ANNAMAYA KOSHA RELEVANT RESEARCH

Postpartum Edema: Relevant Research. (P.79)

Much of the contemporary research into the impact of yogic modalities on swelling focus on lymphedema, which is specifically the buildup of lymph fluid secondary to damage to the lymphatic system caused, for example, by various forms of cancer. A 2016 study by Narahari et al. found continuous practice of yoga in the form of breath work and movement, in conjunction with compression to the swollen area, facilitated lymph drainage in cancer patients. Lai et al. (2017) found that yoga may be suitable in the treatment of edema for cancer patients who are unable to engage in other forms of exercise; whereas high resistance exercise may induce edema, yoga does not. Abbasi et al., 2018 examined the effect of relaxation techniques on edema, anxiety, and depression in lymphedema patients who had undergone mastectomy, finding a significant reduction across all three measures in the experimental group.

 Abbasi, B., Mirzakhany, N., Angooti Oshnari, L., Irani, A., Hosseinzadeh, S., Tabatabaei, S. M., & Haghighat, S. (2018). The effect of relaxation techniques on edema, anxiety and depression in post-mastectomy lymphedema patients undergoing comprehensive decongestive therapy: A clinical trial. PloS one, 13(1), e0190231. https://doi.org/10.1371/journal.pone.0190231

Lai, Y. T., Hsieh, C. C., Huang, L. S., Liu, W. S., Lin, S. H., Wang, L. L., Chen, S. F., & Lin, C. C. (2017). The effects of upper limb exercise through yoga on limb swelling in Chinese breast cancer survivors - A Pilot Study. Rehabilitation nursing: the official journal of the Association of Rehabilitation Nurses, 42(1), 46–54. https://doi.org/10.1002/rnj.217

Narahari, S. R., Aggithaya, M. G., Thernoe, L., Bose, K. S., & Ryan, T. J. (2016). Yoga protocol for treatment of breast cancer-related lymphedema. International journal of yoga, 9(2), 145–155. https://doi.org/10.4103/0973-6131.183713

Venous Thrombosis: Relevant Research. (P.79)

While there is research examining the role of yoga practice on cardiovascular disease, in which thrombosis, or blood clots, play a large role, there is no specific research examining yoga or its component parts on thromboembolic events. While we can’t use contemporary research to draw a direct through line, we can approach this laterally. A 2012 study found that emotional stressors trigger cardiovascular events through the impairment of endothelial function and the precipitation of thrombosis following plaque rupture (Schwartz et al.); study authors determined that both stress management and transcendental meditation “warrant further study,” as initial research supports their efficacy in preventing the acute mental stressors that trigger cardiovascular events. As of 2022, there is a vast body of evidence supporting the role of yoga related modalities in the reduction of stress; we’ll examine this topic on our manomaya kosha section. It follows, then, that yoga practice would reduce rather than trigger cardiovascular events.

Schwartz, B. G., French, W. J., Mayeda, G. S., Burstein, S., Economides, C., Bhandari, A. K., Cannom, D. S., & Kloner, R. A. (2012). Emotional stressors trigger cardiovascular events. International journal of clinical practice, 66(7), 631–639. https://doi.org/10.1111/j.1742-1241.2012.02920.x

Constipation and Hemorrhoids: Relevant Research (P.81)

A 2021 study examining the impact of a 3-month long yoga intervention in the elderly found that regular yoga practice significantly improved quality of life in regard to sleep quality and bowel function (study participants reported a decrease in constipation) (Shree Ganesh, Subramanya, Rao & Udupa). A 2020 systematic review (Gao et al.) found that physical exercise may indeed be effective treatment for constipation, though recommended that the field would benefit from more rigorous research design so as to identify which activities are most effective.

In terms of yoga’s efficacy as it relates to localized inflammation of hemorrhoidal development, as well as the systemic inflammation of constipation, we can look to research that examines the impact of yoga on inflammatory markers. A 2022 review (Estevao) of existing literature found that there is strong evidence to suggest that yoga practice decreases classic inflammatory markers (i.e., c-reactive proteins and cytokines, among others) and the levels of circulating cortisol. Given the “the interplay between yoga and these markers in stress management and depression, vascular and immune function in the older population, cardiovascular and metabolic diseases, auto-immune diseases, breast cancer and pregnancy,” the study author suggest that current research “uncovers the potential for yoga to be used as adjuvant therapy in conditions with an inflammatory component” (p.1).

A 2015 group of researchers (Kavuri, Raghuram, Malamud, & Selvan) developed a comprehensive therapeutic yoga approach for irritable bowel syndrome, or IBS, of which chronic constipation is a sub-type. Their approach includes a vast array of yoga tools—chanting, pranayama, kriya, asana, meditation—geared to treat the issue of IBS from entry points across the koshas. While we won’t include all their offerings here, I encourage you to check out their article as it is representative of the kind of comprehensive approach available in the marriage of research and yogic philosophy.

Estevao C. (2022). The role of yoga in inflammatory markers. Brain, behavior, & immunity - health, 20, 100421. https://doi.org/10.1016/j.bbih.2022.100421

Gao, R., Tao, Y., Zhou, C., Li, J., Wang, X., Chen, L., Li, F., & Guo, L. (2019). Exercise therapy in patients with constipation: a systematic review and meta-analysis of randomized controlled trials. Scandinavian journal of gastroenterology, 54(2), 169–177. https://doi.org/10.1080/00365521.2019.1568544

Shree Ganesh, H. R., Subramanya, P., Rao M, R., & Udupa, V. (2021). Role of yoga therapy in improving digestive health and quality of sleep in an elderly population: A randomized controlled trial. Journal of bodywork and movement therapies, 27, 692–697. https://doi.org/10.1016/j.jbmt.2021.04.012

Kavuri, V., Raghuram, N., Malamud, A., & Selvan, S. R. (2015). Irritable Bowel Syndrome: Yoga as Remedial Therapy. Evidence-based complementary and alternative medicine: eCAM, 2015, 398156. https://doi.org/10.1155/2015/398156

Neck and Shoulders: Relevant Research. (P. 106)

No specific research on the effects of exercise or yoga on neck and shoulder pain specific to postpartum currently exists, and so we will turn to exercise as treatment for non-specific neck pain to evaluate the efficacy of yoga-related treatment measures.

A 2017 article (Cohen & Hooten) discussing advances in the diagnosis and management of neck pain found that although neck pain is a top chronic pain condition in “prevalence and years lost to disability…it receives a fraction of the research funding given to low back pain” (p. 358). Indeed, this is borne out by the paucity of neck-pain related research, and the near total lack in regard to yoga-related research. Instead, clinical practice in regard to neck pain is often informed by the results of studies into other chronic pain conditions: existing research find that muscle-relaxers and NSAIDs are effective; there is strong evidence for exercise, and weaker evidence for the efficacy of massage, acupuncture, yoga, and spinal manipulation. While surgery has been found to be more effective in the short term, research also finds that it may not be the best long-term solution.

A 2016 randomized control trial (Tunwattanapong, Kongkasuwan & Kuptniratsaikul) of 96 subjects experiencing moderate to high neck and shoulder pain evaluated the efficacy of neck and shoulder stretching exercises for office workers. Given the common postural patterning of an office worker—seated, shoulders rolled forward, neck in flexion—this study has implications for postpartum women whose bodies often follow similar patterns. All study participants were provided with education regarding “proper position and ergonomics to be applied during daily work,” (p. 64) while the treatment group was given additional instruction in neck and shoulder stretching exercises, to be performed twice a day, five days a week for four weeks. While education regarding proper posture positively impacted both groups, resulting in an overall improvement of outcome from the baseline, the treatment group demonstrated significantly greater improvement in neck function and quality of life when compared to the control.

