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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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Every Woman

Back pain? It might be caused by your bra…

Millions of women suffer from back pain, and some conditions like osteoporosis and fibromyalgia are more common in women than men as a result of aging and other factors. Women can reduce their back pain by making a few adjustments to their wardrobe or paying closer attention to posture. Deborah Riczo, PT, DPT, MEd, of the MetroHealth Spine Center, offers a few tips women can follow to help ease the pain:
Women can reduce their back pain by making a few adjustments to their wardrobe or paying closer attention to posture.

Look at the type of shoes you are wearing.
They should have a good arch support and cushion to absorb shock that can travel from your feet up to your back. Avoid wearing flip flops or high heels and walking barefoot or in just socks if you are having back pain.

Wear a supportive bra (no stretchy thin straps).
This is especially important if you have large breasts and are already experiencing back pain. Good support will take the stress off your upper back and make it easier to stand with good posture.

Sit and stand so you have a natural curve in your low back.
The curves in our backs should not be too big or too small. When we slump our spine looks like a big “C,” which is not healthy for our spines. Good core muscles will help you maintain this natural curve with less effort. It will take practice to work on this. Choose a supportive chair to help you maintain good posture. Many different kinds of lumbar/back supports are available to purchase. It is a good idea to try them out so you know what is going to feel more supportive for you.

Bend your knees when picking something up from the ground, no matter how light it may be.
This reduces the stress on your low back muscles, and will actually strengthen your knees by bending them. Do not hold your breath, but exhale with the lifting. Breath-holding causes unnecessary pressure on your organs, circulation, and spine.

Mind your mattress or change how you sleep.
If you wake up in the morning with back pain that gets better as you move, think about your mattress. An old or too soft mattress can cause morning pain. You may want to have someone flip your mattress, or even try putting a board between the mattresses to make it firmer.
It also may be your sleeping position. Do not curl up tightly on your side as this rounds the lower back. Often a pillow between the knees will feel more comfortable when on your side, or a pillow under your knees when laying on your back.
If your back pain is persistent, it may be time to see a specialist. The MetroHealth Spine Center offers experts in rehabilitation, pain management as well as minimally invasive surgery.

Reprinted from the Physicians Newsletter. The MetroHealth System © 2002-2012. All Rights Reserved.