Individualized pelvic floor rehabilitation training on psychological and functional recovery in postpartum women with generalized anxiety disorder

Abstract

BACKGROUND

Postpartum women are at an increased risk of generalized anxiety disorder (GAD), which can negatively affect both mental health and physical recovery. Pelvic floor dysfunction, common in this population, can exacerbate psychological distress. Although pelvic floor rehabilitation is effective in physical recovery, its potential to improve psychological outcomes, especially in women with GAD, remains underexplored.

AIM

To evaluate the effectiveness of an individualized pelvic floor rehabilitation program in improving anxiety, pelvic floor function, and quality of life in postpartum women with GAD.

METHODS

A retrospective study was performed to analyze 80 postpartum women with GAD who completed a 12-week individualized pelvic floor rehabilitation program (January 2020-December 2024), combining supervised pelvic floor muscle training and psychological support. Primary outcomes were changes in GAD-7 and Hamilton anxiety rating scale (HAM-A) scores and pelvic floor function measured by surface electromyography (sEMG). Secondary outcomes included World Health Organization quality of life-BREF, pelvic floor symptom severity, and impact on daily activities (pelvic floor impact questionnaire). Assessments were conducted at baseline and 6 and 12 weeks during the intervention period.

RESULTS

Significant improvements were observed in anxiety measures, with mean GAD-7 scores decreasing from 14.8 ± 3.2 at baseline to 8.2 ± 2.9 at week 12 (P < 0.001) and HAM-A scores decreasing from 22.6 ± 4.5 to 12.4 ± 3.8 (P < 0.001). Pelvic floor function showed substantial enhancement, with sEMG amplitude increasing from 22.4 ± 5.6 µV to 35.9 ± 6.8 µV (P < 0.001). Quality of life improved across all domains, with the most significant improvements in psychological (28.5% increase) and physical health (25.8% increase). Program adherence was 91.5% for the supervised sessions, and no serious adverse events were reported.

CONCLUSION

Individualized pelvic floor rehabilitation training effectively improves both psychological and functional outcomes in postpartum women with GAD. The high adherence and significant outcomes make this integrated approach feasible and effective.

Key Words: Generalized anxiety disorder; Pelvic floor rehabilitation; Postpartum care; Physical therapy; Mental health

Core Tip: Individualized pelvic floor rehabilitation combining muscle training and psychological support improved anxiety symptoms significantly and pelvic floor function in postpartum women with generalized anxiety disorders (GAD). This integrated approach led to notable gains in mental health, physical recovery, and quality of life, with high program adherence and no serious adverse events. These findings suggest that a combination of physical and psychological interventions offers a comprehensive and effective treatment option for postpartum GAD.

INTRODUCTION

Generalized anxiety disorder (GAD) represents a significant mental health challenge in the postpartum period, affecting approximately 8.5%-10.5% of women during the first year after childbirth[1]. This prevalence is notably higher than that in the general population, suggesting a unique vulnerability during the postpartum period[2]. The interconnection between psychological well-being and physical recovery in the postpartum period has gained increasing attention in recent years, particularly concerning the role of pelvic floor dysfunction and its potential impact on mental health outcomes[3].

Postpartum anxiety, particularly GAD, manifests as excessive and persistent worry, physical tension, and autonomic hyperarousal, which can significantly affect both maternal well-being and infant care[4]. Recent studies have highlighted the bidirectional relationship between psychological distress and physical recovery during the postpartum period, with pelvic floor dysfunction emerging as a crucial factor in this complex interaction[5]. Studies have demonstrated that up to 65% of women with postpartum anxiety also report symptoms of pelvic floor dysfunction, suggesting a potential mechanistic link between these conditions[6].

The pelvic floor, which comprises muscles, ligaments, and connective tissues, plays a vital role in postpartum recovery and overall physical function[7]. Emerging evidence suggests that pelvic floor dysfunction may contribute to increased anxiety through multiple pathways, including altered body awareness, decreased confidence in physical function, and an impact on daily activities[8]. Contemporary research indicates that the relationship between pelvic floor function and anxiety may be mediated by the autonomic nervous system, highlighting the potential therapeutic value of targeted pelvic floor interventions[9].