Two recent studies (Hidalgo et al., 2017; Rodríguez-Sanz et al., 2020) determined that exercise in conjunction with manual therapy (massage, traction, vertebral manipulation) forms the best therapeutic approach for neck pain. A 2017 systematic review (Steuri et al.) examining conservative, non-surgical interventions to alleviate shoulder pain determined that exercise should be considered, and that manual therapy may be added for greater effect. A 2021 systematic review (Corp et al.) examined clinical practice guidelines across Europe in regard to neck and low back pain, and found “consistent weak or moderate strength recommendations for: reassurance, advice and education, manual therapy, referral for exercise therapy/ programme [sic], oral analgesics and topical medications, plus psychological therapist or multidisciplinary treatment for specific subgroups” (p. 275). While you may not be qualified to offer manual techniques, you can certainly facilitate your client’s stretching and strengthening, as well as reassurance, advice, and education.

Cohen, S. P., & Hooten, W. M. (2017). Advances in the diagnosis and management of neck pain. BMJ (Clinical research ed.), 358, j3221. https://doi.org/10.1136/bmj.j3221

Corp, N., Mansell, G., Stynes, S., Wynne-Jones, G., Morsø, L., Hill, J. C., & van der Windt, D. A. (2021). Evidence-based treatment recommendations for neck and low back pain across Europe: A systematic review of guidelines. European journal of pain (London, England), 25(2), 275–295. https://doi.org/10.1002/ejp.1679

Hidalgo, B., Hall, T., Bossert, J., Dugeny, A., Cagnie, B., & Pitance, L. (2017). The efficacy of manual therapy and exercise for treating non-specific neck pain: A systematic review. Journal of back and musculoskeletal rehabilitation, 30(6), 1149–1169. https://doi.org/10.3233/BMR-169615

Rodríguez-Sanz, J., Malo-Urriés, M., Corral-de-Toro, J., López-de-Celis, C., Lucha-López, M. O., Tricás-Moreno, J. M., Lorente, A. I., & Hidalgo-García, C. (2020). Does the addition of manual therapy approach to a cervical exercise program improve clinical outcomes for patients with chronic neck pain in short- and mid-term? A randomized controlled trial. International journal of environmental research and public health, 17(18), 6601. https://doi.org/10.3390/ijerph17186601

Steuri, R., Sattelmayer, M., Elsig, S., Kolly, C., Tal, A., Taeymans, J., & Hilfiker, R. (2017). Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs. British journal of sports medicine, 51(18), 1340–1347. https://doi.org/10.1136/bjsports-2016-096515

Tunwattanapong, P., Kongkasuwan, R., & Kuptniratsaikul, V. (2016). The effectiveness of a neck and shoulder stretching exercise program among office workers with neck pain: a randomized controlled trial. Clinical rehabilitation, 30(1), 64–72. https://doi.org/10.1177/0269215515575747

Back Pain: Relevant Research.

The research is far more robust in support of yoga and exercise-related treatments for the prevention of the development of back pain in pregnancy, than it is for its amelioration postpartum. Much of the research that has been conducted on postpartum pain focuses on the efficacy of passive treatments such as osteopathy, massage, acupressure and acupuncture—to that end, you might be well served referring your client to pursue body work, just make sure any specific recommendations you make are supported by your first-hand experience of the practitioner to whom you are referring.

In terms of effective treatment for postpartum pain, here’s a digest of what the research says: A 2013 systematic review of 105 studies evaluating the effectiveness of physical therapy for postpartum low back and pelvic pain found that best results were achieved when physical therapy was administered with the individual guidance and adjustments of a physical therapist, rather than as a protocol to be undertaken by the participant on their own (Ferreira & Alburquerque-Sendı). A 2019 study examined the effect of pairing stabilization exercises with training of the pelvic floor muscles, and found that while both the control and tests groups reported improvements, the group that adopted pelvic floor muscle training in conjunction with stabilization showed a significant decrease in pain and functional disability, and a significant increase in pelvic floor muscle strength relative to the exercise-only group (ElDeeb, Abd-Ghafar, Ayad, & Sabbour). A 2020 double blind randomized control clinical trial investigating the impact of stabilization exercises on the function of the transverse abdominis and pelvic floor muscles in women with postpartum lumbar and pelvic pain determined that stabilization exercises outperformed general exercise in the improvement of both abdominal and pelvic muscles (Ehsani et al.); no significant changes in pain were assessed between the general exercise and stabilization groups. In 2021 researchers examined the effects of a core stability-strengthening exercise program on lower back pain after c-section; (Nayyab, Ghous, Shakil Ur Rehman, & Yaqoob); supervised exercise was determined to be more effective than at-home unsupervised exercise—one more vote for your presence in your client’s healing process.

Pelvic Girdle Pain (PGP). A 2006 comparison between two studies with contradictory findings regarding optimal treatment for PGP determined that effective treatment is achieved “when exercises for the entire spinal musculature are included, individually guided and adapted to each individual” (Stuge, Holm, & Vøllestad). In general, the research surrounding effective treatment for PGP is similar to the research for lower back pain, suggesting that postpartum physical therapy should include stabilization and strengthening of the pelvic floor and surrounding musculature. In the case of PGP, “too much exercise may increase pain and disability. This is an important observation which can mean that there is a small boarder between physical ratability and overloading” (Verstraete, Vanderstraeten & Parewijck, p. 34, 2013). In conjunction with exercise, research also supports employing cognitive tools such as information and advice that increase body and postural awareness, and body knowledge.

Sacroiliac Pain: While some research determines surgical fusion to be the best approach when compared to non-surgical interventions for pain secondary to injury of the sacroiliac joint (Fiani et al., 2021), other research finds significant improvement following treatment with progressive pelvic floor muscle exercise in combination with manual therapy (Andersen, Carter, & O'Shea, 2020). The difference may depend on the nature of the SI dysfunction, though one might argue that non-surgical treatment such as that which you and a trained physical therapist can provide is always the best, first route.

Tailbone Pain:  As one 2022 study writes, “the treatment of traumatic tailbone dislocation remains controversial,” (Kumagai, Biyajima, Shimizu, & Ishii, p. 409). As the authors suggest, manual manipulation by a physical therapist, while plausible, is highly invasive. For that reason, clinicians most often consider more conservative treatments such as topical and internal analgesics, exercise therapy, local anesthesia administered through injection, and the avoidance of painful positions—to which one might say: “gee, thanks.” According to a 2019 study, the trajectory of treatment should begin with analgesics, pelvic floor rehabilitation, massage, and psychotherapy, employing surgery as last resort (Márquez-Carrasco, García-García, & Aragúndez-Marcos). In a 2022 study (Neville et al.), some 50 percent of women with pelvic pain also presented with tailbone pain, suggesting that treatment of coccydynia necessarily involve treatment of the pelvic floor, and vice versa.

