Natalie: 0:49

On today's podcast, I chat with Christina Prevet about her work as a physiotherapist in the geriatric and pre and postnatal exercise space as a high level athlete herself. Her recent study, the impact of heavy resistance training on pregnancy and postpartum health outcomes, and what we can do as people who are. Wanting better outcomes for pregnancy and postpartum and what we can do as clinicians as well, who are working with these athletes and these people. Christina Preve is a pelvic floor physiotherapist who has a passion for helping women with different life transitions, including postpartum care and. In 2013, Christina completed her Masters of Physiotherapy and is currently completing her final year of her PhD at the Faculty of Health Sciences at McMaster University. She recently published a study looking at the impacts of heavy resistance training on pregnancy with a group of international collaborators, the first to investigate the safety of heavy barbell training on pregnancy. Christina created strong like Mom during her first entrepreneurial endeavor, stave off focusing on postnatal return to fitness. Christina teaches five courses at the Institute of Clinical Excellence, including clinical management of the fitness athlete, pregnancy and postpartum, where she helps physiotherapists empower their pregnant and postpartum athletes to safely continue strength training. 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. Hey Christina, welcome to the show.

Christina: 2:32

Hi so much for

Natalie: 2:35

You are so welcome. I'm really, really excited to, to have you on. You're the first person to come and talk about heavy lifting on my podcast so

Christina: 2:44

amazing.

Natalie: 2:45

So, yes. I wanna jump right in and just ask you, how did you start with the women's health space? What got you into this world?

Christina: 2:53

Yeah, so I'm actually doing a completely unrelated PhD. I'm doing a PhD in heavy resistance training in older adults, and one of my areas of expertise is in geriatrics. And as a part of my degree, I did a scoping review about where physical therapists can be involved in health and wellness. And the perinatal space overwhelmingly came up as an area that we can help facilitate and remove barriers to exercise and movement for individuals who are pregnant and individuals who are postpartum. because of that, I dabbled into it in my own business. So we started a strong like mom postnatal exercise program, and that was where I kind of started treading into the women's health space. I actually was one of those people that said, I'm never gonna be an internal therapist. Like, do not wanna do it. Like that is not something for me that I obviously lied and I do all that stuff now, but that was something that I just didn't think I wanted to do. I've learned a lot since then about it being a tool and not identity in the pelvic health space, but that's a whole other soapbox. And then when I got pregnant with my daughter, I have a 10 year history of doing CrossFit. I've competed in power lifting. I competed nationally in Olympic weightlift. And then when I got pregnant, I had no. Desire or expectation to not do that. And I post a lot on social media and the comments that I started getting were quite interesting about your baby might die. Like literally somebody said that to me in my second pregnancy. I want to see your pelvic floor biofeedback numbers, thinking that I was gonna spontaneously prolapse, just like the things. As a person who is very educated and informed in this space, it, it even made me pause, you know, it made me think, you know, am I doing the right thing? And the thought then to other individuals who don't have the same knowledge and background that I did, it was just really disheartening to me. I thought there was a lot of fear spiraling that was going on. And therefore I started really diving into the research in this space. Not conducting research at the time, but really starting to synthesize and bring together what research we do have. And I started teaching a course around pregnant postpartum CrossFit with an emphasis on barbell training, return to gymnastics and return to endurance within kinda the CrossFit sphere. And then I was just getting so frustrated thinking, you know, we have all. These individuals, you know, you see them all the time. People who are in CrossFit gyms every single day, and not just elite athletes like the mom who is exercising for health, who really enjoys lifting weights, who are being told all of these myths, like, don't hold your breath ever again postpartum or pregnant. Don't lift more than 20 pounds or giving, they're getting these sheets from their doctors. and it's hard because there wasn't any research on it and because of that, like, you know, we can't even have a really well-informed or evidence informed rebuttal and cause of that. Um, I reached out to Margie Davenport and a group of international collaborators and we started with a cross-sectional survey that was kind of trying to get a picture of. Individuals who are lifting before pregnancy, what their modifications changes, their kind of the way that they modified during their pregnancy, and then what that did for their fetal outcomes, delivery outcomes, and then kind of got an idea about. Postpartum, pelvic floor, physical therapy needs. And when they started returning to things after baby, if they did at all. And that just gave a lot of information. And, and now I'm, I'm kind of a little bit known as like, that pelvic PT that's gonna get you to lift heavy, who's, uh, okay with that? And I'm just like, overjoyed by having that type of, of reputation. And so it's been a really exciting journey from, from that standpoint.

Natalie: 6:41

That's amazing. Yeah. I've like just the little that I've known you and followed you online. I'm just constantly like, oh my gosh. Okay. I need to rethink that. Okay. What is she saying, What can we, what can we

Christina: 6:52

I do that myself.

