Flipping the Script on Pelvic Pain in Pregnancy with Dr. Sinéad Dufour

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On today's podcast. I chat with Dr. Sinead do for about her work surrounding pregnancy related, pelvic girdle pain. And if that sounds complex, don't worry. All it means is pain in your pelvis during pregnancy or into the first year postpartum. We talk about the myth that relaxing is the cause of all of these pains in your pelvis and how we can better approach. Pain in general during pregnancy. So whether you're a clinician or currently pregnant and wanting to improve your pain. I know, you'll find this episode intriguing. I'm Natalie. And 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. Dr. Sinead do four is an associate clinical professor in the faculty of health science at McMaster university. She teaches and conducts research in both the schools of medicine and rehabilitation science. Her current research interests include conservative approaches to manage pelvic floor dysfunction. Pregnancy-related pelvic girdle pain and interprofessional collaborative practice models of service provision to enhance pelvic health. Sinead stays current clinically through her work as the director of public health services at the world of my baby, the womb. A family of perinatal care centers in Ontario, Canada. Sinead has been an active member of the society of obstetricians and gynecologists of Canada sitting on two committees and leading several clinical practice guidelines. Her passion for optimizing perinatal care and associated upstream health promotion for women. Stemmed from her own experience. As a mother of twins, she's an advocate for women's pelvic health and regularly invited speaker at conferences around the world.

Natalie: 2:41

Hello Sinéad. Welcome to the show.

Sinead: 2:44

Hi, Natalie. It's so good to see you. I'm excited to talk to you today.

Natalie: 2:49

Likewise. I wanted to just dive right in and start talking about your work. You've done a ton of research and work around pregnancy related pelvic girdle pain and basically the myths surrounding it. What we used to think caused it and now what we know causes it. If you could talk a little bit about that to start, that would be,

Sinead: 3:12

Yeah, of course. So I'm kind of what you would call an academic clinician. So I work clinically as a pelvic health physiotherapist at a center called the womb, the world of my baby. So pretty much the majority of the population I see our mamas going through this perinatal care stage, right. Either pregnant or um, having recently birthed. Right. So I work that clinically, but then I'm also a professor at McMaster University in Hamilton, in Canada. And so I teach and also conduct research in the School of Medicine and the school of Rehabilitation Science. So because of that position, I kind of have a really unique opportunity that I can kind of see what's happening on the ground, but I'm also up to date in terms of, of the top literature because that has to inform our teaching for the curriculum. And then of course, I'm always working on these different sort of studies. And so what I started to actually see more in that, that role, and this was probably, oh, almost a decade ago now, I guess I would say. I really started to see this, but this disconnect between what was starting to emerge as sort of evolved understanding of science and sort of what's really going on when we have these pains that sort of can be quite distressing and debilitating and persisting when we're pregnant. And getting some, you know, evolved science there and sort of queued on different directions, but seeing that on the clinical. We were really stuck and rooted in those previous ways of thinking. Right? And it was really interesting to me that for other sort of pain conditions, as our understanding of pain science has evolved, we've sort of been able to evolve our approach for those. But this is one pain presentation that has really been cemented into those previous notions, and it's really interesting. Um, but actually it's quite harmful. Like we have enough data at this point to really see that following, you know, those previous notions actually does harm. And so it's really, really important that as many of us kind of, you know, are up to date in setting the record straight so we can help as many moms as possible. So that's kind of, sort of how I, how it got to the space, I guess I would say.

Natalie: 5:33

I love that. Yeah, it's kind of like the perfect combination. You've got the research side, you've got boots on the ground, and Yeah. That's, that's amazing. So what did we used to believe? What is the deal with pelvic pain specifically? Pubic joint dysfunction,

Sinead: 5:48

I think that's a really important place to start, Natalie. So of course, you know we have our synthesis pubis joint at the front of the pelvis, right? And this is a joint that it's actually one of the strongest joints in our body because it's held together by fibrocartilage. Most joints are sort of held together by ligamentous structures, which are much more elastic, right? But this is probably the most robust joint structure in the body. And it makes sense because you know, for mamas, you are actually going through quite a fe of physics to sort of get something that's quite large out of an area that's quite small. So, I mean, it stands to reason that this structure needs to be able to be adaptable and malleable, but also fairly robust. Right? And it is, but it's a structure. That, you know, over the course of time, many mom ups have found, has gotten sort of sensitive or felt uncomfortable through their pregnancy. And so, you know, it kind of came to reason. Well, if there's pain there, then clearly that means a dysfunction, which we know now actually that that's not true. Right? So pain equals some type of a tissue distortion, right? And you know, if there's sort of a tissue distortion there when people are pregnant, surely it must be just the relaxin from the pregnancy is just making everything too lax, too loose. Now we have too much movement. Now we have a distortion or a dysfunction at the structure. And clearly that that's why we have the problem. And in fairness, in ways. It's actually a plausible theory, and I think that's why it has really stuck. Right. It kind of sounds like, oh, that could make sense on a bit of an intuitive level. That theory kind of seems like it makes sense. The trouble is we have now looked at this issue from very different perspectives. You know, different research teams all around the world. And even as far back, so this is a decade ago, a systematic review was published in 2012, which is a review of all the randomized control trials. So this is kind of like the highest evidence we have. So a systematic review was done and concluded, no, relax, and has nothing to do with this pain condition. You know, just because we have more motion at a structure doesn't mean that, you know, that's going to translate to a pain experience. And certainly we don't get enough sort of movement through these structures of the pelvis. This, the synthesis pubis at the front, or even the sacro iliac joints at the back. Those are the two back joints. We don't get enough movement, those joints, even in pregnancy, that should, we should even be talking in terms of dysfunction, right? So, I mean, that's even where we were a decade ago and, and here we are and just kind of like more info and more inform, more info. Kind of confirming that, yes, it was a plausible theory, it made intuitive sense. It's been proven wrong and we need to kind of start following the right path. Right? So that's, that's kind of where we're at now. But that's what we thought. And that's I think, why it's been such a compelling story is because on one hand it sort of makes sense that it could be plausible.