Andersen, A., Carter, R., & O'Shea, R. (2020). The impact of progressive pelvic floor muscle exercise and manual therapy in a patient postpartum who met the criteria for sacroiliac joint pain based on Laslett's cluster of provocation signs. Physiotherapy theory and practice, 36(6), 761–767. https://doi.org/10.1080/09593985.2018.1490940

Ehsani, F., Sahebi, N., Shanbehzadeh, S., Arab, A. M., & ShahAli, S. (2020). Stabilization exercise affects function of transverse abdominis and pelvic floor muscles in women with postpartum lumbo-pelvic pain: a double-blinded randomized clinical trial study. International urogynecology journal, 31(1), 197–204. https://doi.org/10.1007/s00192-019-03877-1

ElDeeb, A. M., Abd-Ghafar, K. S., Ayad, W. A., & Sabbour, A. A. (2019). Effect of segmental stabilizing exercises augmented by pelvic floor muscles training on women with postpartum pelvic girdle pain: A randomized controlled trial. Journal of back and musculoskeletal rehabilitation, 32(5), 693–700. https://doi.org/10.3233/BMR-181258

Ferreira, C. W., & Alburquerque-Sendı N, F. (2013). Effectiveness of physical therapy for pregnancy-related low back and/or pelvic pain after delivery: a systematic review. Physiotherapy theory and practice, 29(6), 419–431. https://doi.org/10.3109/09593985.2012.748114

Fiani, B., Sekhon, M., Doan, T., Bowers, B., Covarrubias, C., Barthelmass, M., De Stefano, F., & Kondilis, A. (2021). Sacroiliac joint and pelvic dysfunction due to symphysiolysis in postpartum women. Cureus, 13(10), e18619. https://doi.org/10.7759/cureus.18619

Kumagai, Y., Biyajima, M., Shimizu, I., & Ishii, W. (2022). Coccyx subluxation: Coccyx pain aggravated by the prone position. Journal of general and family medicine, 23(6), 409–410. https://doi.org/10.1002/jgf2.570 

Márquez-Carrasco, Á. M., García-García, E., & Aragúndez-Marcos, M. P. (2019). Coccyx pain in women after childbirth. El dolor de cóccix en la mujer tras el parto. Enfermeria clinica (English Edition), 29(4), 245–247. https://doi.org/10.1016/j.enfcli.2019.01.005

Nayyab, I., Ghous, M., Shakil Ur Rehman, S., & Yaqoob, I. (2021). The effects of an exercise programme for core muscle strengthening in patients with low back pain after Caesarian-section: A single blind randomized controlled trial. JPMA. The Journal of the Pakistan Medical Association, 71(5), 1319–1325. https://doi.org/10.47391/JPMA.596

Neville, C. E., Carrubba, A. R., Li, Z., Ma, Y., & Chen, A. H. (2022). Association of coccygodynia with pelvic floor symptoms in women with pelvic pain. PM & R : the journal of injury, function, and rehabilitation, 14(11), 1351–1359. https://doi.org/10.1002/pmrj.12706

Stuge, B., Holm, I., & Vøllestad, N. (2006). To treat or not to treat postpartum pelvic girdle pain with stabilizing exercises?. Manual therapy, 11(4), 337–343. https://doi.org/10.1016/j.math.2005.07.004

Verstraete, E. H., Vanderstraeten, G., & Parewijck, W. (2013). Pelvic Girdle Pain during or after Pregnancy: a review of recent evidence and a clinical care path proposal. Facts, views & vision in ObGyn, 5(1), 33–43.

Pain: Relevant Research.

In her chapter on “Current Research in Yoga and Pain” from the truly excellent 2019 publication Yoga and Science in Pain Care, Dr. Steffany Moonaz cites a 2012 meta-analysis which summarizes the quantitative literature on yoga for pain across populations (Büssing, Ostermann, Lüdtke & Michalsen). All studies reported support for the yoga intervention over comparison groups in improvement in reported pain, as well as pain-related disability, and mood. As Moonaz writes, the literature appears to reflect the fact that yoga does not exacerbate pain, which is an equally important finding: “If the evidence is not yet sufficiently robust to say with certainty that yoga decreases pain, we can more confidently say that yoga tends to not increase pain, and therefore need not be discouraged so long as it is practiced appropriately” (p. 50). This will of course vary with population, and where they are in the progression of a given condition or treatment. Women in the acute phase of postpartum may have limitations as it relates to the more overt aspects of yoga like an energetic postural class, but may be perfect candidates for the more subtle aspects, like gentle breath-linking movements, breath work, concentration and meditation.

Moonaz reviewed other research relevant to our current discussion, including that which pertains to the effect of yoga practice on abdominal pain. A 2016 systemic review of literature regarding yoga for irritable bowel syndrome (Schumann et al.) reported positive findings for various yoga practices (Iyengar style asana, Hatha style asana, pranayama, concentration, relaxation) in the alleviation of IBS-related pain (much of which correlates with the postpartum gastrointestinal experience), but could make no specific protocol recommendations because of the variety of yoga practices offered. A qualitative study reviewed by Moonaz (Goncalves et al., 2016) specifically identified breathing techniques as “key to managing pain, as the breath work fostered introspection and therefore pain relief, especially when awareness allowed them to anticipate increases in pain and use pranayama preventively” (p. 48). Study participants also reported using fewer pain and psychiatric medications as a result of their comprehensive yoga practice (good news for women post-caesarean), as well as the benefit of the social support (think anandamaya kosha!) generated by the shared experience and story-telling exchanged within the practice group.

A 2017 systematic review (Hilton et al.) of thirty-eight randomized controlled trials found mindfulness meditation significantly improves pain, depression systems, and overall quality of life. In 2009, researchers (Grant & Rainville) studied the effects of noxious (painful) stimuli on a group of thirteen Zen meditators, and a demographically comparable control group. The group of meditators demonstrated lower pain sensitivity secondary to analgesic effects stimulated in part by the lower respiratory rate associated with mediation. A 2008 study (Wu & Lo) determined that heart rate variability, a measure of parasympathetic activity, is increased through what it called “inward-attention meditation.”

A 2019 study (Miller-Matero et al.) of 60 participants evenly randomized into intervention and comparison groups found that a brief mindfulness-based practice significantly decreased pain and stress in the intervention group. The 10-minute protocol (delivered via script by a psychology postdoctoral fellow) led intervention group participants through diaphragmatic breathing and mindfulness practices, specifically inviting awareness of bodily sensations without judgement. Comparison group participants instead received psycho-education on pain processes. Interestingly, though only the intervention group reported decreased stress, both the intervention and the comparison group reported decreased pain following their time with the postdoctoral fellow. One wonders then how the patient’s pain experience is impacted by understanding the neurophysiological processes at work. A 2011 pilot study (Van Oosterwijck et al.) found that such education increased “pain thresholds and improve[d] pain behavior and pain-free movement” (p.1). The takeaway from these two studies, then is that pain can be mitigated by a few concurring factors: mindfulness instruction, education about pain processes, and the presence of an attuned party. Sounds like yoga therapy to me!

Lastly, Moonaz points out two important facts relevant to our discussion: Arguably, both the quantity and quality of yoga-related research is lacking. “The vast majority of yoga research, on pain and otherwise, is comprised of small pilot studies, both controlled and uncontrolled.” But, Moonaz continues: “Pilot studies are generally conducted to assess safety, feasibility, and acceptability,” and “the existing literature suggests that yoga has all three when developed in consideration of the needs and limitations for a specific population” (p. 50). Therefore, it can be gleamed from the existing research that the foundation for yoga as safe, feasible, and acceptable treatment for pain has been laid. The protocols we’ll review below will build atop this foundational work.