Natalie: 6:55

Yeah, and it's, it's really interesting because my background is Pilates and like no history of going to a gym, quote unquote gym and lifting heavy weights. I totally thought that lifting heavy was dumb When I taught Pilates, like I told people like, you don't need that which now I'm like, oh my gosh, I can't believe I had that mindset. Um, which. You know, I mean, it's good to evolve and change and, and learn new things, but now obviously I encourage heavy lifting. Um, but I don't know as much about the CrossFit background because that's not my world. And so, um, I want to kind of talk about, I, I read your paper and it's amazing. I want you to know it's great. And I'll link it in the show notes too so everybody can, um, go and read it if they so desire. I have a lot of nerds who listen to this podcast as well. Um, The, like, the thing that stood out to me most, I guess from the very beginning was talking about the Alva Maneuver, because that's a huge one that everybody in the pelvic health space is like, don't alva when you're pregnant. Don't Alva when you're lifting. And especially don't do it in postpartum. So, um, It like, according to your, your research, it looked like there weren't any differences in their pregnancy, labor, or delivery outcomes for those who did Alva during pregnancy while they were lifting, um, and those who didn't. So can you talk about that a little bit and, and what does it look like to Alva and is that okay? I have a lot of questions about this, but is that considered like managing your Interabdominal pressure? Well,

Christina: 8:29

Yeah. Okay, so let's try and impact this a little bit. Let's start with the definition of a Valsalva. The hard part that comes into the pelvic health space is that when we are looking for something like a prolapse, which is a movement of one or more of the walls of the vaginal canal towards the opening because of shifting of abdominal contents, we use the Valsalva in order to assess that. So we ask individuals to bear down, and we call that term in the obstetrics and gynecological spaces as the VE selva. Therefore, right, we. That movement is quote unquote bad. I would argue that it isn't, but in general, it is seen in that way and that there's a lot of reframing that has to happen around the prolapse space as well. And then when we use it in strength and conditioning, it refers to bracing. And unfortunately, sometimes the way that females are told to brace is to inhale, feel their belly full of air, and then they're down. And for individuals with male pelvis that are a bit narrow, pelvic floor dysfunctions are not as high in recreationally or elite level athletes who are male. That that isn't going to cause any problems. The problem is when we are using that, that term to refer to bearing down from a strength and conditioning perspective because it can lead to increased, uh, instance of things like uh, urinary incontinence. But really when we're talking about bracing from a a, like that Valsalva strength and conditioning bracing perspective, we really are talking about this, this con co contraction of all the muscles around the core canister, including the internal external oblique rec, modi, you know, our chest wall diaphragm and our pelvic floor. And when we ve Salva, we see. Kind of a synchronous activation of all of the muscles around the core canister, that this acts as a protective mechanism. It increases our force transfer because it increases stiffness around the spine. So by increasing stiffness across the spine, we protect ourselves from injury. We also increase our performance or capacity by allowing us to exert more force against our axial skeletons so that we can lift more load in, in whatever way we're doing that. And in that realm, Valsalva isn't bad. Valsalva is something that allows us to be stronger, and it is something that we do very naturally. Over 80% of our one rent max and kind of tie in my geriatric space. You know, if your client is using their hands to get up out of a chair, their one rat max is less than their body weight, which means that they're Valsalva. Every time they get up from a chair, because that's the only way they're gonna be able to do it. Bringing this back to the pregnant and postpartum space, if we are actively encouraging individuals to decondition, and we may not conceptualize it that way, but by discouraging or creating fear around strengthening and movement and pregnancy and postpartum, we are unintentionally deconditioning. This group of individuals, then their 80% of their one at max may become their car seat because we have told them now for the next nine months that they should not be doing any type of heavy load their strength. Is gonna come down in combination with the physiological changes that happen during pregnancy and then in the postpartum space. We just expect them to be able to baby wear immediately after delivery. We have a, if you're in the United States, a lot of times you're having six to 12 weeks of unpaid leave, and then you're going to full-time work as a physical therapist. Eye lift people's limbs. Those limbs are oftentimes, Light and we are doing that on a deconditioned person. And that's where, you know, as I was, I was thinking about this and reflecting on where our recommendations were, it didn't really make a ton of sense to me. And the Valsalva during pregnancy piece is important, where the theoretical constructs come from because we didn't have any information on it up until the last couple of years. Theoretical constructs are around that. We see a transient increase in blood pressure when we val salva up to about 200 millimeters systolic millimeters. Mercury, stoically, gestational hypertensions. Preeclampsia in pregnancy are something that are extremely relevant and something that are monitored very closely. Heightened sustained blood pressure is very different than transient increases and decreases in blood pressure that occur with resistance training. But something that needed to be evaluated was number one. Number two is that we do have an increase in pressure, which causes an increase of work on the pelvic floor. This is the big pelvic health one that we think, okay, our pelvic floor is already strange during pregnancy. Let's not strain. More, and I am totally was in that camp, right? I still tend to, to bias towards exhaling on exertion. I'm now transitioning into exploring different ways of breathing and seeing what feels good for the pelvis of the person that I'm working with, but, What I think is happening and where our theoretical parts might be wrong, is that for individuals who are already train resistance trained, their bodies are already trained to Alva, and so that progressive overload is happening during pregnancy and their body is adapting as. Baby starts to grow and, and changes start to exas or start to increase in change as individuals go through the first or third trimester. So the body is, I think, adapting and therefore we don't have to be as fearful around the Val Salva piece. Now we have, I know, I'm so long winded. I'm sorry. Last piece, like on the research side, on the research side of things from Valsalva, we now have three studies that have investigated Valsalva in a pregnant person. One, we, uh, two of them have looked at resistance training, one with a 10 max leg press, another one with an incline bench press, and they were looking at maternal and fetal healthcare outcomes and seeing if there was any changes in ultrasound or anything that would. Would indicate fetal distress or something negative happening to mom. What we recognize and what the findings of those two, those were not my studies. Those two, um, previous studies were that there didn't seem to be any abnormalities in fetal heart rate. Pregnant and non-pregnant persons responded to Val Salva the exact same way, and therefore it appears from just a cardiovascular perspective in a healthy pregnancy, free of complications. Valsalva is okay from, from the circulatory, like the transient increase in blood pressure. With that perspective from the pelvic floor perspective, both of these studies were not done in individuals who were standing. With external load on their body. So we couldn't really evaluate pelvic floor outcomes. But the way we tend to, to tip our toes into the, the pregnant space is that we make sure baby is fine first, and then we can start exploring and, and you know, kind of dabbling into different areas. And our study was looking at, we did a subgroup analysis about individuals who said that they continued to Valsalva during their pregnancy and those that didn't, and we did not see an increase in pelvic floor dysfunction postpartum from the 34% of individuals in our cohort Who answered that question? That they continued to Valsalva versus didn't. The one thing to kind of bring this full circle is that that is not saying that Valsalva is protected. That is not saying, you know, it is saying that it is net neutral. I've seen it. I've had to kind of, you know, that's not really what my study said. Um, it didn't say that there was an increase in risk. That doesn't mean that it's protective. It. I will interpret that as it is net neutral and what we, we think and what we know is that many of the predictors for pelvic floor dysfunction, They occur during labor and delivery. These are obstetrical factors and oftentimes are completely outside of mom's control. Um, not all the time, but, but a lot of the time. And so we don't need to be creating shame around what a person did during pregnancy, what they didn't do, what they decided was good for their body and what wasn't good for their. Everybody's pregnancy is going to be different, and we don't have any research to support that. The exercise that you choose to do during pregnancy is going to set you off for bad long-term outcomes from a pelvic floor perspective, and, and that's kind of what I really want this, I wanted this study to highlight is to just add to the body of literature showing. It's okay to lift more than 20 pounds. I was pregnant with my second, my daughter was 25 pounds. If I would've gotten that recommendation, imagine how harmful that is. Oh, I'm potentially harming my body or my unborn child in order to not have my child lose her mind at the park. Cause I have to carry her out cuz she wants to still play. You know, like those situations that moms get into all the time and, and yeah, we just, we just have a, a. a communication change that I think needs to happen.