Traditional approaches to managing postpartum GAD have primarily focused on pharmacological and psychological therapies[10]. However, recent evidence suggests that integrated approaches, including physical rehabilitation, may offer additional benefits[11]. Pelvic floor rehabilitation, traditionally used to address physical symptoms, has shown promising results in improving both physical and psychological outcomes in postpartum women[12]. The integration of individualized pelvic floor rehabilitation programs has emerged as a potential therapeutic approach to address both the physical and psychological aspects of postpartum recovery[13].

Recent systematic reviews have highlighted the importance of personalized intervention strategies in postpartum care, particularly for women with concurrent mental health conditions[14]. Individualized pelvic floor rehabilitation programs that consider specific patient needs, physical conditions, and psychological states have demonstrated superior outcomes compared with standardized approaches[15]. The incorporation of biofeedback, targeted exercises, and progressive training protocols has shown promise in addressing both physical dysfunction and psychological distress[16].

Despite these advances, a significant gap remains in understanding the specific effects of individualized pelvic floor rehabilitation on psychological outcomes in postpartum women with GAD. Although previous studies have examined pelvic floor rehabilitation and psychological interventions separately, few have investigated the combined impact of these approaches, particularly in the context of individualized treatment programs[17]. Furthermore, the long-term effects of these interventions on physical and psychological recovery are poorly understood[18].

This retrospective analysis evaluated the effectiveness of individualized pelvic floor rehabilitation training for the psychological and functional recovery of postpartum women diagnosed with GAD. This study aimed to provide insights into the potential therapeutic benefits of integrated physical and psychological care approaches for this vulnerable population by analyzing data from 80 cases between 2020 and 2024.

MATERIALS AND METHODS

Study design and setting

This retrospective analysis was conducted at the Department of Ultrasound Obstetrics and Gynecology of the Second Hospital of Hebei Medical University in collaboration with the Department of Psychiatry. This study analyzed data collected between January 2020 and December 2024. The institutional review board approved this study, and written informed consent was obtained from all participants to use their clinical data.

Participant selection

This study focused on postpartum women diagnosed with GAD who underwent individualized pelvic floor rehabilitation training. Patient records were screened according to predetermined criteria. The inclusion criteria were as follows: (1) Women aged 18-45 years who had given birth within the previous 12 months; (2) Clinical diagnosis of GAD according to the DSM-5 criteria; (3) Completion of at least 12 weeks of individualized pelvic floor rehabilitation; and (4) Availability of complete medical records, including psychological assessments. The exclusion criteria were as follows: (1) The presence of severe psychiatric comorbidities requiring intensive psychiatric care; (2) A history of pelvic floor surgery; (3) Ongoing pelvic inflammatory conditions, and (4) Inability to complete the rehabilitation program due to medical complications.

Assessment protocol

Initial assessments were conducted by a multidisciplinary team of gynecologists, physiotherapists, and mental health professionals. The GAD-7 scale was used to assess anxiety, with scores ranging from 0 to 21; higher scores indicate greater anxiety severity. The Hamilton anxiety rating scale (HAM-A) was used as a clinician-rated measure of anxiety. Quality of life was evaluated using the World Health Organization quality of life-BREF (WHOQOL-BREF) questionnaire.

The pelvic floor function assessment incorporated both subjective and objective measures. Using the Modified Oxford Scale, a digital pelvic examination was performed to evaluate muscle strength. Surface electromyography (sEMG) provided objective measurements of pelvic floor muscle activity. The pelvic floor distress inventory (PFDI-20) and pelvic floor impact questionnaire (PFIQ-7) were administered to assess symptom severity and their impact on quality of life. All assessments were conducted at baseline and 6 and 12 weeks during the intervention period.

Intervention protocol

An individualized pelvic floor rehabilitation program was designed based on a comprehensive initial assessment. Each participant received a personalized treatment plan that integrated physical rehabilitation with psychological support. The core components of the rehabilitation program consisted of supervised pelvic floor muscle training sessions conducted twice a week, supplemented by a home exercise program. Training sessions were conducted by certified pelvic floor physiotherapists who had received additional training in managing patients with anxiety disorders.

