fighting myself.
I could, like, the experiencewas just so different knowing
that I had to, to have thatrelaxation.
Natalie (43:55):
Interesting.
Christina (43:55):
And that's where I think even our perennial
massaging, where we're, we'reapplying that stretch, if a
person's goal is an unmedicateddelivery, applying that stretch
is very similar to that ring offire feeling and then being able
to relax that pelvic force.
So again, getting our athletes,you know, there is a, a bigger
trend towards unmedicated ortrying for an unmedicated
(44:16):
delivery.
Applying that stretch and thenworking on some of that
relaxation and open and closedpushing strategies can be
helpful.
Um, and then on the flip side,you know, we have some research
saying that an epidural maylengthen the second stage of
labor.
I don't know if that's alwaystrue.
You know, like, especially ifyou have an athlete that's
really fighting their ownprogression, that epidural may
(44:38):
actually get their body torelax.
And, and so I've had clients toowho.
Said, you know, I was reallyfighting until I got that
epidural, and then I felt likemy body relaxed and I went from
three centimeters to eightcentimeters in like no time.
Natalie (44:51):
Yeah.
Yeah.
Christina (44:51):
So, so we have to,
Natalie (44:53):
in practice.
Yeah.
Christina (44:55):
yeah.
So we have to take all of thisdata as things that are, are
trends, but then obviously applyour clinical reasoning and then
be able to modify and, and adaptto the person that's in front of
us.
And that's really the truedefinition of evidence informed.
Natalie (45:09):
Yeah, reading the person, not the studies.
Only
Christina (45:12):
Right, that trium it, right?
Natalie (45:16):
Okay, So I wanna kind of wrap up with what are your
favorite resources, books,accounts that you recommend
following?
For someone who really wants tolearn more, do more research,
dive into this world,
Christina (45:31):
So I'm gonna have to shamelessly self plug some of
these things.
Um, so I teach cliniciansthrough the Institute of
Clinical Excellence.
I teach two courses.
I teach our eight week onlinecourse.
Um, that goes all the way frompreconception with the female
athlete or, or a person whowants to move their body all the
way through pregnantmodifications, labor and
(45:52):
delivery for trimester, and thenreturn to exercise postpartum.
We also have a two day livecourse where we focus a lot on
lab.
We teach the basics of theinternal assessment and then
teach how to bridge that into.
Return to intensity and exerciseand movement, we get, you know,
we get the information in theinternal exam and then we're
(46:14):
able to move that to returningto tipping pullups and returning
to handstand pushups andreturning to heavy squatting and
deadlifting.
And so I teach those two courseswith, um, Alexis Morgan and our
team, and we teach that throughthe Institute of Clinical
Excellence for clinic.
And then for athletes who arelistening to the podcast, I run
a company called The BarbellMamas, so I do programming.
(46:38):
For pregnant CrossFitters,weightlifters, power lifters,
postpartum CrossFit,weightlifters power lifters,
that take into considerationsome of the pelvic floor, uh,
factors in both of those timesin a person's life and have
created filters for return.
So for pregnant modifications,we help individuals stay moving.
In a way that makes them feelsupported and then postpartum,
(47:00):
we really try to use thatpostpartum programming to bridge
them back to their communities.
So get them back into theCrossFit gyms, get them back
into their Weightlift clubs, getthem back into movement, and so,
you know, We are not fearful ofpelvic floor issues coming up,
especially for individuals whoare high intensity athletes
because they're pushing theirboundaries.
And until you know where thoseboundaries are, you're really
(47:21):
not gonna know where those linesare.
So these athletes are gonna bethe ones who are going to.
You know, start jumping orrunning and they're gonna be
like, oh, body went too far.
That's okay.
We're gonna take that down alittle bit.
Just like we're not afraid ofpain.
Pain is a signal.
Our pelvic force issues are asignal of where our body
readiness is.
And so, okay, you'reexperiencing leaking with this
(47:42):
squat, here's how I want you tomodify it.
And so we have different filtersfor that.
And the idea.