Natalie: 10:04

It makes sense logically if you think about it that way. Like, oh, okay, I have more relaxing, more relaxed tissues and obviously it's gonna be weaker. Um, but, and that's the way I was taught, that's the way that I learned it from the very beginning, which informs how we practice with clients and patients. Right. So would you say that the research has made its way into practice for all, like physiotherapists and osteopaths, or would you say that we're still behind?

Sinead: 10:37

No, definitely we're still behind. I mean, and this is one of the reasons why I'm continuing to do research on this and, you know, trying to do other different research studies rather than collecting raw data, trying to synthesize the data and publish something more in an infographic form and kind of get it out to people that way. And just different ways of trying to get out what we know, get it out to the public because it really, it isn't, you know, it isn't being, um, put out there in practice, unfortunately, I have been involved in studying this in Canada, Ireland, and just most recently the UK really looking at physiotherapists. So just to use that specific provider group, it's one of many that are gonna have a role here. But even just looking at that provider group, we see that, you know, still the majority of physios, even though they are moving to start conceptualizing this pain experience more from what physiotherapists will call a biopsychosocial perspective, which really is just meant to mean we're not just kind of looking at the tissues and the mechanics. We're understanding these other contextual factors really actually have something to do with the global experience of a pain experience. So certainly we're seeing that physios in all those countries. Are starting to adopt that concept. But then when we ask them questions in the survey specific to assessment and treatment, like the so what, okay, so you're thinking of it from the slightly more broad perspective, but how do you assess it? And then what do you actually do, do about it completely reverts back to the biomechanical test and strengthen the core. And it's a weak core and stability training and manual therapy to make sure everything is kind of balanced. And so it sort of reverts back to those previous notions. So we still do see some cognitive dissonance and lack of really kind of, um, implementing this on the side of physiotherapists for sure. Because, I mean, we've studied this. I would stay clinically every single day probably I have at least one client because this is a, a pain experience that I work with a. So I have at least one client who has come to see me, um, after already seeing many different well-meaning practitioners, you know, in many cases, sometimes already seeing a physio, already seeing a pelvic health physio, chiro, osteo like everyone, and, you know, still is kind of spinning their wheels. And, you know, often, again, it's very well meaning, but it has been communicated to the individual in front of me that yes, this has to do with like the biomechanics of your tissue and this is kinda off and this is dysfunctional and this is this imbalance and this is moving too much and this is this. And it's not any of that, right? So, very well meaning practitioners, um, who are just kind of focusing on the wrong targets. And if you're focusing on the wrong targets, I mean, you're never gonna get anywhere, right? So as soon as we kind of get these folks actually on the right path, they do well so fast, right? And they're really able to completely nip this issue in the bud before they birth their baby, right? So it's important that, um, more of us are kind of getting online in terms of, you know, what is the state of the science and kind of what should we be doing?

Natalie: 13:56

That's so, so interesting to me because what I've heard from other clinicians has been like, oh, this is basically to cure this or to get it better is to birth your baby. And so like you can't really do anything except like just relieve your pain and do do things that can kind of help make you more comfortable. Um, but you're saying the complete opposite, you can actually improve it to the point of a hundred percent recovery before giving birth

Sinead: 14:25

Absolutely. Cause at the end of the day, and I mean I see that play out in my practice every single day. I mean, after just one time of seeing someone, by the time I follow up with them four weeks later, they're like, oh my goodness, I'm so much better. Like I don't even wanna talk about that anymore. Let's talk about the birth and I wanna have an awesome birth. And we're kind of onto the next important focus, right? And I have colleagues I've collaborated with in Ireland and England who have run proof of concept studies, which has essentially shown the exact same thing when you actually target the central factors, and this is more mediating from central factors, not peripheral factors, you nip this thing in the bud, we can help people understand it in ways by saying, look, if this actually had to do with the pregnancy, why doesn't every single person who's pregnant have this issue? Cuz they don't. It's about 50%. And why do we see this much more often in a second? Or third pregnancy. It's very, very rare in a first pregnancy. You know, if it has to do with the pregnancy, that's a consistent factor. We should see consistency, but we don't. If it had to do with the pregnancy, then some of the established risk factors for this issue, which there are many that are very robust risk factors, would have something to do with the pregnancy and not a single one of them does. So we know that this is a situation that has to do with all of these other factors that are winding up the system and the pregnancy is like the straw that breaks the camel's back and is the thing that finally pushes the system to the edge that a threat response comes out. Because in fairness, when we are. Every single biological system is really taxed and put to the edge, right? We know even, for

Natalie: 16:05

Mm-hmm.

Sinead: 16:06

estrogen increases a thousand fold estrogen's, actually a bit of a sensitizer, you know? So it's actually more plausible that if any hormone has something to do with it, it would be estrogen. But we know that estrogen is only a problem if we're kind of dysregulated to begin with, right? People who get cramps and painful periods and have these other issues through their cycle, that's a sign you're dysregulated. You should never have that issue, right? So it's kind of a sign that these folks are sort of going into pregnancy already with some like kind of close to the edge in their system, or something happens through their pregnancy that puts them close to the edge. So it's not the pregnancy, itself. It's all of the other things and all of the other things we wanna help people understand.