The rehabilitation protocol included progressive muscle training, biofeedback therapy, and relaxation techniques. Biofeedback sessions utilized real-time sEMG to provide visual feedback on muscle activity, facilitating proper muscle recruitment and relaxation patterns. The intensity and progression of the exercises were modified based on individual progress and psychological state. Each supervised session lasted 45-60 minutes, including 15 minutes of psychological support and anxiety management techniques.

Home exercise programs were prescribed and modified individually throughout the intervention period. The participants received detailed written instructions and were taught the proper techniques during supervised sessions. Compliance with home exercises was monitored using exercise diaries and regular follow-up discussions.

Psychological support was integrated into the rehabilitation process. The participants received education about the relationship between physical symptoms and anxiety, along with strategies for managing anxiety during daily activities. Regular communication between physiotherapists and mental health professionals ensured coordinated care delivery and appropriate modification of treatment plans when necessary.

Data collection and outcome measures

The primary outcome measures included changes in GAD-7 and HAM-A scores, reflecting psychological improvement, and changes in pelvic floor function, as measured by sEMG and clinical examination. Secondary outcomes encompassed quality of life scores (WHOQOL-BREF), PFDI-20, and impact on daily activities (PFIQ-7).

Demographic data, obstetric history, and medical information were extracted from the medical records. Treatment adherence was documented through attendance records for supervised sessions and completion rates of home exercise diaries. Adverse events and reasons for discontinuation were systematically recorded during the intervention period.

Statistical analysis

All statistical analyses were performed using SPSS version 26.0 (IBM Corp., Armonk, NY, United States). The normality of data distribution was assessed using the Shapiro-Wilk test. Continuous variables are expressed as the mean and standard deviation or median and interquartile range, as appropriate. Categorical variables are presented as frequencies and percentages.

Changes in the outcome measures over time were analyzed using repeated-measures analysis of variance (ANOVA) or Friedman’s test, depending on the data distribution. Post-hoc analyses with Bonferroni corrections were conducted for significant findings. The relationships between changes in psychological measures and pelvic floor function were examined using Pearson’s or Spearman’s correlation coefficients as appropriate. Multiple regression analysis was performed to identify the predictors of treatment response, with adjustments for potential confounding variables, including age, parity, and time since delivery.

Statistical significance was set at P < 0.05. All analyses were conducted using two-tailed tests. Missing data were handled using multiple imputation techniques to minimize bias. Sensitivity analysis was performed to assess the robustness of the findings.

RESULTS

Participant characteristics

Among 112 eligible postpartum women initially screened, 80 met the inclusion criteria and completed the 12-week intervention program. The mean age of participants was 31.4 ± 4.8 years, with a median time of 4.2 (IQR: 2.8-6.5) months since delivery. Most participants (65.0%) had vaginal deliveries, and 57.5% were primiparous. The detailed demographic and clinical characteristics are presented in Table 1.

Table 1 Baseline demographic and clinical characteristics of study participants (n = 80).

Characteristic	Value
Age (years)
mean ± SD	31.4 ± 4.8
Range	22-42
BMI (kg/m²)
mean ± SD	24.6 ± 3.2
Range	19.2-31.5
Time since delivery (months)
Median (IQR)	4.2 (2.8-6.5)
Range	1.5-11.0
Mode of delivery, n (%)
Vaginal delivery	52 (65.0)
Spontaneous	38 (47.5)
Instrumental	14 (17.5)
Cesarean section	28 (35.0)
Elective	16 (20.0)
Emergency	12 (15.0)
Parity, n (%)
Primiparous	46 (57.5)
Multiparous	34 (42.5)
Educational level, n (%)
Secondary education	18 (22.5)
Tertiary education	62 (77.5)
Employment status, n (%)
Employed	58 (72.5)
Unemployed	22 (27.5)
Marital status, n (%)
Married/partnered	75 (93.8)
Single/separated	5 (6.2)
Baseline anxiety measures
GAD-7 score, mean ± SD	14.8 ± 3.2
HAM-A score, mean ± SD	22.6 ± 4.5
Baseline pelvic floor assessment
Modified Oxford Scale score, median (IQR)	2 (2-3)
sEMG amplitude (µV), mean ± SD	22.4 ± 5.6
PFDI-20 score, mean ± SD	85.4 ± 22.3
Concurrent treatments, n (%)
Psychological counseling	32 (40.0)
Anxiolytic medication	18 (22.5)
Previous pelvic floor therapy	12 (15.0)