Büssing, A., Ostermann, T., Lüdtke, R., & Michalsen, A. (2012). Effects of yoga interventions on pain and pain-associated disability: a meta-analysis. The journal of pain, 13(1), 1–9. https://doi.org/10.1016/j.jpain.2011.10.001

Gonçalves, A. V., Makuch, M. Y., Setubal, M. S., Barros, N. F., & Bahamondes, L. (2016). A qualitative study on the practice of yoga for women with pain-associated endometriosis. Journal of alternative and complementary medicine (New York, N.Y.), 22(12), 977–982. https://doi.org/10.1089/acm.2016.0021

Grant, J. A., & Rainville, P. (2009). Pain sensitivity and analgesic effects of mindful states in Zen meditators: a cross-sectional study. Psychosomatic medicine, 71(1), 106–114. https://doi.org/10.1097/PSY.0b013e31818f52ee

Hilton, L., Hempel, S., Ewing, B. A., Apaydin, E., Xenakis, L., Newberry, S., Colaiaco, B., Maher, A. R., Shanman, R. M., Sorbero, M. E., & Maglione, M. A. (2017). Mindfulness meditation for chronic pain: Systematic review and meta-analysis. Annals of behavioral medicine: a publication of the Society of Behavioral Medicine, 51(2), 199–213. https://doi.org/10.1007/s12160-016-9844-2

Miller-Matero, L. R., Coleman, J. P., Smith-Mason, C. E., Moore, D. A., Marszalek, D., & Ahmedani, B. K. (2019). A brief mindfulness intervention for medically hospitalized patients with acute pain: A pilot randomized clinical trial. Pain medicine (Malden, Mass.), 20(11), 2149–2154. https://doi.org/10.1093/pm/pnz082

Schumann, D., Anheyer, D., Lauche, R., Dobos, G., Langhorst, J., & Cramer, H. (2016). Effect of yoga in the therapy of irritable bowel syndrome: A Systematic Review. Clinical gastroenterology and hepatology: The official clinical practice journal of the American Gastroenterological Association, 14(12), 1720–1731. https://doi.org/10.1016/j.cgh.2016.04.026

Van Oosterwijck, J., Nijs, J., Meeus, M., Truijen, S., Craps, J., Van den Keybus, N., & Paul, L. (2011). Pain neurophysiology education improves cognitions, pain thresholds, and movement performance in people with chronic whiplash: a pilot study. Journal of rehabilitation research and development, 48(1), 43–58. https://doi.org/10.1682/jrrd.2009.12.0206

Wu, S. D., & Lo, P. C. (2008). Inward-attention meditation increases parasympathetic activity: a study based on heart rate variability. Biomedical research (Tokyo, Japan), 29(5), 245–250. https://doi.org/10.2220/biomedres.29.245

Chronic Pain Following C-section.

While the development of CPSP is confounded by unknowable variables, Borges et al. identified a number of risk factors. Acute post-surgical pain 7 days following surgery was found to be highly predictive of the development of CPSP; interestingly, immediate post-surgical pain was not positively correlated with CPSP, meaning that effective mitigation of pain at the outset may decrease the likelihood of the development of a chronic condition.

The study authors also examined additional risk factors; smoking, and the experience of anxiety and depression were all associated with increased risk for CPSP. If these risk factors were to be taken into consideration in anticipation of surgery, Borges and the other authors note, caesarean candidates at high risk for the development of CPSP might be prophylactically aided. As Borges et al. note, given that these risk factors are “modifiable,” preventative strategies such as the provision of emotional care, the discouragement of smoking in anticipation of the surgery, and better pain management in the first days following could be beneficial (p. 10).

Borges, N. C., de Deus, J. M., Guimarães, R. A., Conde, D. M., Bachion, M. M., de Moura, L. A., & Pereira, L. V. (2020). The incidence of chronic pain following Cesarean section and associated risk factors: A cohort of women followed up for three months. PloS one, 15(9), e0238634. https://doi.org/10.1371/journal.pone.0238634 

Scar Tissue.

Scar tissue can be a major issue for many women, stemming from the c-section scar itself, subsequent infection, or keloid formations (thickened, raised scars), all of which can increase the likelihood of pain and restriction on maternal mobility which, as we know, has a host of downstream consequences.

As authors Stupak, Kondracka, Fronczek Kwaśniewska write in their 2021 study on the development and implications of scar tissue following c-section, the wound healing process is long and complex. There are three distinct stages: in the acute phase following incision, the damaged blood vessels inflame and the immune system reacts to the trauma; during the next four weeks, new connective tissue and microscopic blood vessels form on the surface of the wound, a process called granulation that “fills” the wound and supplies oxygen and nutrients to the damaged cells; lastly, in a process that takes 1-2 years to complete, maturation and remodeling occurs via collagen synthesis and formation. Tissues strengthen as the wound contracts and fibers reorganize. The correct sequence and timeframe for this process are essential to adequate healing of the uterus; inadequate healing, as the study authors note, is responsible for a host of downstream consequences including the thinning of the muscle layer which has been found to occur in some 60 percent of cases (Roberge et al. 2016). The consequence of such thinning is “associated with obstetrical and gynecological complications, such as: ectopic scar pregnancies, placenta accreta spectrum (PAS), uterine rupture, intracycle spotting, dysmenorrhea, pelvic pain, and infertility” (Stupak, Kondracka, Fronczek Kwaśniewska, 2021, p. 2).

Keloid formations—firm, rubbery nodules that result from abnormal wound healing—are painful during the formation process, which can take up to a year following tissue trauma. Their development occurs when the second stage of wound healing—the granulation and neovasculation phase—continues unchecked (McGinty & Siddiqui, 2022). There are both genetic and environmental factors that inform keloid development. Surgical methods that decrease the likelihood of keloid formation are being currently explored. Current treatment involves the use of steroids, cryotherapy to necrotize scar tissue, surgical excision, radiotherapy and laser therapy (McGinty & Siddiqui, 2022), among other topical treatments such as silicone gel.

McGinty S, Siddiqui WJ. Keloid. [Updated 2022 Jul 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507899/

Roberge, S., Demers, S., Girard, M., Vikhareva, O., Markey, S., Chaillet, N., Moore, L., Paris, G., & Bujold, E. (2016). Impact of uterine closure on residual myometrial thickness after cesarean: a randomized controlled trial. American journal of obstetrics and gynecology, 214(4), 507.e1–507.e6. https://doi.org/10.1016/j.ajog.2015.10.916

Stupak, A., Kondracka, A., Fronczek, A., & Kwaśniewska, A. (2021). Scar tissue after a cesarean section-the management of different complications in pregnant women. International journal of environmental research and public health, 18(22), 11998. https://doi.org/10.3390/ijerph182211998 

Neck and Shoulders: The Biomedical Lens.

The following factors were associated with neck pain: a history of premenstrual syndrome, prenatal anemia, breastfeeding, and psycho-emotional complaints of fatigue, confusion, anger-hostility, and depression. Breastfeeding and emotional changes were most correlated with pain complaints in women whose experience of pain worsened after pregnancy, as opposed to those who reported no change in pain.

A 2022 study (Ojukwu et al.) of 310 lactating mothers found that more than half experienced breastfeeding-related neck pain; of those, 60 percent reported severe pain. The cradle hold position, by which a mother supports her baby with one arm to feed from the same side’s breast, was utilized by 94 percent of women. The majority of women breastfed more than 10 times a day, for less than 30 minutes each session. Given the frequency of nursing sessions, and because no additional correlates were found between maternal characteristics and neck pain, researchers recommend that nursing mothers switch nursing positions regularly so as to increase comfort.