Natalie: 16:50

Oh, I, I wanted to ask you too, because personally I have endometriosis and I know that I have estrogen dominance, but I've never made the connection that estrogen is a sensitizer and that's why there might be more pain. Um, so is that true for everybody who has estrogen dominance? More pelvic pain in general.

Sinead: 17:13

uh, you, you could be more likely. And not just pelvic pain, just more pain. Like it, it's a sensitizer, it can make the tissues more sensitive.

Natalie: 17:21

Okay. Interesting. Interesting. That's something more

Sinead: 17:25

And endometriosis is also inflammatory condition too, right? So you're also gonna have more pain mediation from systemic inflammation, right? It's also considered an autoimmune issue. So, you know, as it ebbs and flows and you're in flares, when you're in in a flare, that's a time when your body's in kind of disrupt with your gut microbiome. So that's gonna be another reason why things are like a little bit more sensitive and dysregulated, like there's a lot of factors. Do you know what I mean?

Natalie: 17:51

Yeah, that makes a lot of sense. So people who are pregnant and having all of these issues, you said their system, it's like the straw that broke the camel's back. Like they have all of these, these upregulated systems and pregnancy pushes them over the edge. So what are the other causes or central issues that contribute to the the pain?

Sinead: 18:16

Yeah. So if we look at the established risk factors, right, and we see that, you know, one of the first ones on the list that's very robust is previous trauma. Right, and we know from lots of data what, what a trauma will do. Like trauma when you are a child, right? Adverse events as a child, there's so much data to show that that actually literally upregulates and kind of changes the signature within your autonomic nervous system, and your fight or flight response is kind of tied into that system, right? We also see that whenever we have a trauma, you know, forget that sort of signature if this is happening at a critical time, like when you are child. But there's a lot of data to show that actually when a mom births her baby that this is a really powerful, critical transitional time. In a mama's life, and unfortunately the percentage of women who come out of a first birth experience and experience trauma is very high, right? So, you know, there's now some qualitative data, sort of triangulating, okay, you have this trauma with your first birth, you know, that has kind of like this priming and signature effect in your nervous system. Is it really a surprise that then you get pregnant the next time and your whole system is like, uhoh, here we go again. Now we're back in the state. And, and that's gonna happen again. Like that's how our systems are designed, right? For survival. So that would be considered more central factors, not, you know, peripheral tissue related factors. So there's previous trauma is. Parity is one meaning you're much more likely to have it the second time you birth right, rather than the first time. And so, I mean, that's a factor that has nothing to do with the tissues. So you have to kind of take a step back and say, well, why might that be? Well, one. Go back to the first factor trauma. It could be that something traumatic either happened in your birth and the time in the postpartum period, or even in the time between your last birth and this birth. You know, when we think about, you know, the rate of miscarriage and baby loss is actually way up in the last few years, we think of the rates of, you know, fertility difficulties. Even if you've, you know, had no trouble the first time around having some difficulties the subsequent times around. And we see that all of these factors kind of span across with this concept of reproductive trauma, right? So it could be that the parity piece is actually connected to trauma, but it also could be that we know from an energy system perspective that when we don't have enough energy to go around, that's another thing that is interpreted as threatening to our brain. right? And so if we think of a mama who is now pregnant for the second time, She is not nearly as sort of like recouped in terms of her battery being recharged this time around. She was the first time around because, you know, she's caring for a toddler, you know, she's back to work. She's juggling how to be, you know, the type of professional she was before in her work and also be a mom at, with a child at this very, very busy age. Now she's pregnant again and growing a human being. I mean, that's a lot of energy that is required for those things, right? So it stands to reason that, you know, some people's scenario, if they really didn't recoup their batteries, like even to the bare minimum that they needed to, that their system is going to start hollering at them. You know, that, you know, things are sort of, you know, not optimal. And pain is an output that's telling us, you know what, something's kinda up, something's not optimal here. right? So we think that that might be playing into the energy system component. Again, that's a central factor. That's not a tissue related factor. The next risk factor is increased bmi. We know that increased BMI when we have increased bmi, particularly, um, if we have increased, uh, waste to he ratio, like we have increased, um, weight around the middle, that that correlates with a highly inflammatory environment in the body. And we know that inflammation is a sensitizer. The next risk factor is smoking. Well, smoking is inflammatory. So again, it's that vector of inflammation. These, again, are physiological central issues, not tissue issues. And then the last. Is lack of a belief of improvement. This is not only a risk factor for this issue developing, but it's also a risk factor for this issue persisting, you know, well into the postpartum period, and this one's really, really important. Because if you think of the common incorrect narrative that this is an issue that has to do with the pregnancy, you are going to get more pregnant as time goes on. So this issue is going to get worse as time goes on. And then you are going to be asked to birth this baby through this dysfunctional structure. And then hopefully it was all just because your pregnancy and then hopefully it just goes away after. So you can appreciate that most people aren't going to feel like it's gonna get any better before they birth that baby. They are going to have a lack of belief of improvement, right? So this is kind of where we're at with our established factors. They all point towards central factors and they all kind of go hand in hand with us, disproving some of the notions around the local biomechanics of the tissue. So actually all the data's kind of coming together.

Natalie: 24:05

This is like making my brain explode in a good way. there's so many questions that I have, so I'm just gonna kind of go back over it because I think it's really important that people hear, like you said at the beginning, that pubic synthesis in the front of our pelvis is robust. I have never heard it described that way, and most people assume that it's weak or not robust at all. Some the opposite of robust. Um, and so we're perpetuating the narrative that. Women are weak through their pelvis. Therefore they will have pain just because of pregnancy and it's not gonna get better until they have a baby. And good luck having a vaginal birth because you already have dysfunction there.