Natalie: 18:02

I, I agree. There's so much fear just not only in the exercise during pregnancy space, but also just pregnancy in general. Women's health in general. There's such a lack of research and information and. Good information and education that, yeah, people just end up being scared of things and then that, what I've seen I guess in my, my years of working with pregnant people is it tends towards I'm just not gonna move. Like it's safer for me to not move than to try something new or continue what I've been doing because I don't know.

Christina: 18:36

Yeah, and, and that's even being challenged, right? When we look at a systematic review that. Put individuals on bedrest versus pelvic rest. So bedrest don't do anything except go to the bathroom, get food, come back to bed versus pelvic rest. Don't have any penetrative intercourse, any speculate exams, et cetera. But continue with activities of daily living and lower intensity exercise. Individuals who are put on bedrest have worse obstetrical outcomes, and, and that intuitively makes sense. Again, you're deconditioning that person. It makes labor a lot harder if you've lost 30% of your fitness than if you haven't. I'm not saying that your labor will be shorter if you're fitter. That's another misnomer that comes into the space all the time. But what I'm saying is it takes a lot of exertion to, to deliver a baby in whatever way that you deliver, and your body needs to be ready for that.

Natalie: 19:36

Yeah. I know you probably heard the labor is a marathon kind of analogy, but I like to call it a Spartan race. More so in the

Christina: 19:43

Yeah. I love that. Yeah, I love that.

Natalie: 19:47

know what obstacle you're going to encounter, and you have to have the strategies and the tools to overcome those obstacles. And if we're left weaker, Typical or that what, what we were before pregnancy, then we're going to have struggles, right? And, and

Christina: 20:05

Yeah.

Natalie: 20:06

finish that race in a different way than we anticipated.

Christina: 20:09

Yeah, absolutely. Absolutely. So our study tried to look at a bunch of different outcomes that tried to put all those myths around pregnancy. And one of my theories, because I see it so often in barbell athletes, is that they tend to be on the hyper side of things. And therefore, you know, especially for elite level athletes, I think they may be potentially more at risk for delivery VST section because they are very good at performing the bear down, but closing their spans. And as we know with labor and delivery, Is going to be counterintuitive or counter to progress. And um, so we were looking at that, but, but we saw actually less rates of C-section compared to within where 13 of individuals in our survey delivered via C-section versus our current standard, which is,

Natalie: 21:01

yeah. Yeah. That's incredible. I was looking at that and only four people had gestational diabetes. Is that correct?

Christina: 21:08

yeah.

Natalie: 21:09

That's amazing.