Ojukwu, C. P., Okpoko, C. G., Okemuo, A. J., Ede, S. S., & Ilo, I. J. (2022). Breastfeeding-related neck pain: prevalence and correlates among Nigerian lactating mothers. International health, ihac050. Advance online publication. https://doi.org/10.1093/inthealth/ihac050

Diastasis Recti: Condition Etiology and Presentation from Both the Biomedical and Yoga Therapy Lens.

While some abdominal separation in pregnancy is natural, and even necessary, persistent separation following birth is not normal, nor will it resolve on its own.  Diastasis Recti persists in 39 percent of women at 12 months postpartum, and can present well after childbearing years (Cavalli et al., 2021). Untreated DRA has lifelong consequences, including back pain, poor pelvic floor health, reduced function in activities of daily living, and reduced quality of life (Thabet & Alshehri, 2019).

Similarly, it’s challenging to specifically define DRA. It can be broadly defined as “a protruding midline as a result of an increase in intra-abdominal pressure” characterized by “a gradual thinning and widening of the linea alba, combined with a general laxity of the ventral abdominal wall muscle” (Cavalli et al., p.883). What constitutes abnormal separation, i.e., the degree or measurement of space between right and left rectus abdominis muscles that is considered pathological, varies. The criteria for DRA used in assessment and research is  “a separation of more than 2 cm at one or more points of the linea alba, including the level of the umbilicus or 4.5 cm above or below it or a visible midline bulge with exertion” (Thabet & Alshehri, 2019).

Additionally, there’s little consensus around specific risk factors, though Cavalli et al. identify the following: Pregnancy, of course, is a risk factor, and the more pregnancies a woman undergoes, the greater her risk for the development of DRA; it’s difficult to assess age as a risk factor as pregnancies tend to be concentrated during a woman’s younger years, and so data is biased in that direction; c-section appears to only be a factor if a woman has experienced more than one birth; higher body mass index appears to be correlated with the DRA, likely because of the greater mass adipose tissue exerts more force on the abdominal wall; diabetes and smoking are also correlated with increased presentation of DRA, perhaps in part due to the related breakdown of collagen (Cavalli et al., 2021). Pregnancy of multiples, pregnancy in quick succession (two pregnancies within 18 months), higher baby birth weights, and genetics are also known factors. 

Additionally, as physical therapist Dr. Sara Reardon—or The Vagina Whisperer as she is known to her Instagram followers—notes in her blog post on DRA, it can result from “returning to activity to rapidly, especially high-intensity activity like running, HIIT classes, Crossfit and powerlifting” (2023b)—all activities that increase intra-abdominal pressure. As Reardon notes, straining on the potty secondary to constipation can also inform the development of DRA.

From a yoga therapy perspective, the vayus are an excellent hypothesis-generating tool that can guide treatment. Intra-abdominal pressure that wears heavily on a taxed abdominal wall and weak and tight pelvic floor can be imagined as the result of an imbalance between prana and apana vayu. This is one of the reasons why mindful breathing in movement is so important. In the exercises we’ve explored above, the breath always plays a role. The pelvic floor releases tension on the inhale, and gently engages during the exhale; so too does the abdominal diaphragm release and contract. This is one of the reasons why we exhale during moments of contraction—i.e., when we press thighs against the strap, or hand to the thigh, in hip stability practices. We’re using the natural oscillation of the breath to lean into the intuitive strengthening-release rhythm of the core body musculature. In doing so, we help bring balance to prana and apana vayus.

Diastasis Recti Abdominis: Relevant Research.

While no research has been conducted specifically identifying yoga tools as treatment for DRA, we can look to studies that examine exercise in general. While one 2021 systematic review with meta-analysis found little high-quality existing research to recommend a specific exercise program for the treatment of DRA (Gluppe, Engh, & Bø, 2021), another 2021 study (Keshwani, Mathur, & McLean) found that both abdominal binding and exercise therapy can positively impact both body image and what it called “trunk flexion strength” which can be understood as the ability for the core body to flex while stable.

The most useful research for our purposes is a 2019 study conducted by Thabet & Alshehri that compared two intervention groups—one given a protocol that involved abdominal bracing and deep core stability program in conjunction with traditional abdominal exercises, and a control group only administered the traditional exercise protocol. While acknowledging that the small sample size (40 women total) might impact the generalizability of their work, Thabet & Alshehri found statistically significant decrease in DRA, as well as statistically significant improvement in quality of life. Study participants practiced three times a week for eight weeks. The most effective regimen the researchers identified included the use of abdominal bracing, such as a towel or a sheet wrapped securely around the woman’s waist. Additionally, women were instructed in diaphragmatic breathing, pelvic floor contraction, plank, and isometric abdominal contraction. These deep abdominal stabilizing and strengthening exercises were paired with what was considered a more traditional abdominal exercises: static abdominal contractions, posterior pelvic tilt, reverse sit-ups, and trunk twists.

Cavalli, M., Aiolfi, A., Bruni, P. G., Manfredini, L., Lombardo, F., Bonfanti, M. T., Bona, D., & Campanelli, G. (2021). Prevalence and risk factors for diastasis recti abdominis: a review and proposal of a new anatomical variation. Hernia: The journal of hernias and abdominal wall surgery, 25(4), 883–890. https://doi.org/10.1007/s10029-021-02468-8

Gluppe, S., Engh, M. E., & Bø, K. (2021). What is the evidence for abdominal and pelvic floor muscle training to treat diastasis recti abdominis postpartum? A systematic review with meta-analysis. Brazilian journal of physical therapy, 25(6), 664–675. https://doi.org/10.1016/j.bjpt.2021.06.006 

Keshwani, N., Mathur, S., & McLean, L. (2021). The impact of exercise therapy and abdominal binding in the management of diastasis recti abdominis in the early post-partum period: a pilot randomized controlled trial. Physiotherapy theory and practice, 37(9), 1018–1033. https://doi.org/10.1080/09593985.2019.1675207

Thabet, A. A., & Alshehri, M. A. (2019). Efficacy of deep core stability exercise program in postpartum women with diastasis recti abdominis: a randomised controlled trial. Journal of musculoskeletal & neuronal interactions, 19(1), 62–68.

C-Section Recovery 

While I can’t offer hard data to support this —visualizing the healing of wound may instill a sense of agency and ownership over an event that may have left your client feeling vulnerable and powerless.

This may not be easy for your client. I’ve worked with a woman whose c-section was so traumatizing, she could barely acknowledge she had an abdomen, let alone imagine the wound inflicted by the surgeon’s knife. Slowly though, we leaned into this discomfort, each session inviting another layer into our in-session visualization. With time she was able to tell herself a different story about what took place the day she became a mother. Her murky memory of what happened was replaced by sense of clarity. She would never not be wounded by the day, but she was able to establish a more loving relationship with her own capacity to heal.