Sinead: 24:54

Right. That's exactly it. Like all of those narratives are, are false. It requires a huge, huge, huge mechanical force to be strong enough to bust the fiber cartilage of that joint, right? So it's not to say that it is impossible for that to happen. Of course, anything can happen in the human body. Anytime. Right. So there are specific cases of pregnant mamas experiencing an extreme mechanical trauma that traumatizes multiple structures in addition to that one. And in that case, absolutely you would have dysfunction at that joint. But when we're talking about mamas just spontaneously kind of their synthesis, pubis muscle st or or joint kind of starts to hurt and it kind of starts to hurt when they're like getting changed or they're standing on one foot or they start to walk. But then we might notice, but some days it doesn't hurt and some days it hurts more than others. We're already poking holes in the theory cuz if it's mechanically disrupted, It's going to consistently hurt every single day, whether you're walking forwards or backwards. And we see that it often won't hurt if you're walking backwards cuz that's a novel movement. And so like we can poke holes all over this theory, right? It's made of fibro cartilage, which is like way stronger than ligaments or muscle tissue. Right? But you're right that most people have been led to believe this other narrative.

Natalie: 26:20

Hmm. Wow. Okay. This is, this is good stuff. So talk to me a little bit about novel movements and your approach to treating to the physiology of the problem with those central causes rather than a biomechanical approach.

Sinead: 26:37

Yeah, of course. So the first thing is people need to understand their pain experience for what it actually is. And we need to start there. That's critical. So most people are coming in thinking their pain experience has something to do with the relationship of those structures, the integrity of those structures, those structures not being strong enough, those structures being too loose. Most people have these false notions, so we have to make sure people really, really understand, you know, that that. Isn't likely given what we know. And in addition to going through and explaining all the science and biology to people, oftentimes when I'm with them in clinic, I have an opportunity to prove it to them in their body. So if they really kind of, if it truly is a weakness causing the problem, we know at minimum with consistent training, we're not gonna get a strengthening effect. For at least sort of three or four weeks of a consistent training protocol. So when I have someone in my office and I can kind of be talking to them about what's more likely at the root of their issue and just kind of getting them sort of slightly shifted onto potentially exploring this different way of seeing their issue. And then I'm kind of doing some gentle kind of different movement techniques with them. I'm guiding them with it. That's what we'll call, we call novel movement, and I can talk more about that later. But what I'll do with that process is we have some very basic testing that we use for this issue. That's sort of like my before and after litmus test. So one of them is called an active straight leg raise. And I love this test because it even allows me to execute it when I'm working with clients virtually. And at the moment, I, a lot of my care now is provided virtually. And so, you know, you just ask the individual, they're lying on their back. You just ask them to lift their one leg up about six inches without even thinking about it. And people who have this sensitivity through their pelvis structures for all these sort of risk factors we've discussed already and kinda what that is actually doing in their system, you know, they will find it very difficult and uncomfortable to do that movement. Right. So we'll kind of score positive on the straight leg raise. And then after I've kind of talked to them and taken them through some of the movement, maybe I've also kind of done an internal exam to check their pelvic floor. You know, always we find with this issue, because when you think of all the risk factors, it's gonna map onto this problem. But the pelvic floor held up in this very, very protective position, right, which certainly doesn't lend well to optimal blood flow and oxygen moving through that space doesn't allow for. Proper coordination of muscles, um, muscle activation. So you are gonna get this like bracing and these aberrant movements, right? So, you know, might check the pelvic floor, give the individual some strategies for their brain to connect to their pelvic floor, send a safety and release, and we kind of do like just these basic little things. And then I'll redo the active straight leg raise. And of course it's a million times better. And I can say right in that moment, see, it's not a strength problem. All we did was a few different things to put a slightly different input in your system. Really sending a signal of safety and getting the protection mechanisms out, getting that anticipatory, feed forward, pain out, put some novel, safe inputs in. And look, it's a dramatic, so it's not a strengthening problem, right? And you can kind of prove it to them. And a lot of people do need that proof because they've really been told by a lot of people, this has to do with posture and weakness, and I have a weak core as this, that, and the other thing, right? So you need to first get people understanding the pain for what it actually is. That's first, first, first. But then always your goal has to be, how am I gonna get mama? We need mamas moving and exercising and really kind of thinking. Yes. Once we kind of get over this hiccup of this pain experience and sensitivity in the tissue, then we're gonna be on like prepping this mama for the marathon of birth. So she has an awesome birth and an awesome recovery, right? So it is totally not acceptable to think that it's okay to be trying to just manage discomfort and have people not moving. And so we always start with novel movement. Cause novel movement's really good to calm down, a cranky nervous system novel movement in involves, you know, the brain and mindfulness and kind of really intentional sort of thinking and cognitively reframing the sensations you're feeling. And oftentimes it does require a degree of guidance from, you know, someone who is sort of skilled in some of these strategies, these cognitive and mindful strategies. So we incorporate that sort of with movement as a form to actually rewire the nervous system, improve sensory motor mapping, right? And then it can be helpful, you know, if you're skilled in hands-on techniques to just do some of those gentle techniques externally, internally, onto the pelvic floor. Again, just to kind of start to nudge the system to a place of safety and a place of different possibilities, right? To get it kind of out of this kind of wiring threat mode. Right? then sort of beyond that, it's a matter of the individual then understanding what are their own unique things. So someone who maybe had a lot of trauma, not with their last birth, but in that postpartum period, they kind of acknowledge, oh my goodness. You know, breastfeeding was like really, really tough and maybe had a tongue lip tie and oh my gosh, like even thinking about it now, like my heart rate's starting to go up and I had kind of just like tucked that under the rug. You know, helping people to be aware of things that might still be driving that excessive sort of, um, cycle of their hypothalamic pituitary adrenal access. That's your stress response system when that system's kind of going. you know, that does dysregulate your other biology, you know, does actually create a slightly pro-inflammatory environment. So we need people to be aware, maybe of traumas that have not been processed yet and are kind of in their body, sort of wreaking havoc. We need people to be aware if, like sleep has been a big, big issue cuz now they're pregnant again, but they have a two and a half year old who still is like up three times a night crawling into their bed and they got, they're, they're thinking, oh my gosh, what am I gonna do when I have like baby? And we helped people to understand, you know, how these impact their biology, how they're probably impacting their current circumstances and we problem solve around them to try to find some solutions, um, to sort of get things so at least the system's not quite so taxed. So, you know, it's, yes, every single person needs to understand their pain experience and every single person needs to engage in the novel movement initially and then working towards more of a. An exercise plan that kind of is inspiring to them. But then beyond that, it's quite individualized and it's just tackling all those different things that are going to make the tissues more sensitive and the brain more likely to interpret threat, which is what pain is, cuz it's an output.

