Boundaries, Self-Care, and Meditation Part 1 and Boundaries, Self-Care and Meditation Part 2, scheduled for November 23, are instructed by Nari Clemons, PT, PRPC and Jenna Ross, MSPT, BCB-PMD, PRPC.

Women are often socialized to be these kinds of words: sweet, likable, giving, generous, helpful, and accommodating. If that bend of conditioning is particularly strong, it shapes our relationships and our career choices. We often choose a career that makes us feel like we are being sweet, helpful, and generous. These traits serve others around us well, and they may increase our likability with others. We begin to see our likability as how much we embody these traits, and we can see our worth to others and ourselves as how much we show up in this one-dimensional way to others.

Taken to an extreme, this starts to look like being uber-available for patients calling them on our own time, emailing from home, running over in sessions to give the patient everything they could possibly get from a session, adding in hours to accommodate a patient, writing our notes during our lunchtime, and finding that resource for our patient by searching the web for an hour.

“Tis better to give than receive” or “giving them the shirt off our back” may be mantras we use or grew up with. But is it really true? Is giving more than we receive actually sustainable as a model? And if you give someone the shirt off your back, what would you wear? So many of the models we are raised to see as virtuous are actually rooted in martyrdom and are the hallmarks of poor boundaries.

When we hyper-inflate the “likable” characteristics of ourselves, it is often because we are deeply afraid of being seen as selfish, unlikable, or worst of all, a bi#ch. But why? We make these traits shadows…the traits to deny in ourselves and go to extreme lengths to hide from ourselves and others. Maybe instead, these are the very traits that can help us to understand where we need to set a boundary, rest, or realize we really don’t want to say yes to that added demand.

They can remind us of our energy limits and draw lines that help us have more room for joy, fun, and self-care. If we could honor these shadow traits as helpful protectors of ourselves, we could consider our happiness and balance equally as important as our patients’ happiness and balance. We could find ways to leave work on time to make it to that fun dance class, and we could empower our patients to have greater self-sufficiency. Often, when we are conflicted or tired, we can do well to ask ourselves, “What would a selfish bi#ch do?” The answer is usually what our being needs for balance, but we are too afraid to embrace our shadow to acknowledge our deeper needs and wants.

By ridding ourselves of the need to be seen as syrupy sweet (and utterly drained) and by embracing self-care that may look harsh or selfish to others, we can empower ourselves to have better boundaries. This can also help our patients as we model balanced caregiving, without self-sacrifice. By embracing and honoring these important traits of self-care, self-protection, and acknowledging our needs, we set the stage for less burnout and more healthy relationships in life. So, next time you are overwhelmed by the number of obligations you have or the time you are bleeding energy for others, ask yourself “What would my selfish bi#ch do?” And, if you manage to hear and honor her, high-five yourself as you strut to better self-care and integrated self-love.

Enter the course I co-wrote and teach with Jenna Ross - Boundaries, Self-Care, and Meditation Part 2. This course was born out of our own personal and professional struggles and our journey to having a life and a practice that we love and can sustain. This class provides a safe space to facilitate deep, personal, and professional transformation through evidence-based information and practices. Join us in Boundaries, Self-Care, and Meditation Part 2 on November 23 to learn new strategies to address both oneself and one's patients with a mind, body, and spirit approach.

AUTHOR BIO
Nari Clemons, PT, PRPC

Nari Clemons, PT, PRPC (she/her) has been teaching with the institute since 2004. She has written the following courses: Lumbar Nerve Manual Assessment /Treatment, as well as Sacral Nerve Manual Assessment/Treatment. She has co-authored the PF Series Capstone course with Allison Ariail and Jen Vande Vegte, and the Boundaries, Self Care, and Meditation Course (the burnout course) with Jen Vandevegte. In addition to teaching the classes she has authored, Nari also teaches all the other classes in the PF series: PF1, PF2A, PF2B, and Capstone. She was one of the question authors for the PRPC, and she has presented at many conferences, including CSM.

Nari’s passions include teaching students how to use their hands more receptively and precisely for advanced manual therapy skills while keeping it simple enough to feel successful. She also is an advocate for therapists learning how to feel well and thrive as they care for others, which is a skill that can be developed. “Basically, I love helping therapists learn to help themselves and others more while having a lot of fun doing it”. Nari lives in Portland Oregon, where she runs a local study/mentoring group and has a private practice, Portland Pelvic Therapy. Her interests include meditation, working out, nature, and being constantly humbled from raising her three amazing teenagers!

I have always enjoyed working with the peripartum population. However, the longer I worked in pelvic rehabilitation the more I heard the same story over and over when interviewing patients. For example, when working with a patient with urinary incontinence or prolapse, I would say: “when did this start” and some of my elderly patients would laugh and say “when Johnny was born” and I would say “how old is Johnny” they would reply “40!” Many of the pelvic patients I was treating had symptoms originating around the time of childbirth and they had been suffering for decades. So, I figured, let’s get to the root of the problem and focus on earlier intervention.    