Christina: 21:11

And, and we have this aerobic literature, right, where individuals who are participating in aerobic uh, training before pregnancy are less likely to develop gestational diabetes and are better able to manage gestational diabetes once it has occurred in pregnancy, if there is genetic predispositions and things. But we didn't really have an accumulation of anything within resistance training just because our, our literature is so sparse within that space and. But, so yeah, it's a really encouraging finding for us to show, and it just makes so much intuitive sense, right? We know that resistance training helps specifically with ostial diabetes because our muscles are so metabolically active that they're gonna be drawing all of that blood sugar out of our, our blood to be able to fuel that recovery. And so it just, it, it does make sense that it is true within pregnancy, but we hadn't evaluated it in, in that cohort of individuals. And so, and then we saw very low rates of gestational hypertension in preeclampsia as well, which is also wonderful. And then, um, very low rates of perinatal mood disorders. And again, that's a another. Big health piece, like there's a lot of potential confounding there because individuals who are lifting heavy prior to pregnancy probably had a lot of those healthy lifestyle factors in place before they got pregnant. And so it's, it's important to recognize that this is cross-sectional data and we can make inferences and we can use this as potential justification for more longitudinal or, or going forward perspective data collection. Um, but we can't. You know, resistance training is, is protected against all these things. We, we can start, you know, it starts to, to hint that there could be a relationship there, but we still have a of work to do in research to try and really delineate some of those relationships and what the magnitude of.

Natalie: 23:01

Yeah, yeah, no, the outcomes were impressive. I was really encouraged, especially about the, the postpartum prolapse too. I don't remember the number, but it was very low.

Christina: 23:12

13% had subjective symptoms. So, and we said heaviness or a balding or a feeling like a golf ball is in the vaginal opening. That was kind of our, our markers for subjective complaints. So important to note, similar to Laurie Forner study on lifting and, and prolapse. She was looking subjectively, she didn't do objective exams cuz it was a cross-sectional survey, but our study kind of collaborates with what she saw. Um, with respect to, to incidence of prolapse symptoms. And again, that's a big. Fear a spiral that a lot of individuals have. Um, I always joke that with prolapse, we, our training has done us a disservice because every anatomy textbook makes us feel like our, our vaginal canal is this hollow tube that is like collab. And if I look at an internal exam, I'm just gonna stick right through to see the cervix. And I was like, that is not how. Our vaginas are. And um, so we have this assumption that, you know, that moving and shifting it's smooth muscle. Like we're just seeing that movement happen and, and yet we can heighten and sensitize so many pelvises about that. And so one of my. Things I really encourage, um, allied Health and, um, obstetrical and, and individuals in the birth provider space is to tell them what is, what is normal to feel down there after a vaginal birth, like a descent of the bladder, a slight descent of the ba bladder is normal. When we look at the natural history of vaginal birth, we are gonna have more AP movement like. Before when you were lifting during, um, pre-pregnancy, or if you're Nelly Paris, your first pregnancy, you're not gonna feel a lot of up and down movement there. But because of this stretch injury from a vaginal birth, you are gonna feel more pelvic movement. And that is. Normal. But a lot of individuals can link that to something that is pathological or something that is wrong and something that they are trying to avoid. So they start to lift and they start feeling very sensitized saying, I'm feeling these prolapse symptoms and you know, we have to start teasing that apart. Like, is that prolapse symptoms? Is that fatigue of your pelvic floor? Cause those muscles are gonna be the weakest across your system, or is that normal movement after a vaginal.

Natalie: 25:29

Hmm. That's really fascinating. I think that's, that's something that like pro providers, practitioners need to be more aware of, like you said. And then also empowering women to do their own assessment on themselves and figure out like, what did I feel before? What do I feel now? And comparing that, am I still strong? Am I leaking? You know, all of the, all of the self assessment questions can be helpful. Um, okay. Why isn't this space more studied? It bothers me,

Christina: 26:05

Yeah, that's a great question. Well, the first thing, and the reason why we did a cross-sectional survey is because, Have to, when you're doing research, you have to go through an ethics board. So when you're going through an ethics board, and this is just due diligence within the research space, anytime you're doing a study, you have to make sure that. When you're dealing with a pregnant person, the risks are already elevated, right? Because our adverse outcomes are something that are really devastating, right? If we had a fetal loss or a maternal complication or something that led to a birth defect, whatever it may be, like it, the risk is very low, but, but the risk is there and the risk is very high. Versus other, you know, exercise programs where we're thinking maybe a musculoskeletal injury or like an exacerbation may. The adverse event that we're looking at. So that's number one. So we tend to, to tread very slowly and that's why we did a cross-sectional survey because the, the last, like really the research that we have in resistance training is around, you know, lifting 20 to 30 pounds. So it makes sense that this is where the recommendation comes from. You know, the resistance studies that we do have, this was the load that individuals were lifting. There was no adverse events to that. We don't know anything above that threshold. So the threshold that we are gonna give people is don't lift more than 20 or 30 pounds. Right? It's like this bad case of telephone that happens. And so we went to the, we went to our ethics board and said, People are doing it. We wanna see if people are doing it anyway because our next step, which they are, right, they are. But we have to have that justification. But now we haven't. So we can say, you know, I know that this is something that is riskier or something that has not been evaluated, but based on our study, we got almost 700 female. Who lifted heavy during their pregnancy. So there is a cohort of individuals who are, who are self-selecting that this is an exercise modality that they enjoy and wanna continue doing. Let's do more research in this area and, and research is a long game. You know, it took us, we did a cross sectional survey that was open for 12 weeks. It still took us 18 months to get it from start of project to finish. And I think a lot of people who are our clinicians or consumers of research who have never been in that space, it, it's hard to truly. Appreciate that. You know, it is such a long game and so I'm hoping that this is, is step one. I have so many different ideas around where we can go next from this study, and I think in the CrossFit space, in the aerobic space, in the return to running space, like we now have a lot of cross-sectional data that is starting to describe what is happening. We need interventional studies now we need, you know, longitudinal data. It's expensive. It takes a lot of time. And so I think we're having more individuals interested. This study, we pub I knew that the study was needed. All of us did in, in our research group. I cannot even believe the uptake of our paper. It was just unbelievable. It just, it just showed. How much this was needed. You know, I'm still getting messages at people asking me for it because they had this interaction or, or this happened and it's open access, which is wonderful because then you can, you can access it for, from anywhere, anyone, even if you're not involved in, um, a college or a university, and. Yeah, so we're getting there. It just, the more people who are asking for this research, the more people who are pushing it in clinical practice, it comes into the research space, informs our projects, and then vice versa.