You know, we always say this,that it's bad advice, you know,
to wait six weeks and thenlisten to your body.
And I've kind of reallyreflected on that.
I'm not being very nice sayingthat.
I want you to listen to yourbody, but I want to tell you
what to listen for.
You know, I want to tell you,you know, what your guideposts
(48:05):
are because you're not gonnaknow, especially if you've never
done this before.
Natalie (48:10):
Huh.
Christina (48:11):
What, what you're listening for and you're, you're
an athlete.
You've been very in tune to yourbody, but your, your.
Feels and looks a little bitdifferent now.
And, and that's okay.
So we just, we just wanna helpguide you on that journey.
And so the Barb Mamas isdefinitely, um, one where, where
we talk a.
Natalie (48:29):
Awesome.
Awesome.
Okay, last two questions that Iask every single guest, The
first one is if you could boileverything down to one.
Like your number one piece ofadvice for our listeners, what
do everyone to know?
Christina (48:44):
Okay.
My piece of advice is that yourbody is strong and your body is
resilient.
And if pelvic issues come up, weknow how to handle them.
But that does not mean that yourbody is not strong and that your
body is not resilient.
It's just.
Natalie (49:03):
Preach it.
I love it.
Last question.
What is your favorite wellnesshabit that you incorporate into
your daily life?
Christina (49:14):
Hmm.
Lifting heavy weights.
my husband and I live together.
Yeah.
My husband and I live togetherand so it's kind of two for one
because it's my connection timewith him and you know, having
two little kids.
It takes a big toll on yourrelationship too.
And so it's a way that weconnect together and we, we
(49:35):
compete together in the CrossFitspace.
We've competed together inweight lifting and power
lifting, and that's justsomething that we've always done
together.
And so, I'm just that personthat is just in love with
fitness in every stretch of theimagination.
I like go to bed thinking aboutit.
I just have found something thatI just love doing.
It just sets my soul on fire.
So that is definitely mywellness habit that I, you
(49:59):
would, any physician would haveto give me very good reasons for
me to stop lifting weights,
Natalie (50:06):
And you would probably be able to argue them
intelligently, so it wouldn'tmatter that way.
Christina (50:11):
Yeah, they would have to come, they would have to do a
tent with me for a little bit,for me to be okay with it.
Natalie (50:17):
That's awesome.
I love it.
Well, thank you so much forbeing here today and, and
spending your time and energywith me.
I, I super appreciate it.
Christina (50:25):
you're so, thank you for having me, and thank you to
your listeners for chiming intothis.
Natalie (50:30):
My top takeaway from my conversation with Christina was
there are so many different waysto approach fitness during
pregnancy and postpartum, butheavy resistance training has so
many benefits, and I wasparticularly interested in the
topic of the Alva maneuverduring pregnancy because this is
something that historically thepeople in the pelvic health
(50:53):
space, Recommend avoiding, andso it was really encouraging and
good to hear that doing Alvaproperly while pregnant,
especially if you've beenlifting prior to pregnancy, does
not result in any adverseoutcomes for pregnancy,
postpartum, or during labor andbirth as well.
It's not necessarily protective,but, it showed no adverse
(51:17):
outcome.
There are so many things thatstill need to be researched, but
we are making progress, and ifyou are an athlete who lifts
heavy and enjoys lifting heavy,you should definitely follow
Christina.
I also love how she brought inthe concept of we do not need to
be fearful of postpartum pelvicfloor issues or even during
(51:38):
pregnancy because it's just likepain.
We're not scared of pain.
It's a signal and it tells uswhat we need to know and we
adjust accordingly.
So that should be encouragingfor all of you as well.
I have linked all of theresources she mentioned as well
as her sites and social pagesfor you to follow in the show
notes for this episode.
So please go read her study andplease remember that what you
(52:01):
hear on this podcast is notmedical advice, but remember to
always do your own research andtalk to your provider before
making important decisions aboutyour healthcare.
If you found this podcasthelpful, please consider leaving
a five star review in yourfavorite podcast app Or sharing
it with a friend.
Thanks so much for listening.
I'll catch you next time.
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