PFDI-20: Pelvic floor distress inventory; GAD-7: Generalized anxiety disorder-7 scale; BMI: Body mass index; HAM-A: Hamilton anxiety rating scale.

The participant retention rate was 92.0%, with seven participants withdrawing from the study for relocation (n = 3), time constraints (n = 2), and personal reasons (n = 2). No serious adverse events occurred during the study period. Minor discomfort was reported by five participants (6.25%) during the initial weeks of training, which was resolved with program modifications.

Psychological outcomes

Significant improvements in anxiety were observed throughout the intervention period. The mean GAD-7 score decreased progressively from baseline (14.8 ± 3.2) to week 6 (11.3 ± 3.0) and week 12 (8.2 ± 2.9) (P < 0.001). A similar trend was observed in HAM-A scores, which decreased from 22.6 ± 4.5 at baseline to 17.2 ± 4.1 at week 6, and further decreased to 12.4 ± 3.8 at week 12 (P < 0.001). The trajectory of the anxiety scores is illustrated in Figure 1. This figure illustrates the progressive reduction in anxiety scores, as measured by both the GAD-7 and HAM-A scales, during the 12-week individualized pelvic floor rehabilitation program. The most substantial improvements were observed during the first six weeks, with continued but more gradual improvements in the latter six weeks.

Figure 1 Changes in generalized anxiety disorder-7 scale and Hamilton anxiety rating scale scores over the 12-week intervention period. GAD-7: Generalized anxiety disorder-7 scale; HAM-A: Hamilton anxiety rating scale.

Post-hoc analysis revealed that improvements were most pronounced during the first six weeks of intervention (P < 0.001), with continued but more gradual improvements in the latter six weeks (P = 0.003). Clinically significant improvement, defined as a ≥ 50% reduction in GAD-7 scores from baseline, was observed in 67.5% of participants (n = 54) by week 12.

Pelvic floor function outcomes

Objective measurements of pelvic floor function showed progressive improvement throughout the intervention period (Table 2). Surface EMG amplitude increased significantly from baseline (22.4 ± 5.6 µV) to week 12 (35.9 ± 6.8 µV) (P < 0.001). Maximum contraction duration improved from 4.2 ± 1.8 seconds at baseline to 8.9 ± 2.3 seconds at week 12 (P < 0.001). Modified Oxford Scale scores showed significant improvement, with median scores increasing from 2 (IQR: 2-3) at baseline to 4 (IQR: 3-4) at week 12 (P < 0.001).

Table 2 Changes in physical and psychological outcomes over the 12-week intervention period.

Outcome measure	Baseline	Week 6	Week 12	Mean change (95%CI)	P value
Anxiety measures
GAD-7 score	14.8 ± 3.2	11.3 ± 3.0	8.2 ± 2.9	-6.6 (-7.2 to -6.0)	< 0.001
HAM-A score	22.6 ± 4.5	17.2 ± 4.1	12.4 ± 3.8	-10.2 (-11.1 to -9.3)	< 0.001
Pelvic floor function
sEMG amplitude (µV)	22.4 ± 5.6	28.7 ± 6.2	35.9 ± 6.8	13.5 (12.2 to 14.8)	< 0.001
Contraction duration (s)	4.2 ± 1.8	6.8 ± 2.1	8.9 ± 2.3	4.7 (4.2 to 5.2)	< 0.001
Modified Oxford Scale score1	2 (2-3)	3 (3-4)	4 (3-4)	-	< 0.001
Clinical assessments
PFDI-20 score	85.4 ± 22.3	62.8 ± 20.1	42.6 ± 18.4	-42.8 (-47.3 to -38.3)	< 0.001
PFIQ-7 score	68.9 ± 19.8	48.5 ± 17.2	32.4 ± 15.6	-36.5 (-40.4 to -32.6)	< 0.001
Quality of life (WHOQOL-BREF)
Physical health	45.2 ± 8.4	58.6 ± 9.2	71.0 ± 10.1	25.8 (23.5 to 28.1)	< 0.001
Psychological health	42.8 ± 7.9	57.2 ± 8.8	71.3 ± 9.8	28.5 (26.2 to 30.8)	< 0.001
Social relationships	48.5 ± 9.1	58.9 ± 9.5	67.2 ± 10.2	18.7 (16.4 to 21.0)	< 0.001
Environmental	52.3 ± 8.8	60.1 ± 9.3	67.7 ± 9.9	15.4 (13.1 to 17.7)	< 0.001