Natalie: 29:54

Oh yeah. A door. It's like the first little step into this whole world where we really need more research, we, we need more information. And I, I bet in the next 10 years, like you probably have your theories about this, but in the next 10 years we're gonna see like a bunch of studies and a bunch of change in not only like pelvic PT practice, but recommendations from practitioners, general obstetrics and all of that.

Christina: 30:22

Oh, I hope so. And, and I think, you know, the way exercise, even recreational exercise has changed with respect to high intensity. CrossFit was one of those methodologies where at first, Every clinician, what are you doing those kicking pullups for? Like, you're just gonna hurt yourself. That CrossFit stuff, it's reckless. And now that it's changed for now, a lot of allied health providers are coming alongside CrossFit and saying, you know, this high intensity stuff, it's helpful. You can get really fit. You wanna make sure that coaching is there. You're doing it progressing, you know, we call it mechanics, consistency, intensity, master all those basics and fundamentals. Then build that consistency up and you can add that high intensity, start putting it into workouts. But now we have, you know, like the burn body bootcamps and the orange theories that are all really kind of spinoffs of this high intensity paradigm. That's so needed. You know, we have high intensity interval training research for individuals in ICU who have had strokes. You were actively in cancer treatment. You know, like that intensity matters and that intensity is helpful across the lifespan, and that's, I think, gonna come and be true in the pregnant postpartum space too.

Natalie: 31:37

I'm so

Christina: 31:37

When your body is ready for.

Natalie: 31:39

Yes. Yeah. Um, okay. I'm gonna kind of go go back to pelvic PT and specifically the internal exam. Um, what does that look like for an athlete, for someone who has been lifting heavy prior to pregnancy, during pregnancy, and then in postpartum? What does that look like? Do you do things different than the general population?

Christina: 32:00

Yeah. So yes and no. So we will do a supine assessment where we are doing external, um, palpation, making sure there's no pain points, doing an external check of what they're doing from cough sneeze, looking for basically the range of motion of the pelvic floor. What. Their keel looks like, or what they think a keel is, a bear down to look at their movement. We will add in a brace in supine. So we will say, you know, do a, like, pretend you have a Mac squat on your back braces if you're about to, to squat that weight or pick that weight off the floor, see what happens. And then our internal checks are all the exact same. The demands of our, you know, our, especially our lifters, I am more likely going to see them instead of being able to isolate the pelvic flora, they're gonna kick on everything, right? They're gonna kick on their glutes, their addicts, their abdominal wall. They're gonna stop breathing, and they're gonna do a keel and. That makes a lot of sense, right? Because when I am Max Deadlifting, I'm not just trying to turn on my pelvic floor. I'm trying to turn on everything with as much recruitment as possible. And so that for them is very sport specific. It is absolutely helpful for them to be able to, to tease apart and isolate those muscles. And we're starting to get some research on using pelvic floor muscle training for athletic incontinence, which is individuals who are leaking specific to sport and outside of activities of daily living. And then we'll do the standing assessment as well. So we can get individuals in standing, going through that same sequence and looking at external checking In standing, we can do it in the bottom of the squat, which tends to be a point where individuals are leaking. So go through a pelvic floor contraction, whatever that means for you, a bear down, a coffer, sneeze, and a brace. Again, whatever that means for you. And then we can do that with, uh, a digital assessment as well, getting them to see some of those movements. And that's where we live our life. You know, we live our life in standing. Our supine assessment, do not get me wrong, we have tons of evidence for it. It is extremely helpful. It gives us our baseline, but we need to get people off the table. Oh my gosh, six to eight weeks of transfers of dominance training just makes me wanna blow my brains out. Like that is not. and individuals don't wanna do that. Like eagles are boring. Like they are useful and that is where we start. But then we integrate that into function as fast as we can. Right? Like that is the goal is yes. Get them doing that Pelvic four contraction. We have grade A level one evidence for using it against pelvic four dysfunction. There's a whole, right now there's a lot of people on social media being like, stop doing keels. I was like, stop telling them to stop doing keels. That is not, Gosh, the social media space can be so annoying sometimes. But

Natalie: 34:50

Overgeneralization for sure.