Touch Your Scars. I have two-inch scar on my throat that’s the souvenir of the emergency cervical spine surgery I endured in my fortieth year. Some days I admire it like a badge of survival, and then forget it’s there. Other days it’s all I can see—a bright red, keloid-filled, still painful-to-the-touch reminder of a very difficult time. My scar is both of these things. And, regardless, every day I touch it. I dab two fingertips with ointment and massage the fibrous knots, breathing deeply, paying attention to the discomfort. I know that touching it daily helps me track the progress of its healing so that I’ll be aware of protruding stitches (which can occur months after surgery), and other wound healing complications. I also know it’s essential that I pay attention, because I know the consequences of avoidance—the incremental, unconscious injuries born by dissociation. I want the whole of my neck to be part of my mental map so that I can accurately pay attention to it and give it what it needs. If I dissociate, and numb my neural connection to cervical sensations, I may blindly stray into re-injury. This lesson has reinforced what I’ve long known about scars—we must touch them, even—especially—when we don’t want to remember the injury that bore them.

The majority of evidence for c-section scar massage efficacy is anecdotal—and I see no problem with that, particularly when the anecdotes are delivered by practitioners who have decades of experience treating women. That standardized research hasn’t deemed this a topic of investigation worthy—or profitable—doesn’t negate its importance. And, I’m all for the rebranding of old wives and their tales—historically, old wives are the repositories for all of the practical knowledge passed down for generations! Nurse midwives Rastas and McKnight-Cowan report that soft tissue mobilization techniques have “excellent benefits, including desensitising [sic] the area; reducing pain; reducing adhesions and scar tissue; allowing touch and acceptance of the scar; lessening the development of keloid scar tissue; [and] stimulating vascular activity to the area” (p.196). As Johnson writes, “both movement and heat can contribute to the dissolution of the scar tissue. The body then flushes with blood, lymph and hydration and is able to carry away the collagen fibers that are no longer needed, replacing them with healthy, new structures and enabling reorganization to occur. This means that scars can become elastic and pliable and even completely disintegrate” (p.183).

All of this being said, it’s important we invite our clients to notice and touch their scars without the suggestion that the scar itself is wrong, or even needs changing. As yoga therapist Cheri Dostal Ryba so beautifully writes: “the scar serves a purpose.” She continues: “Like a beautiful tapestry needing repair, the ‘threads’ of a scar may pucker, gather, or pull differently across the blanket of our skin. The patchwork thickening at the site of intrusion or injury is a normal response and does not necessarily indicate a need for massage or remediation, provided we can happily go about our lives asymptomatically.” When we invite our clients to begin to make contact with their scar, “we’re not prescribing that they touch with the purpose of changing or ‘doing something’ to their scar. Rather, we’re inviting consciousness and a compassionate invitation back to wholeness, reclaiming any part of their body that felt forgotten, separated, or judged” (2022, p.156). Touch invites the body and the mind to lovingly reconnect. In this way, just as Rumi wrote, “The wound is the place where the Light enters you.”

How to Touch Your Scars. There is no right or wrong way to touch your scar, so long as the guiding force behind the action is patient, gentle persistence. Johnson highlights how important it is to “touch the scar non-aggressively and allow the tissue the time it needs to soften” (p.183). Here are a few ideas to help your client re-engage with her scar—note that this massage should only begin following the six-week mark when the cutaneous layers of incision have well healed. Additionally, should you invite this work in session with your client, make sure you’re attuned to her breathing, facial expressions, and tone. Walk softly into the practice with her, being willing to turn around if the time isn’t right.

·      Take two fingers, and with a small circular motion, massage across the scar. You might use a moisturizer of some kind, but make sure to run its use by your medical care team.

·      If the pressure of two fingers is too intense, try the simple, softer touch of using one finger to write your name, or that of your baby’s, in cursive across the length of the scar. You might even scroll a one-word mantra—healing, mending, awesome, capable—repeating it yourself as you do. Though less of an active massage, this act of gentle touch can be a intermediary between you and greater association.

·      As you touch your scar, breathe. Let the feeling of the breath draw you inward toward the presence of the experience. When the mind wanders away, return it to the breath, and let the breath be the onramp to the experience of sensation generated by touching your scar.

The psycho-emotional benefits of touching one’s scars are just as crucial as the physical ones. “Scars are physical artifacts of trauma,” writes Johnson. “Often emotions come up when scar tissue is touched for the first time” (P. 183). Rastas and McKnight-Cowan agree: “Caesarean birth can sometimes be a traumatic experience, depending on the circumstances. Massaging the C-section scar can help you work through difficult emotions and is therapeutic beyond the physical needs” (p. 196). Inviting your client to acknowledge and lovingly touch her scar, and to let it be touched in a healing way, may be salve for the emotional wound.

Touch Your Scars: Relevant Research. It should be noted that the research in support of mobilization for c-section scars is limited, as is the research into massage-as-scar treatment in general. The majority of the literature regarding scar massage refers to burn scars; c-section scars are different in character and have been the subject of little specific research. A 2012 literature review of ten studies (Shin & Bordeaux) found that given the lack of standardization of both treatment regimen and outcome measurement, the evidence supporting scar massage is weak; however, the authors report, the efficacy of scar massage appears to be greater in surgical scars like c-section scars, than other kinds of tissue damage, like burns. One recent study seeks to begin to bridge the gap in tissue mobilization-related research. In 2022, Gilbert, Gaudreault & Gaboury investigated the impact of standard mobilization techniques on 32 women who had undergone caesarean. An osteopath trained in post-caesarean tissue mobilization performed a specific protocol of massage. After two sessions, assessment revealed significant increase in elasticity, and decrease in stiffness and “improved pain pressure thresholds” (p. 2). This study has limitations: scope, sample size, and the fact that instrumentation of measurement only evaluated the superficial changes, rather than changes to the iceberg of tissue below the surface. However, at the very least, study authors have charted the course for further formal investigation.

Gilbert, I., Gaudreault, N., & Gaboury, I. (2022). Exploring the effects of standardized soft tissue mobilization on the viscoelastic properties, pressure pain thresholds, and tactile pressure thresholds of the cesarean section scar. Journal of integrative and complementary medicine, 28(4), 355–362. https://doi.org/10.1089/jicm.2021.0178

Shin, T. M., & Bordeaux, J. S. (2012). The role of massage in scar management: a literature review. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.], 38(3), 414–423. https://doi.org/10.1111/j.1524-4725.2011.02201.x

Pelvic Floor Awareness: Exploring Dysfunction Through the Yoga Therapy Lens

To that end, forgive the broken record, but I highly recommend Ryba’s work Pelvic Floor Yoga Therapy for the Whole Woman (2022). In it she offers step-by-step tools including observation-assessment in movement, breath assessment, and pelvic self-assessment, through which you can guide your client toward understanding the state of her pelvic floor. Before you try to assess your client’s pelvic floor to any specific degree, please read this book! And—because you know that you must embody what you teach—please practice her protocols yourself, on your own body, first. They’re so good, so thorough and loving; experience them—both their ease and their challenge—so that you may connect with your client’s experience authentically.

I also love yoga therapist Leslie Howard’s text Pelvic Liberation (2017). It’s funny, insightful, and offers clear exploration of the anatomy of the pelvic floor, as well as yoga tools to support your client’s healing and reconnection to this most essential aspect of self. Another gift to the field is Blandine Calais-Germain’s The Female Pelvis (2003), which is an excellent in-depth guide to the forces that act on the pelvis throughout a woman’s life cycle. Lastly, Dr. Sara Reardon’s The Vagina Whisperer Blog is also an excellent resource for all things pelvic in pregnancy and postpartum. If I could include herein the length of these protocols, I would, but that would rob the authors their due, and you of the joy of exploring their works beginning to end. All three authors are cited regularly below from the texts I’ve mentioned. My hope is that these borrowed gems will inspire you to dive into their work in total.