Natalie: 33:55

Right. Wow. Okay. Yeah, you've got my brain going. I have so many questions. Um, so it's more of a, it's,it's more of a brain thing than it is a strength or biomechanical thing, correct?

Sinead: 34:10

Well, pain is always a brain thing, right? And it's not just the brain, but at the end of the day, what pain is in any circumstance is the brain kind of making a bit of the determination is this, you know, do I need to sort of communicate with the organism that something might be up? Right? That's what pain is. It's an output, it's a communication. Right. So pain is always that. So when we have very specific, like I, you know, stub my toe and I have pain at my toe, the primary mechanism for that pain is a process called no csection, right? And in that case, it's like you banged your toe, your brain's gonna be like, okay, pay attention. Like you might need to get a bandaid on it or you might need to, but really it's all these sort of chemical receptors are now fired up because you have this in flood of the different sort of immune components that are coming into play. And that's what's called sort of the process of no C-section, right? But you can have different thingss that will color that pain experience. So I can be, you know, with all my girlfriends, you know, having a glass of wine and really great mood and be getting up to get something and kind of stub my toe. And I might not honestly even really notice it until the next morning and I see a bruise because in that moment your body's kind of like, your brain's like, nah, you just bumped your toe. But honestly, you're good. Like there's no threat. You're with your girlfriends, you're having a good time, you're no threat. Or I could be in the context of sort of tidying up like the toy room and my children have left it in this and I'm really like mad. I'm furious, I'm already tired and whatever. So my system is already in a bit of a different state and I stub my toe the exact same way. And it can be interpreted as. A hundred times is threatening. So then it's gonna feel like, oh my gosh, that's so sore. Right? So in acute pain, the primary mechanism is no csection, but it's still always influenced by all of these other factors. Once we are beyond acute pain, so pain that just lasts for a day or two, anytime we step outside of that, we have to start thinking, okay, the pain is gonna be more likely colored less by no, no csection, and more by these other things like the inflammatory atory status of the system, and then what are the things that are driving up that protection and inflammation, right? So I mean, really it's always the brain is putting out a communication tool for any pain. It's just this one. Anytime we're thinking of biomechanics and tissue related, That's really implying that you understand the main mechanism to be no csection, where this is not that. Right. Many mamas will come to me at like 27 weeks and say, I've been having this issue since 14 weeks pregnant,

Natalie: 37:06

Mm.

Sinead: 37:07

so this is not something that's just gone. This is something that's persisting and persisting and persisting. So we're stepping into what's called noy plastic pain.

Natalie: 37:14

you've, it's got my brain going more. This is great. Thank you for schooling me on all of this stuff.

Sinead: 37:20

Okay, good.

Natalie: 37:22

Okay. So basically the approach would be down, regulate the nervous system, try to reduce as many inflammatory issues as possible prior to even going into pregnancy, but then also during pregnancy. And I guess my next question is, do you know, has there been any research done on people who are approaching. This, these issues in a more physiological way, the outcomes of their birth and postpartum experience. Is there any research to back that up?

Sinead: 37:54

There is research to back up that people who have this issue, so what I would call. Unresolved pregnancy related pelvic girdle pain. And it's either gonna be unresolved cuz you didn't seek care or you were given the wrong type of care. Right? So we see that unresolved pregnancy related pelvic girdle pain makes it more likely that you'll end up with a cesarean birth or all sorts of sort of extra interventions in your birth. And the trouble with that is any type of operational assistance for birth, whether it be, uh, forceps, vacuum, or cesarean birth, like anything kind of operative actually is a risk factor for more persistence of pelvic pain in the postpartum. So that's kind of the irony, right? Is that then the birth ending that way and, and births like that oftentimes are felt to be quite traumatic now for these people. So now we're compounding the system with these other things, right? And we see that it's more likely to have this issue than in the postpartum period.