Christina: 34:51

yes, it's teach it. Teach the coordination of it, make sure the prerequisites strength is there, and then integrate it into function. Like that's our steps. And that should be the first two sessions that we're doing that not, you know, week 12

Natalie: 35:07

Yeah. Agreed. Yeah. And

Christina: 35:10

and then,

Natalie: 35:11

up and up and carrying their babies around the house anyways. Going up and downstairs and lifting the car seat and getting in and out of the car. Like normal

Christina: 35:18

was doing a 50 pound carry with my toddler baby wearing my son because my toddler lost it in the park and she didn't wanna leave. So I was like, Maya, you can walk with me, or Mommy can pick you up. And she didn't wanna walk. So off I went, you know, I think it was three weeks postpartum. It just is what it's, you do what you have to do. And then from the, the pelvic side of things, we also, um, really strongly advocate for coaching first. So if you were seeing individuals who are lifting or leaking with lifting, then you gotta see them lift. And if you don't have the equipment in your, your, your clinic. I, I think you should get the equipment number one, but number two, if you don't have it right now, then you should be video getting their videos and, and seeing what's happening. Like are there any deviations in their movements? What does their bracing sequence look like? What does it look like when they put a weightlifting belt on? Does that change the way that they brace? Because that can lead to leaking. Like what is their threshold when they leak? If they are deadlifting 2 85, are they fine? And then when they bump up to 2 95, now they aren't. All of those things are gonna be so, so important for assessing a person who enjoys lifting and experiencing symptoms with lifting, um, to really create that bridge from like what we are seeing in our internal evaluations and then what is happening in the gym, and then creating that bridge for them, for them to get back to those movements.

Natalie: 36:44

Awesome. Yeah, that should be the standard. That's what I think.

Christina: 36:48

A hundred percent.

Natalie: 36:49

you mentioned weightlifting belts, and I didn't ask you that question I was going to. Um, so why would someone choose to use one for one question? When is it contraindicated and like, what's the purpose or the goal? There were 45 people. In your study that used them during pregnancy? Um, up to like 18 weeks, I think, if I read that correctly.

Christina: 37:09

Yes.

Natalie: 37:10

Can you talk about that

Christina: 37:12

Um, in the first trimester, I generally do not have any contraindications to exercise that I would advise my clients unless there was a pregnant complication or something that we were working around. Um, it's gonna be how sick are you feeling and what is your fatigue doing, and what does your rebound fatigue look like after exercise? And the rebound fatigue is gonna be relevant throughout pregnancy. You know, you do it heavy workout, you feel a bit tired when you're in day to day. When you're pregnant, you like five x that and that's what your rebound fatigue feels like when you go really high intensity. And, and if that, if you're doing your exercise and you're able to go home and just kind of rest and relax and you wanna hit that intensity, that's totally fine. If you are working out in the morning and it's making it so that you feel like you can't parent or do your job, then we're gonna have to scale at intensity back. From the weightlifting belt perspective in the first trimester, I generally don't make any recommendation. If people want to use it, they can. If they don't wanna use it, they don't have to. Baby is really far in the posterior aspect of the pelvis. It is not like there is no direct compression on uterine wall, on baby themselves. Um, Until further along, and so most of my clients, I don't really need to make a recommendation because they start feeling real cringy about it around weeks 10 to week 14, and then they just ditch it, and that's totally fine. Um, and so that, that's kind of generally where the recommendation is. Individuals will use weightlifting belts because we'll get a 10% increase in, uh, EMG activation of the spinal or para of spinal muscles in the spine, um, which allows us to feel more supported through the spine and allows us to lift more weight. So there is a performance advantage to using a weight lifting belt in the sports of CrossFit. Weight lifting and Olympic weightlifting. They're also legal aids to be able to use in competition. And because they give us a performance advantage, we want to be utilizing them. So therefore it's something that we want to be encouraging if we can. It is also a time when individuals can be experiencing more pelvic four symptoms is when they use a belt. So a couple of kind of standard things that we talk about with the weight lifting belt. Number one is that we shouldn't be using it for all sets. It is for a top set, the heaviest load that we are utilizing for my postpartum clients. I ask them, are you using the belt because it makes you feel. Better at your top sets or are you using it as a crutch because we haven't built up the foundation yet that you need in order to be exposing yourself to these loads and, and truly reflecting on, are you ready for those loads just yet? If you feel like you need to use one at eight or 10 weeks postpartum, it might be more because we need to build more of the foundations and your core is your weak point, not your quad. Um, and, and we need to work on the weak point across the, the system. And then when we utilize it, the, the problem where leaking can happen is that individuals change their bracing strategy. So the way that I'll teach a Valsalva is I get them to bring. Take a big breath and then contract their belly like somebody was gonna give them a little punch to the stomach, or your toddler was about to jump on your belly. And everyone knows that feeling, right? Like you start to tighten up. That's what you wanna be experiencing. So that'll create a nice, um, closed canister. Allow for increase in EMG activation throughout the entire system. When you put a weightlifting belt on, that should not change. What some people will do is that they will be told to actively push out against the belts, and that's where, especially postpartum, when you have more of that movement down there, it feels like you're pushing in the middle of a balloon and. You know, your, your ribcage is above, so that's not where that extra energy or pressure is gonna go. It's gonna go down towards the pelvic floor and people are gonna feel potentially symptomatic there. And so the idea is that it really should just be an extra proprioceptive little bit of support. It should not be something that you are utilizing as a crutch. Your body needs to be ready for it, and then it's gonna help give you that performance a.