¹Modified Oxford Scale score presented as median (IQR).

Other values are presented as the mean ± SD. GAD-7: Generalized anxiety disorder-7 scale; HAM-A: Hamilton anxiety rating scale; PFDI-20: Pelvic floor distress inventory; PFIQ-7: Pelvic floor impact questionnaire; WHOQOL-BREF: World Health Organization quality of life-BREF questionnaire; sEMG: Surface electromyography.

Symptom severity, as measured by PFDI-20, showed substantial improvement, with mean scores decreasing from 85.4 ± 22.3 at baseline to 42.6 ± 18.4 at week 12 (P < 0.001). Similarly, PFIQ-7 scores improved significantly from 68.9 ± 19.8 to 32.4 ± 15.6 (P < 0.001), indicating reduced impact of pelvic floor symptoms on daily activities.

Quality of life and functional outcomes

WHOQOL-BREF scores significantly improved across all domains. The most substantial improvements were observed in psychological health (mean increase of 28.5%, P < 0.001) and physical health domains (mean increase of 25.8%, P < 0.001). The social relationships and environmental domains showed moderate improvements (mean increases: 18.7% and 15.4%, respectively; P < 0.001).

Correlation analysis revealed significant associations between improvements in pelvic floor function and a reduction in anxiety scores. Changes in sEMG amplitude showed moderate correlations with reductions in GAD-7 (r = -0.58, P < 0.001) and HAM-A scores (r = -0.62, P < 0.001). Similar correlations were observed between improvements in PFDI-20 scores and reductions in anxiety measures (GAD-7: r = 0.55, P < 0.001; HAM-A: r = 0.59, P < 0.001).

Treatment adherence and patient satisfaction

Adherence to supervised training sessions was high, with a mean attendance rate of 91.5%. Home exercise compliance, assessed through exercise diaries, showed that 72.5% of participants completed ≥ 80% of the prescribed home exercises. Patient satisfaction surveys indicated high satisfaction with the program, with 85% of participants rating their experience as "very satisfied" or "extremely satisfied". The most frequently reported benefits include improved confidence in physical function (88.7%), reduced anxiety during daily activities (82.5%), and enhanced overall well-being (79.8%).

DISCUSSION

This retrospective analysis demonstrated that individualized pelvic floor rehabilitation training significantly improved psychological and functional outcomes in postpartum women with GAD. The observed reduction in anxiety symptoms, coupled with enhanced pelvic floor function and quality of life, supports the potential therapeutic value of integrated physical and psychological interventions in this population.

The substantial improvement in anxiety symptoms, evidenced by significant reductions in both GAD-7 and HAM-A scores, aligns with recent research suggesting an interconnection between physical rehabilitation and psychological well-being in the postpartum period[19]. The observed 44.6% reduction in GAD-7 scores by week 12 exceeded the typical response rates of 35%-40% reported for conventional psychological interventions for postpartum anxiety[20]. This enhanced therapeutic effect may be attributed to the multimodal nature of the intervention, which addressed both physical and psychological aspects of postpartum recovery[21].