Natalie: 38:56

Okay, so you could infer that the opposite would be probably a, a more smooth birth and postpartum experience if they get the correct treatment and resolve the pain,

Sinead: 39:09

Well, yeah. I mean, if people are kind of, they don't have that issue anymore and they can actually start to switch their focus onto the birth and they're no longer thinking, oh my gosh, my pelvis isn't gonna be able to birth the baby. I have a dysfunctional pelvis. My synthesis puts in all these narratives that will go through, right? So if people have kind of had the record straight, they understand this was sort of physiological, it was related to tissue sensitivity. They effectively weren't empowered in terms of how to dial that down. They feel kind of in control. If anything, those people think, oh my goodness, I was able to turn that around. And here I am, like, I got this, like I'm empowered. Like I, I'm gonna get this with, with my birth. I mean, in fairness, the people who I'm seeing. People who are seeing me, and I'm also a pelvic health physio, so I mean I'm also going through all the other things to have a great birth right. Making sure their pelvic floors are good. And I'm kind of going through all of the clinical practice guidelines around pushing and positions and all the things. So they're getting all of that too. So I mean, do my clients have excellent outcomes with this? Well, yes, but I'm doing a whole bunch of things in addition to just looking at the pelvic pain. Do you know what I mean? And probably that's one of the things that's gonna be the most helpful is if we're kind of doing all of that. But absolutely, I wouldn't expect for a second someone going into a birth with the pain in their pelvic girdle that they have, thinking it has something to do with their pelvis being dysfunctional. How on earth is that person going to be empowered to, you know, have a, a good birth? Right. So, Yeah. And we do see that, that play out in the data that they consistently don't

Natalie: 40:53

Hmm. I feel like women's health in general, and specifically around the prenatal, you know, birth and postpartum space, we are constantly telling women they can't do something one way or another. Whether it's actually saying those words or convincing them that they're not. You know, their body is broken or they're not able to do whatever it may be, breastfeed or give birth vaginally or, you know, like that is so common and I'm realizing how common it is through doula practice and, and working with clients in exercise physiology. Like there's so much that needs to change for us to get back to empowered birth for everyone.

Sinead: 41:34

Yes, I agree with that. Um, that narrative of, you know, your body is just not up. The task of this, you know, this is why we need all these medical interventions because your innate systems are just not up to it. I mean, that is so problematic on so many levels, but also really is an important vector for this issue of pregnancy related pelvic girdle pain. So it's gotta change.

Natalie: 42:00

Yeah. Yeah. So what about like, SI joint? either during pregnancy or not, or other types of pelvic pain. When should someone seek treatment and kinda what's the approach to those?

Sinead: 42:15

So actually it's the same, any pain within sort of the geography of the pelvis. So the synthesis pubs at the front, the two sac iliac joints at the back, or any of the tissue, even just right around that pelvic g. Right, any pain in that region, there is now consensus. We shouldn't be referring to it as synthesis, pubis, pain, or sac, really act joint pain. It should always be under the umbrella, pregnancy related pelvic girdle pain, and that covers off the entire time you're pregnant and the full year postpartum, pregnancy related. And all of it is this approach because we see that all of it has very little to do with the structure and everything to do with all of the other things we've talked about. So it's all under the same.

Natalie: 43:01

Okay. Okay. That makes a lot of sense to me. And our pelvis is like, they hold a lot of weight in terms of value and where we hold trauma. And so it just, it just makes so much sense that you would have to approach it this way.

Sinead: 43:14

Yeah, exactly. And even if we think of the pelvic floor, the pelvic floor, which is attaches to the pubic bone at the front, it attaches to the tailbone at the back and it attaches to each is tuberosity or your sit bones on each side. Like a big diamond structure. It's a muscular structure that is connected to your threat response. So there is some automatic or involuntary control over the pelvic floor. And so anytime we kind of go into that sympathetic mode of our nervous system, the pelvic floor automatically goes up into a protective position. So you know if your body is holding onto unprocessed traumas or other stressors or other things. your system is chronically going to be in that held position, right? So yes, it stands to reason that you're not, you're not gonna have optimal movement through the sacc joints and everything, cuz the whole thing right there is lifted and anchored and it's gonna impact all those. But trying to correct it with strategies that are right around those structures is just so misguided, right? You didn't need to go upstream to the reason why is there the stressor or why is it being held? Cuz it's being held by the autonomic nervous system. So that's what we have to address, right?

Natalie: 44:32

Okay. Yeah. Another case of the squeaky wheel is not the cprit It seems to be that way commonly. Um, okay. I'm curious, do you, are you comfortable sharing about your own birth process with twins?