What is the root of the problem? In my opinion, it is the lack of postpartum care. Pregnant patients are often inundated with birth education programs and information about pregnancy and childbirth. Additionally, there is a battery of prenatal visits, prenatal testing, and preparations for birth. All of which are wonderful to help prepare for birth. Conversely, the resources and guidance to help with physiological and musculoskeletal healing postpartum are lacking. Patients are counseled about serious signs and symptoms, but clear guidance to help to return to daily functional activities including recreation and exercise is often not provided. As musculoskeletal and exercises experts we are in a wonderful position to help patients reduce pain and improve function following the birth of a child.

Prior to 2018, the first post-partum checkup was six weeks following birth. Barring any severe problems, this was often the last contact with a medical provider for the parent. Patients were not provided specific guidance on how to return to daily activities, let alone higher-level activities such as running, exercising, and/or lifting weights.

In 2018, the American College of Obstetrics and Gynecology (ACOG) revised its guidelines, which now support earlier and more frequent postpartum visits. It is recommended that the first contact between patient and obstetric care provider occur in the first three weeks following birth and that subsequent visits are scheduled as needed in an ongoing fashion¹. This is important, as many consider the patient is still healing from birth up to 12 weeks (definitions vary). Depending on their knowledge and experience, a patient may not immediately realize they have a musculoskeletal problem. A new parent is busy adapting to their role as a care provider and may not be thinking about themselves. Additionally, they may not know what “normal” is for their body postpartum, including vaginal, abdominals, and/or bowel, and bladder functions. For example, the patient may be experiencing urinary incontinence (UI) which they “think” is normal postpartum, therefore, they may not bring it up to their provider. Patients often seek advice from family and friends who may even joke about peeing their pants when they sneeze or laugh or play with their children. Urinary incontinence is not ever “normal”, however, is it common in the postpartum period. Availability of vetted resources and a relationship with a healthcare provider are essential to cure these misconceptions.       

According to a systematic review, the prevalence of urinary incontinence is 33% at three months postpartum² and remains at 29% four years postpartum³. This means about one-third of women have urinary incontinence postpartum and remain that way without intervention. We also know the prevalence of urinary incontinence is strongly related to increasing age and underreported. This example highlights a common misconception: pelvic dysfunction is a normal part of the after-birth stage. However, with intervention, these problems can be alleviated, and we can improve the quality of life for these patients. 

According to the American College of Physicians (ACP) clinical practice guidelines for non-surgical management of UI there is high-quality evidence that strongly recommends pelvic floor muscle training as the first-line treatment for stress incontinence.⁴

So why isn’t pelvic assessment and rehabilitation recommended for all people who birth in our country? In several European countries, pelvic rehab is standard postpartum care for anyone who births. Over the last two decades, I do see more postpartum patients referred for rehabilitation for their musculoskeletal impairments. However, I still think we need more skilled providers assisting these patients and spreading the word about the interventions rehabilitation professionals provide. These can range from common orthopedic complaints (e.g neck or back pain from repetitive baby care) to specific bladder and/or bowel dysfunction, such as leakage and/or constipation, abdominal separation (Diastasis Rectus Abdominus-DRA), prolapse, pelvic pain, perineal tearing, and/or pain with intercourse.    

When developing this four-course postpartum series, I wanted rehabilitation providers to have more advanced skills to provide examination and treatment to this special population. This includes techniques to assess and treat the abdominals and pelvis, as these areas are physiologically impacted by pregnancy and birth over a relatively short amount of time. To effectively treat this population, one needs to be familiar with physiological changes from pregnancy, and stages of labor and birth to understand the journey of your patient. There is so much we can do to help these patients over a range of complaints, from acute breast and perineal care to DRA and pelvic dysfunctions.  As with any special population, postpartum patients have unique red flags and concerns to monitor, and due to our more frequent patient contact, it is imperative to be proficient in screening for these conditions. These topics and more are included in the course series. 

I am grateful and appreciative of this collaboration between Herman & Wallace and Medbridge to provide a platform for clinicians to progress their knowledge. Hopefully, this improves access to postpartum care and increases referrals for rehabilitation services to improve the function and quality of life for parents. Together we can reduce chronic impairments stemming from the childbirth period.

Resources:

1. Accessed on 5/9/2022: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/05/optimizing-postpartum-care
2. Thom, D. H., & Rortveit, G. (2010). Prevalence of postpartum urinary incontinence: a systematic review. Acta obstetricia et gynecologica Scandinavica, 89(12), 1511-1522.
3. Gartland, D., MacArthur, C., Woolhouse, H., McDonald, E., & Brown, S. J. (2016). Frequency, severity and risk factors for urinary and faecal incontinence at 4 years postpartum: a prospective cohort. BJOG: An International Journal of Obstetrics & Gynaecology, 123(7), 1203-1211.

4. Qaseem, A., Dallas, P., Forciea, M. A., Starkey, M., Denberg, T. D., Shekelle, P., & Clinical Guidelines Committee of the American College of Physicians*. (2014). Nonsurgical management of urinary incontinence in women: a clinical practice guideline from the American College of Physicians. Annals of internal medicine, 161(6), 429-440.

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