Pathologies of Under-Retention:

Postpartum urinary incontinence is highly correlated lower back pain (Mutaguchi et al., 2022), which speaks to the relationship between a weakened pelvic floor, and the lumbar and pelvic girdle pain we discussed in the previous section on structural pain.

Some 25 percent of postpartum women will experience at least one pelvic floor disorder (PFD) such as urinary incontinence (UI), fecal incontinence (FI), and pelvic organ prolapse (POP); the percentage rises with age (Hage-Fransen et al., 2021). According to a 2015 study of epidemiological trends (Dieter, Wilkins & Wu), UI is the most common PFD (15-17 percent), followed by FI (9 percent of adult women). Pelvic organ prolapse is likely underreported, with prevalence estimates ranging from 3 to 8 percent. Disorders of the pelvic floor are highly correlated with decreased quality of life.

A 2004 cross-sectional study (Uustal Fornell, Wingren & KjØlhede) of 1340 women ages 40 and 60 determined the following risk factors for what they called “pelvic floor insufficiency.” Their goal in part was to discover the factors informing the intersection of UI, FI, and POP, rather than tease the disorders out individually. Statistically significant associations were revealed between UI and FI. Chronic bronchitis in the older age group of 60 was strongly associated with UI (think intra-abdominal pressure and its impact on the pelvic floor). Pelvic organ prolapse was strongly associated with both UI and FI, and more highly correlated with acute injuries sustained during the birth process than with chronic strain of the pelvic floor.

The 2004 study also determined the following risk factors for the development of UI: anal sphincter rupture, pelvic heaviness, a body mass index greater than 30, multiple pregnancies and births, varicose veins surgery, and age. A 2021 systematic review (Hage-Fransen et al.) found additional risk factors for UI: prenatal UI, vaginal delivery with instruments, episiotomy, tears, and constipation. Risk factors for FI included prenatal FI, higher maternal age, greater BMI, both spontaneous vaginal delivery and instrumental vaginal delivery, oxytocin augmentation during delivery, and greater baby birth weight. Limited research around POP revealed only caesarean section as the shared risk factor among the studies reviewed.

Dieter, A. A., Wilkins, M. F., & Wu, J. M. (2015). Epidemiological trends and future care needs for pelvic floor disorders. Current opinion in obstetrics & gynecology, 27(5), 380–384. https://doi.org/10.1097/GCO.0000000000000200

Hage-Fransen, M. A. H., Wiezer, M., Otto, A., Wieffer-Platvoet, M. S., Slotman, M. H., Nijhuis-van der Sanden, M. W. G., & Pool-Goudzwaard, A. L. (2021). Pregnancy- and obstetric-related risk factors for urinary incontinence, fecal incontinence, or pelvic organ prolapse later in life: A systematic review and meta-analysis. Acta obstetricia et gynecologica Scandinavica, 100(3), 373–382. https://doi.org/10.1111/aogs.14027

Uustal Fornell, E., Wingren, G. and KjØlhede, P. (2004), Factors associated with pelvic floor dysfunction with emphasis on urinary and fecal incontinence and genital prolapse: an epidemiological study. Acta Obstetricia et Gynecologica Scandinavica, 83: 383-389. https://doi.org/10.1111/j.0001-6349.2004.00367.x

Urge and Stress Incontinence. A healthy bladder is able to retain about 400-500 millimeters of urine; when functional, the initial impulse to void the bladder occurs at about the 200-millimeter retention mark. Though the owner of the bladder may feel the sensation that stimulates the thought “I have to pee,” the urge isn’t severe, and urine is adequately retained. If the sphincter of the bladder is unable to sufficiently contract (stress incontinence), or if the bladder is hyperactive or unstable (urinary urgency), the bladder cannot adequately retain liquid, no matter how empty or full. Stress incontinence is often (but not always) a result of laxity of the pelvic floor muscles, a state clinically described as hypotonic; urge incontinence is often (but not always) due to overly tight pelvic floor muscles, a condition referred to as hypertonicity.

Conceptually, urge incontinence is evidence of the mind-body connection that underpins urinary control (and likely many other autonomic functions!). While the origin of urinary urgency is not well understood, it’s clear that it’s a learned cognitive-behavioral pattern that strengthens with habituation. I remember the first time that I learned that I have a degree of agency over my bathroom runs—that I didn’t have to give in to urinary urgency. It felt insane—the urge to urinate was so strong—how could I deny it? It surely meant my bladder was full! Instead, I learned by counting the length of my voiding sessions that I was peeing little, relative to my bladder’s full capacity. General consensus is that a count to ten or more is indicative of having emptied a full bladder. Most women suffering urinary urgency find that they are peeing for only a few seconds, but every 30 minutes—and every time they give in to the urge, they strengthen the “faulty brain-bladder connection where the desire to urinate occurs even if there is little or no urine present” (Howard, p. 104). Urge incontinence is often coupled with urinary frequency. Where a healthy bladder requires emptying five to eight times a day, a brain-bladder trapped in dysfunctional patterning may induce hourly, even bi-hourly trips to the potty. As we’ll discuss in our tools section, the fact that the development of urinary urgency is informed to some degree by neuroplasticity means that we can shift our patterning using the same cognitive mechanisms.

As Howard writes, “if urge incontinence is left unaddressed in its early stages, it may progress to the point where urine escapes before the person makes it to the bathroom” (p. 105). This can lead to a mixed state in which a person experiences both urge and stress incontinence, that is, “pelvic floor muscles that are too loose and too tight, but in different areas” (p. 106). Howard suggests that it is “crucial to address the urge symptoms first” (p. 106), and though it may seem counterintuitive, “the solution is to relax your pelvic floor muscles” (p. 105). We’ll look more at this in our tools section. 

Fecal Incontinence. Incontinence “can take a tremendous toll on the quality of life,” writes Howard, causing “shame, fear, and even depression” (p. 103). Howard describes the many people she’s worked with whose lives are bound by the constant mental pressure of an over-active, under-retaining bladder. Where’s the nearest bathroom? How long a walk can I take before I’ll have to “go”? What happens if I soil my pants during a public exercise class? Howard cites a 2011 study that determined that though 38 percent of women with frequent incontinence discussed their issue with a physician, only 13 percent reported receiving treatment (Howard, p. 104). While accounting for the disparity between complaint and treatment demands a multifaceted analysis, we can simply say that your care can be part of what fills this health care gap.

Postpartum Urinary Retention (PUR). In a 2022 study that followed 62 women over the course of a three-year period, 8.2 percent, 6.7 percent, and 4.9 percent of the women were found to have long-term voiding difficulties after 1, 2, and 3 years respectively (Mohr et al., 2022). Women with PUR are often tasked with self-catheterization to drain retained urine.

Mohr, S., Raio, L., Gobrecht-Keller, U., Imboden, S., Mueller, M. D., & Kuhn, A. (2022). Postpartum urinary retention: what are the sequelae? A long-term study and review of the literature. International urogynecology journal, 33(6), 1601–1608. https://doi.org/10.1007/s00192-021-05074-5

Common Pathologies of the “Lesser Pelvis”: Relevant Research.