Sinead: 44:50

Yeah, of course. Yeah. I'm very happy to. So, yeah, I, my twins are now almost 12 years old and you know, it's interesting. So I actually only really got interested in this whole area of pelvic health and perinatal care actually, after I birthed my twins. That's what really inspired me to understand, wow, there's a lot of like dodgy things going on. And it was even tough for me to navigate as a physio. And I was a physio for about seven years at that point in orthopedics, a manipulative, hands on physiotherapist. Okay. And so, you know, when I met my OB. He basically said, nice to meet you. You're having a cesarean birth because you have, um, you're pregnant with twins. And I was like, oh, okay. And I kind of thought seems a bit weird to make that determination now, you know, I get it if as I go along and baby bees in the wrong position, like I get it, but it's my first time meeting you at 16 weeks pregnant and like, you already kind of know this. But I thought, you know what? Honestly, if that's, there was a big story given to me about Baby B and how it's really tough for baby B two rounds of contractions and I was given this whole story. And I thought, okay. I'm like, sure. I didn't really have strong feelings otherwise. And I thought, okay, you know, there, there must be a reason. But it's, it was really in hindsight, after kind of going through that process, actually before I had my babies, they were both perfectly head down. They were both, you know. So I remember leading up to kind of thinking about it, I wonder why, like, we're not even just gonna kind of try to do this the way that, you know, intuitively to me, I thought made more sense that it was better for them, right? And lo and behold, in the end, through my birth, doesn't baby be end up having problems and needing to stay in the nicu? And then I was told, oh yeah, well you know, when you have a cesarean birth sometimes, you know, you don't quite get that sort of healthy stress that the baby needs squeezing through the birth canal and whatnot. And I thought, are you kidding me? The only reason why I did this was because it was supposed to be better for baby B. and now that's my baby who's having trouble because it actually wasn't, it was a lie. Right. And it kind of got me into really seeing how what happens in our, in our hospitals around birth doesn't at all correlate with what the best practice guidelines say. So yeah, it really was that my birth experience, um, that inspired me to, um, really move into the space. I got pregnant with my twins while I was completing my PhD. I was towards the end of it, but I was looking at actually primary healthcare and the roles of physiotherapists and primary healthcare systems and interprofessional care and health promotion. Like, that's more of what my PhD work was on. Nothing to do with this. So really I was inspired to move into this area, um, after having, uh, my children and while I didn't have the issue at all of pelvic girdle pain through my pregnancy or in the postpartum, uh, my pregnancy was great. My postpartum was great. Like no issues, no, no pain. Even with the, even with major abdominal surgery with the cesarean, no problems, no issues. Like that was all fine. It was more my frustration with kind of what I was told was gonna be optimal for me in my birthing. And really I was told things that weren't true. And, uh, that got me really interested in kind of trying to bring to light what actually we should be doing and helping to kind of advocate for. I did have the issue of diastasis. Um, and certainly having a cesarean birth is now an established risk factor for diastasis rec ado. So I did have, my abdominal wall was really not in the best shape after, um, having my kiddos. And um, and I also had a couple, um, hernias, so I did need some surgery for that. But, um, otherwise, yeah, like elective cesarean birth really, like, as far as that was all concerned. It was fine. It was just more, um, my frustration after the fact of, you know, why was I told one thing, which then when I actually looked up to see if any of what I was told was substantiated, it wasn't. It was a story that kind of was convenient for the hospital to do the things, things the way they wanted to do them, right? So, yeah, so that my, my birth really doesn't have much, um, with the pregnancy related pelvic girdle piece. Um, unfortunately

Natalie: 49:49

Well, that's okay. I mean, you're here now and Yeah. I think a lot of times providers are not educated on twin vaginal birth or breach vaginal birth, and so they just revert to cesarean because that's what they know, which is unfortunate. It's kind of a loot, like a dying art almost.

Sinead: 50:08

yeah, I would agree with that. I mean, one thing I would say though, um, to be fair is as I've kind of worked in this area now, like very specifically for about a close to a decade, I have seen some improvement with some things, like some things have kind of, you know, gotten a little bit better over time and one of the things is I have seen more often twins, as long as they're both head down, vaginal births, you know, back to back vaginal births much more often. So, so that is, that is something that is moving in the right direction.

Natalie: 50:44

That's awesome. Good to hear. For sure. okay, so I wanna ask you if someone is like, okay, I'm ready to dive into more research and information, what are your favorite resources, whether it's, you know, social media accounts or papers or books? What are your favorite resources for someone who wants to do more research and, and look?

Sinead: 51:05

I would say. First look at the clinical practice guidelines that have been published. In the last five years because clinical practice guidelines, they are a nice synthesis of all the research. So it's a lot of the research done for you. The guidelines are graded, so you're able to kind of accurately like wait out, like how strong is the evidence. There's a clinical practice guideline that was published in 2017, specifically for the pregnancy context, and that was for the American Physical Therapy Association. So these guidelines are free. If you go to the Pelvic Health Academy and their American Physical Therapy Association, all of their clinical practice guidelines are free. Whereas their other journal, um, manuscripts aren't free. You have to be a member. Subscribe. Right. But their clinical practice guidelines are free. So that's the pregnancy one. And then just this, this year, 2022 January of this year, their postpartum. Pregnancy related pelvic girdle pain guidelines were published. So I would start with looking at the guidelines, right? Rather than kind of like random, low rated papers. And then another thing that might be helpful is myself and um, four other physiotherapists, also Canadian physiotherapists that are all out British Columbia. They worked on an effort with me, really in the spirit of, so we know what we need to. It's just a matter of most people don't read these clinical practice guidelines. So like those ones have been, you know, in circulation since 2017 and very few people have even read them, right? So, you know, what might be a better way to mobilize or translate the science that we know. So we actually kind of turned all the most updated science that we have, those two guidelines as well as a Delphi consensus that was a collaborative effort from researchers in New Zealand and Europe that was just published last year. So quite a robust bit of work, kind of gathering all the perspectives and data. So we kind of collated these sort of three important, um, documents and studies and collated it and kind of translated it into a summary, like an editorial summary with an in associated infographic. So that's something, Natalie, I can even send you, um, if you want to have it available in, uh, like your show notes or you wanna have it available to disseminate

Natalie: 53:45

yeah. Yes, please. That would be love.

Sinead: 53:48

Yes. The guidelines, I can't because I'm pretty sure they're free anyways. And because they're not my own pieces of work, I can't do that. But this other one, um, because I'm an ath on it, I can, I can share that.

Natalie: 54:01

Awesome. Yeah, that's great. So if you were to boil everything down, which is a hard task to like your number one piece of advice for our listeners, and you can do, you could do two if you'd like, one for the clinician and one for the woman who's pregnant or postpartum. Um, what do you want people to know?