Natalie: 41:20

I don't think I've ever heard somebody explain it that way before, and that makes way more sense than what I've heard from other people, and especially since that's not my wheelhouse. That Thank you for, for going over that. I appreciate it.

Christina: 41:33

Yeah, you're welcome. The last thing probably about the weightlifting belt is that the general recommendations that we wanna give is that the weightlifting belt should maintain the same size all the way around. Ideally, you'll see some where it'll be very narrow as it goes across the sides of the ribs, and then very wide in the back, but that's gonna distribute that force unequally. So we really want to be thinking that it is going to go like around that ring of your belly and and distributing that load very evenly across. All sides of that canister. So things that if individuals are asking, you know, what belt should I be utilizing? One, we want it to be consistent, um, with all the way around. And then the second thing is that different sports will have different rules around what weight lifting belts are legal versus not. And so it's important for the athlete to check. With that as well. Like a power lifting federation will only have specific brands and are only gonna allow leather, like thicker lever or prong belts versus CrossFit and weight lifting, which has a little bit more flexibility and most will use a cloth belt, a lot more cinching and pressure and stability and all thick leather belt than in the cloth prong belts. And, but that can be a way that you go from not using belt, you use the cloth. Then use the leather if you're trying to progress an athlete back to power lifting, for example, and they need to use that leather belt.

Natalie: 42:59

Okay. Okay, gotcha. Makes a

Christina: 43:01

Mm-hmm.

Natalie: 43:01

of sense. Something I was gonna ask you, I don't, I didn't see pushing times for outcomes in your study. Was that included,

Christina: 43:11

Yes. So we have like 60 pages of supplementary tables. Did you take a look?

Natalie: 43:17

Yes. I started, I didn't get through all of them.

Christina: 43:20

Yeah, so we had some around like length of second stage of labor, um, that was there. I'm not sure if it was in the subgroup analysis, but we did ask that question. Nothing really remarkable came out that would be outside of the norm. Um, but yeah, nothing lengthened. Nothing shortened.

Natalie: 43:39

Okay, cool. Yeah, I'm curious cuz I'm like, okay, if these individuals are doing Alva, if they're using different bracing techniques, how does that translate to pushing a baby out or not

Christina: 43:49

From a birth prep perspective, you know, for my athletes, I'm getting them doing, I, I call them birth prep workouts, where it is mandatory that they do them. It is in their programming every week, and it's all about down training. So it's around learning. You know, sometimes pelvic health can only talk about open. GLAD is pushing, but even coached open, GLAD is pushing, ends up being a combination of open and closed just because of performance and, and what's happening in the moment. You. And so we need athletes to be aware of, we need everyone to be aware of both, I shouldn't just say athletes. We need everybody to be aware of both. And working on that relaxation can really help with the labor and delivery process. And you know, I've had a lot of athletes who have had second babies and they say, oh yeah, the first time I was absolutely fighting myself. I could, like, the experience was just so different knowing that I had to, to have that relaxation.

Natalie: 44:44

Interesting.

Christina: 44:44

And that's where I think even our perennial massaging, where we're, we're applying that stretch, if a person's goal is an unmedicated delivery, applying that stretch is very similar to that ring of fire feeling and then being able to relax that pelvic force. So again, getting our athletes, you know, there is a, a bigger trend towards unmedicated or trying for an unmedicated delivery. Applying that stretch and then working on some of that relaxation and open and closed pushing strategies can be helpful. Um, and then on the flip side, you know, we have some research saying that an epidural may lengthen the second stage of labor. I don't know if that's always true. You know, like, especially if you have an athlete that's really fighting their own progression, that epidural may actually get their body to relax. And, and so I've had clients too who. Said, you know, I was really fighting until I got that epidural, and then I felt like my body relaxed and I went from three centimeters to eight centimeters in like no time.

Natalie: 45:40

Yeah. Yeah.

Christina: 45:40

So, so we have to,

Natalie: 45:42

in practice. Yeah.

Christina: 45:44

yeah. So we have to take all of this data as things that are, are trends, but then obviously apply our clinical reasoning and then be able to modify and, and adapt to the person that's in front of us. And that's really the true definition of evidence informed.

Natalie: 45:58

Yeah, reading the person, not the studies. Only

Christina: 46:01

Right, that trium it, right?