A 2019 study (Madokoro & Miaki) investigated the relationship between transverse abdominis muscle thickness and urinary incontinence, finding that muscle thickness during contraction was significantly lower in women with urinary incontinence; findings suggest that promoting contraction of the deep abdominal muscle may be effective therapy. A 2021 review of relevant research determined that most studies demonstrate the efficacy of pelvic floor muscle training in preventing the symptoms of urinary incontinence (Romeikienė & Bartkevičienė). The available evidence also suggests that pelvic floor physical therapy can improve symptoms, and even cure a number of pelvic floor related disorders including urinary incontinence (Sigurdardottir et al., 2020), fecal incontinence, pelvic organ prolapse, general pelvic floor dysfunction including hypo and hypertonic presentations, including pain disorders like dyspareunia, vaginismus, and vulvodynia (Wallace, Miller, & Mishra). The efficacy of supervised but self-administered non-manual pelvic floor exercises is mixed, with some studies suggesting no significant change following pelvic floor muscle training (Hilde et al., 2013), despite the fact that many practitioners support its utility; the challenges to research may lie in both the heterogeneity of approaches, as well as the difficulty in ensuring that self-administered and at-home practices are uniformly followed.

In the arena of improvement of sexual function, the research is mixed. Some research suggests that although pelvic floor muscle training decreases patient report of vaginal laxity, sexual function was not improved (Kolberg Tennfjord et al., 2016); by contrast, other researchers found significant improvement, particularly in the area of sexual function and quality of life (Hadizadeh-Talasaz, Sadeghi & Khadivzadeh, 2019). Speaking to the mind-body connection we know to be present in disorders involving pelvic pain, one 2022 systematic review (Bittelbrunn et al.) explored the role of mindfulness in pelvic floor physical therapy, finding that both sexual function and pain catastrophizing improved significantly following treatment. Study authors suggest these findings support a multidisciplinary approach to pelvic pain treatment.

Yoga and yoga-related tools were assessed specifically in three recent studies. A 2015 study (Kim et al.) explored the impact of a combined pelvic muscle exercise and yoga program on symptoms of urinary incontinence in middle-aged women, finding significant improvements in continence and quality of life. A 2021 randomized controlled trial (Nie et al.) evaluated the impact of community-based pelvic floor muscle training on peri-menopausal women; the intervention group received both Kegel and yoga exercise instruction, while the control group received Kegel instruction alone. The combined protocol alleviated symptoms of pelvic floor dysfunction, improved quality of life, and increased pelvic floor muscle strength. Another 2021 randomized control trial (Sweta, Godbole, Prajapati, & Awasthi) assessed the effect of what the authors call “mulabandha yoga therapy,” finding that 12 weeks of exercise therapy that involved various forms of pelvic contraction strengthened the participants pelvic floor muscles, relative to the control group. It’s important to add here that mula bandha is a complicated and poorly understood concept, and I would advise caution it its utilization therapeutically. Make sure you are inviting your client to develop awareness over what she is recruiting in the interest of mula bandha. We’ll explore this more in our tools section.

Perhaps most relevant to the work of our greater text, new research suggests that early onset of a general exercise program has no negative effect on pelvic floor muscle function, urinary incontinence, or pelvic organ prolapse—a finding that runs contrary to the common suggestion that women avoid general exercise during the first six weeks postpartum so as to limit negatively impacting the pelvic floor. Given the benefits of general exercise, these findings support the early adoption of exercise that commonsensically takes risk for pelvic floor dysfunction into account (Tennfjord, Engh, & Bø, 2020).

Bittelbrunn, C. C., de Fraga, R., Martins, C., Romano, R., Massaneiro, T., Mello, G. V. P., & Canciglieri, M. (2022). Pelvic floor physical therapy and mindfulness: approaches for chronic pelvic pain in women-a systematic review and meta-analysis. Archives of gynecology and obstetrics, 10.1007/s00404-022-06514-3. Advance online publication. https://doi.org/10.1007/s00404-022-06514-3

Hadizadeh-Talasaz, Z., Sadeghi, R., & Khadivzadeh, T. (2019). Effect of pelvic floor muscle training on postpartum sexual function and quality of life: A systematic review and meta-analysis of clinical trials. Taiwanese journal of obstetrics & gynecology, 58(6), 737–747. https://doi.org/10.1016/j.tjog.2019.09.003

Hilde, G., Stær-Jensen, J., Siafarikas, F., Ellström Engh, M., & Bø, K. (2013). Postpartum pelvic floor muscle training and urinary incontinence: a randomized controlled trial. Obstetrics and gynecology, 122(6), 1231–1238. https://doi.org/10.1097/AOG.0000000000000012

Kim, G. S., Kim, E. G., Shin, K. Y., Choo, H. J., & Kim, M. J. (2015). Combined pelvic muscle exercise and yoga program for urinary incontinence in middle-aged women. Japan journal of nursing science: JJNS, 12(4), 330–339. https://doi.org/10.1111/jjns.12072

Kolberg Tennfjord, M., Hilde, G., Staer-Jensen, J., Siafarikas, F., Engh, M. E., & Bø, K. (2016). Effect of postpartum pelvic floor muscle training on vaginal symptoms and sexual dysfunction-secondary analysis of a randomised trial. BJOG: an international journal of obstetrics and gynaecology, 123(4), 634–642. https://doi.org/10.1111/1471-0528.13823

Madokoro, S., & Miaki, H. (2019). Relationship between transversus abdominis muscle thickness and urinary incontinence in females at 2 months postpartum. Journal of physical therapy science, 31(1), 108–111. https://doi.org/10.1589/jpts.31.108

Nie, X. F., Rong, L., Yue, S. W., Redding, S. R., Ouyang, Y. Q., & Zhang, Q. (2021). Efficacy of Community-based Pelvic Floor Muscle Training to Improve Pelvic Floor Dysfunction in Chinese Perimenopausal Women: A Randomized Controlled Trial. Journal of community health nursing, 38(1), 48–58. https://doi.org/10.1080/07370016.2020.1869416

Romeikienė, K. E., & Bartkevičienė, D. (2021). Pelvic-floor dysfunction prevention in prepartum and postpartum periods. Medicina (Kaunas, Lithuania), 57(4), 387. https://doi.org/10.3390/medicina57040387

Sigurdardottir, T., Steingrimsdottir, T., Geirsson, R. T., Halldorsson, T. I., Aspelund, T., & Bø, K. (2020). Can postpartum pelvic floor muscle training reduce urinary and anal incontinence?: An assessor-blinded randomized controlled trial. American journal of obstetrics and gynecology, 222(3), 247.e1–247.e8. https://doi.org/10.1016/j.ajog.2019.09.011

Sweta, K., Godbole, A., Prajapati, S., & Awasthi, H. H. (2021). Assessment of the effect of Mulabandha yoga therapy in healthy women, stigmatized for pelvic floor dysfunctions: A randomized controlled trial. Journal of Ayurveda and integrative medicine, 12(3), 514–520. https://doi.org/10.1016/j.jaim.2021.04.001

Tennfjord, M. K., Engh, M. E., & Bø, K. (2020). The influence of early exercise postpartum on pelvic floor muscle function and prevalence of pelvic floor dysfunction 12 months postpartum. Physical therapy, 100(9), 1681–1689. https://doi.org/10.1093/ptj/pzaa084

Wallace, S. L., Miller, L. D., & Mishra, K. (2019). Pelvic floor physical therapy in the treatment of pelvic floor dysfunction in women. Current opinion in obstetrics & gynecology, 31(6), 485–493. https://doi.org/10.1097/GCO.0000000000000584