Sinead: 54:24

Honestly, I want people to know that pregnancy related kind of aches and pains is very different than pregnancy related pelvic girdle pain. So it's important that people kind of understand that outta the gate. So that way if you self-identify yourself in this now umbrella of pregnancy related pelvic girdle pain, now where this, in this noy plastic pain, you can immediately understand you need to go to someone to get some guidance and some help. Ideally, someone who has some understanding and pain science doesn't even matter if they don't even live in your same country. Cuz most of this care can be delivered really well virtually. Sometimes you'll only need one or two consultations with a skilled person to be able to kind of figure things out and get on track. Okay, so, so what the difference is probably most mamas would say, At some 0.1 day, maybe more than one day, they had a bit, a little bit of soreness in their back or hip or in one of their joints. But, and I would put myself into this category, but you know, I throw a heat pack on it. I do a little bit of extra prenatal yoga, I rest a little bit more and I sort it out right? Then I don't have the issue. Maybe a couple weeks later I have another little ache and I can kind of sort it out. So these little aches and pains that kind of come and go throughout the pregnancy, that's not what we're talking about. Of course, we're gonna expect a certain degree of that, given the reality of what's happening in pregnancy. But what we're talking about with this thing is this pain experience that you can't just manage on your own and it is persisting. And now it's to the point that you think, oh my gosh, like I had to stop going for my walks because like now I'm walking and this is a problem. Or I almost needed help, like kind of getting dressed the other day, or I really think I, I'm gonna have to come off work. Like this is really becoming now. Distressing and disabling, like as soon as you're crossing into that category, that is when do not waste another millisecond, you know, get some guidance from someone who knows what they're doing.

Natalie: 56:30

Okay.

Sinead: 56:31

That's what I want people to know.

Natalie: 56:33

Yeah, I love it. Um, how would you sort out the clinicians who know what they're doing versus those who don't? Is there something that you look for on their profile or their bio of, of what they've studied?

Sinead: 56:48

Well, generally, you know, certainly the added benefit of seeing a pelvic health physiotherapist is you're going to get some of that pelvic health kind of understanding, pelvic floor understanding. And there is that role of the pelvic floor because it's connected to the threat response. And I do think that component's important. So my bias probably would be for a pelvic health pt, but a pelvic health PT that has tons of training in pain science because the pain science part is actually a lot more important. So that's kind of what my bias would be.

Natalie: 57:22

Yeah. No, that's really, really helpful. I know, um, there are several registries online that you can. Search for pelvic PTs in your area or not if they do virtual visits as well. Um, and I can link those in the show

Sinead: 57:36

Yeah, exactly.

Natalie: 57:39

Um, okay. Something that I like to ask every single guest I have on my show is what is your favorite wellness habit that you incorporate into your daily life?

Sinead: 57:51

For myself,

Natalie: 57:53

Yeah. Mm-hmm.

Sinead: 57:55

yes it is getting for a walk first thing in the morning when the morning sun is just coming up, that low horizon. Um, natural sunlight. It's so important to actually set your circadian rhythm and many of your biological systems like, so to me it's the health behavior that's gonna give you so much bang for your buck. And I've just come to sort of love that quiet time in the morning, um, where I'm kind of on my own. It's kind of my mindful time, but then I know through that little biohack I'm doing all sorts of great things for my body, including setting myself up for optimal melatonin production at night in a good.

Natalie: 58:36

Amazing. I'm over here just chuckling because our son just came up and it's 11 in the morning here in Alaska, so we have a little bit later sunrise these days.

Sinead: 58:50

Yes. Fair enough. Fair enough that that's, that's a weed bit of a challenge. You might need to get one of those lights or something to get that effect, but uh, yes, in Ontario it works reasonably well.

Natalie: 59:03

That's amazing. So, okay. Where can listeners find you online? What services do you offer? And then how would someone book with you if they're looking for a virtual?

Sinead: 59:15

Yeah, so listeners can find me through the womb, www.thewomb.ca, and you can book with me. I worked, uh, at the Burlington site, so even though I do a lot of virtual care, it still needs to be booked through that site. Um, so you can book with me there and you can kind of see all the things I'm engaged with at the womb on the womb. You can also connect with me, um, at my, uh, McMaster experts webpage. So it's literally www dot McMaster experts slash uh, du four. And all of my research publications come up. That same sort of, um, website is connected on my bio on my Instagram. So my Instagram is, um, dr dot, and so you can kind of find me there. I have some content onassis on pelvic girdle pain. Uh, but you can link into my bio and just kind of see some of like the other courses that I teach and other things that is truly just a professional, uh, Instagram page. I really wish I was on there more often. I don't have a ton of time, but whenever I do get on there, it's all stuff on, on this topic. So yeah, those are probably the best ways to, to find me.

Natalie: 1:00:32

Perfect. And I'll link all of those in the show notes so they can find them easily as well. Shanee. Thank you so, so much for being here, spending your time and energy with me and explaining all of these things in a new way. I feel like all of our listeners are gonna, they're gonna have just as much brain work to do, as I have after listening to you.

Sinead: 1:00:56

Okay. Well thank you so much for inviting me, Natalie. This has been great to chat with you and for all the work you do, bringing this information to everyone. And hopefully people do find that the infographic that's gonna be available in your show notes, we'll just be a nice sort of summary, um, of a lot of the content I spoke about. It might make it a little bit more digestible. So yeah, thank you.

1:01:19

My top takeaways from my conversation with Sinead was figure out the root cause of your pain. We know that often in the body what's shouting, the loudest is typically not the issue. Find a provider who has an understanding of pain science, and don't give up on feeling better. I've linked all of the resources that she mentioned as well as her sites and social pages for you to follow. In the show notes for this episode. Please remember that what you hear on this podcast is not medical advice, but remember to always do your own research and talk to your healthcare team before making important decisions about your wellness. If you found this podcast helpful, please consider leaving a five-star review in your favorite podcast app. It really helps other people find the show. Thanks so much for listening i'll catch you next time