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Blues Busters

It seems almost intuitive that physical therapy and exercise would help alleviate postpartum depression, and while a couple of studies have shown it beneficial, the practice has not taken off in the U.S. 


“It’s been shown generally in the literature that exercise is beneficial for mood disorders, anxiety and depression,” said Marcy L. Crouch, PT, DPT, CLT, clinic director of the Pelvic Health and Rehabilitation Center in Oakland, Calif. “In the postpartum population, it’s a huge piece of the well being of the mothers, and if they are at risk for baby blues or depression, exercise can help.”


Yet physical therapists receive few PPD referrals. Great Britain, Switzerland and other countries are ahead of the U.S. in incorporating physical therapy in postpartum recovery, said Wendy Baltzer-Fox, PT, DPT, GCS, WCS, supervisor of physical therapy at Women & Infants Hospital of Rhode Island in Providence. “It makes sense,” she said. “There are a lot of changes to the body during pregnancy.”


Between 11% and 18% of new mothers suffer from frequent depressive symptoms, according to the Centers for Disease Control and Prevention. Treatment in the U.S. typically involves medication and counseling with mental-health professionals. 


The evidence for PT

Canadian researchers, reporting on a randomized clinical trial in the Journal of Psychosomatic Obstetrics & Gynecology in 2009, found a home-based exercise program a feasible nonpharmacological PPD intervention, especially beneficial for women who were most depressed at the start of the study. 


In 2010, Australian researchers, reporting in the journal Physical Therapy, found that postnatal women who participated in an eight-week “Mother and Baby” program, with a special PT-led exercise and a education program, experienced significant improvement in well-being and reduction in depressive symptoms compared with a control group, which received only the educational materials. 


Deborah B. Riczo, PT, DPT, MEd, at MetroHealth Medical Center in Cleveland and owner of Riczo Health Education, conducted a similar program in the 1980s and also observed favorable outcomes. “It’s a great thing for women,” Riczo said. “It gives emotional support and someone to give guidance.”


Screening for depression

“Even though there’s some good evidence in the research to support [that] exercise decreases the risk of postpartum depression, therapists, at least in my part of the country, are screening and referring out,” said Stacy Tylka, PT, DPT, WCS, CLT, therapist at Washington University Physical Therapy Clinic and an assistant professor in the DPT program at the St. Louis school. 


The American Physical Therapy Association Section on Women’s Health’s pregnancy and postpartum courses often teach how to use common PPD-screening tools, in particular the Edinburgh and the shorter EPDS-3, and discuss risk factors, signs and symptoms and general medical treatment, said Darla Cathcart, PT, DPT, WCS, director of education for the section.


“If we can screen, if we can be better practitioners by being better listeners and observers, then we may play an important role in getting her symptoms evaluated and addressed by her primary care provider or a counselor/mental health professional,” Cathcart said. 


New mothers often are referred to physical therapy for urinary incontinence, sexual dysfunction, back pain or other musculoskeletal conditions. Back and pelvic girdle pain can increase the risk for PPD, Cathcart said. 


Patients seeking care for such conditions offer therapists an opportunity to screen for depression. If the screening indicates a potential mental health problem, the therapist would notify the patient’s provider and adjust the care plan appropriately, Crouch said. “Asking about these issues is important,” she said. “Having a baby is a huge transition.”


APTA’s Section on Women’s Health recommends PTs become educated about postpartum depression, listen to patients, and on a one-to-one basis, encourage aerobic activity and teach relaxation techniques to help manage the symptoms.


“It feels good to do something for yourself, and endorphins are important,” said Eliza Andrews, PT, WCS, at Inspirit Therapy Associates in Green Bay, Wis. In addition, hormone levels will even out more quickly in women who are more physically active, she said. Women can start exercising shortly after a vaginal delivery and a limited walking and isometric program about two weeks after a Caesarean section, once cleared by the physician, she said. 


Riczo said even “gentle stretching will make the woman feel much better.”


A postpartum treatment plan

“It’s a team approach to treatment of women at risk or with postpartum [depression],” said Maureen Watkins, PT, DPT, MBA, LMT, assistant professor in the physical therapy department in the Bouve College of Health Sciences at Northeastern University in Boston. “Exercise alone will not heal postpartum depression. It’s a multifaceted issue.”


Watkins would incorporate a cardiovascular program into the PPD patient’s plan of care, in addition to strengthening exercises. 


Heather Moky, PT, DPT, at UIC Medical Center in Chicago and Kamin Physical Therapy in Park Ridge, Ill., encourages women to accept that they may need help, and teaches proper body mechanics and the importance of sleep and stress management. 


When a patient of Andrews screens positive for PPD, she will teach the woman biofeedback as a tool to help manage stress and anger and focus on what is contributing to the depression and how to get the person back to physical health by treating the incontinence or pain. “Who you were just changed and you need to feel that [you] can be you again,” said Andrews, who advocates group exercise for postpartum women because it brings women with similar experiences together. “A support-group mentality forms.”


The Australian study notes the value of the group program as well. Being part of a group is part of the motivation for the woman to participate, Riczo added. When they do, women develop friendships, which helps on multiple levels, she said.


“Postpartum depression is a very real thing, and it’s complex,” Riczo said. •


Debra Wood is a freelance writer.

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