Natalie: 46:05

Okay, So I wanna kind of wrap up with what are your favorite resources, books, accounts that you recommend following? For someone who really wants to learn more, do more research, dive into this world,

Christina: 46:20

So I'm gonna have to shamelessly self plug some of these things. Um, so I teach clinicians through the Institute of Clinical Excellence. I teach two courses. I teach our eight week online course. Um, that goes all the way from preconception with the female athlete or, or a person who wants to move their body all the way through pregnant modifications, labor and delivery for trimester, and then return to exercise postpartum. We also have a two day live course where we focus a lot on lab. We teach the basics of the internal assessment and then teach how to bridge that into. Return to intensity and exercise and movement, we get, you know, we get the information in the internal exam and then we're able to move that to returning to tipping pullups and returning to handstand pushups and returning to heavy squatting and deadlifting. And so I teach those two courses with, um, Alexis Morgan and our team, and we teach that through the Institute of Clinical Excellence for clinic. And then for athletes who are listening to the podcast, I run a company called The Barbell Mamas, so I do programming. For pregnant CrossFitters, weightlifters, power lifters, postpartum CrossFit, weightlifters power lifters, that take into consideration some of the pelvic floor, uh, factors in both of those times in a person's life and have created filters for return. So for pregnant modifications, we help individuals stay moving. In a way that makes them feel supported and then postpartum, we really try to use that postpartum programming to bridge them back to their communities. So get them back into the CrossFit gyms, get them back into their Weightlift clubs, get them back into movement, and so, you know, We are not fearful of pelvic floor issues coming up, especially for individuals who are high intensity athletes because they're pushing their boundaries. And until you know where those boundaries are, you're really not gonna know where those lines are. So these athletes are gonna be the ones who are going to. You know, start jumping or running and they're gonna be like, oh, body went too far. That's okay. We're gonna take that down a little bit. Just like we're not afraid of pain. Pain is a signal. Our pelvic force issues are a signal of where our body readiness is. And so, okay, you're experiencing leaking with this squat, here's how I want you to modify it. And so we have different filters for that. And the idea. You know, we always say this, that it's bad advice, you know, to wait six weeks and then listen to your body. And I've kind of really reflected on that. I'm not being very nice saying that. I want you to listen to your body, but I want to tell you what to listen for. You know, I want to tell you, you know, what your guideposts are because you're not gonna know, especially if you've never done this before.

Natalie: 48:59

Huh.

Christina: 49:00

What, what you're listening for and you're, you're an athlete. You've been very in tune to your body, but your, your. Feels and looks a little bit different now. And, and that's okay. So we just, we just wanna help guide you on that journey. And so the Barb Mamas is definitely, um, one where, where we talk a.

Natalie: 49:18

Awesome. Awesome. Okay, last two questions that I ask every single guest, The first one is if you could boil everything down to one. Like your number one piece of advice for our listeners, what do everyone to know?

Christina: 49:33

Okay. My piece of advice is that your body is strong and your body is resilient. And if pelvic issues come up, we know how to handle them. But that does not mean that your body is not strong and that your body is not resilient. It's just.

Natalie: 49:52

Preach it. I love it. Last question. What is your favorite wellness habit that you incorporate into your daily life?

Christina: 50:03

Hmm. Lifting heavy weights. my husband and I live together. Yeah. My husband and I live together and so it's kind of two for one because it's my connection time with him and you know, having two little kids. It takes a big toll on your relationship too. And so it's a way that we connect together and we, we compete together in the CrossFit space. We've competed together in weight lifting and power lifting, and that's just something that we've always done together. And so, I'm just that person that is just in love with fitness in every stretch of the imagination. I like go to bed thinking about it. I just have found something that I just love doing. It just sets my soul on fire. So that is definitely my wellness habit that I, you would, any physician would have to give me very good reasons for me to stop lifting weights,

Natalie: 50:55

And you would probably be able to argue them intelligently, so it wouldn't matter that way.

Christina: 51:00

Yeah, they would have to come, they would have to do a tent with me for a little bit, for me to be okay with it.

Natalie: 51:06

That's awesome. I love it. Well, thank you so much for being here today and, and spending your time and energy with me. I, I super appreciate it.

Christina: 51:14

you're so, thank you for having me, and thank you to your listeners for chiming into this.

Natalie: 51:19

My top takeaway from my conversation with Christina was there are so many different ways to approach fitness during pregnancy and postpartum, but heavy resistance training has so many benefits, and I was particularly interested in the topic of the Alva maneuver during pregnancy because this is something that historically the people in the pelvic health space, Recommend avoiding, and so it was really encouraging and good to hear that doing Alva properly while pregnant, especially if you've been lifting prior to pregnancy, does not result in any adverse outcomes for pregnancy, postpartum, or during labor and birth as well. It's not necessarily protective, but, it showed no adverse outcome. There are so many things that still need to be researched, but we are making progress, and if you are an athlete who lifts heavy and enjoys lifting heavy, you should definitely follow Christina. I also love how she brought in the concept of we do not need to be fearful of postpartum pelvic floor issues or even during pregnancy because it's just like pain. We're not scared of pain. It's a signal and it tells us what we need to know and we adjust accordingly. So that should be encouraging for all of you as well. I have linked all of the resources she mentioned as well as her sites and social pages for you to follow in the show notes for this episode. So please go read her study and 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 provider before making important decisions about your healthcare. If you found this podcast helpful, please consider leaving a five star review in your favorite podcast app Or sharing it with a friend. Thanks so much for listening. I'll catch you next time.