The improvement in the pelvic floor function parameters demonstrated the physiological effectiveness of the individualized rehabilitation program. The significant increase in sEMG amplitude and contraction duration aligns with the findings of recent studies on pelvic floor rehabilitation in postpartum women[22]. However, the current study extends these findings by demonstrating a correlation between improved pelvic floor function and reduced anxiety. This relationship may be explained by the emerging understanding of bidirectional communication between the pelvic floor and the autonomic nervous system[23]. Recent neuroimaging studies have shown that pelvic floor muscle activity can modulate activity in brain regions associated with emotional regulation and anxiety[24].

The observed improvements in quality of life across all WHOQOL-BREF domains suggest comprehensive benefits beyond symptom reduction. The most substantial improvements in the psychological and physical domains (28.5% and 25.8%, respectively) are noteworthy as they exceed the minimally important clinical differences established in previous studies[25]. These findings support recent research indicating that integrated physical and psychological interventions may offer superior outcomes compared to single-modality approaches in postpartum care[26].

The high adherence rates observed in this study (91.5% for supervised sessions) contrast favorably with the typical adherence rates of 65%-75% reported in standard postpartum rehabilitation programs[27]. This enhanced engagement may be attributed to the individualized nature of the intervention and the integration of psychological support throughout the program[28]. Recent meta-analyses have underscored the importance of high adherence rates, demonstrating a strong correlation between treatment adherence and outcomes of both physical rehabilitation and psychological interventions[29].

The significant correlation between improvements in pelvic floor function and reductions in anxiety scores provides new insights into the potential mechanisms underlying the effectiveness of this integrated approach. These findings align with the emerging concept of body-mind integration in postpartum care, suggesting that physical rehabilitation may serve as a gateway to psychological well-being[30]. Recent neurobiological research has demonstrated that improved physical function can enhance emotional regulation through multiple pathways, including reducing inflammatory markers and enhancing autonomic balance[31].

The absence of serious adverse events and the low rate of minor discomfort (6.25%) supported this population’s individualized floor rehabilitation safety profile. This safety profile is particularly important, given the heightened anxiety levels in this patient group and the potential for physical interventions to exacerbate psychological symptoms if not appropriately tailored. The successful resolution of minor discomfort through program modification emphasizes the importance of individualization in treatment delivery[32].

The patient satisfaction rates in this study (85% reporting high satisfaction) are particularly meaningful, given the complex nature of postpartum recovery in women with GAD. The high satisfaction levels may be attributed to the comprehensive nature of the intervention, which addressed physical and psychological needs[33]. Recent qualitative research highlights the importance of integrated approaches in meeting the diverse needs of postpartum women with mental health conditions[34].

The improvement in functional outcomes, as measured by the PFDI-20 and PFIQ-7, suggests that the benefits of the intervention extend to activities of daily living and social functioning. This finding is particularly relevant, given the known impact of both pelvic floor dysfunction and anxiety on postpartum women’s ability to engage in regular activities and social interactions[35]. The observed improvements in these measures align with recent research emphasizing the importance of functional outcomes in postpartum rehabilitation[36]. It is important to acknowledge the inherent limitations of the retrospective study design. A potential selection bias may exist, as participants who completed the 12-week program might differ systematically from those who did not engage in or complete the intervention.

Furthermore, information bias could be present because of the reliance on medical records and retrospective assessment of outcomes. We attempted to minimize these biases through strict inclusion criteria, standardized assessment protocols, and the use of validated measures. However, future prospective studies with randomized designs would be valuable in confirming our findings while controlling for potential confounding factors and selection biases.

Several distinctions should be noted when comparing our intervention approach with previous studies examining pelvic floor rehabilitation’s impact on psychological outcomes. Unlike the studies by Woodley et al[3] and Hadizadeh-Talasaz et al[5], which primarily focused on standard pelvic floor exercises without psychological components, our intervention specifically integrated anxiety-management techniques and psychological support. Additionally, while VanWiel et al[8] examined the association between pelvic floor dysfunction and mental health outcomes, they did not implement an intervention combining both physical and psychological elements, as our study did. These distinctions highlight the unique contribution of our integrated approach to the existing literature.

CONCLUSION

This study demonstrates that individualized pelvic floor rehabilitation training offers significant psychological and functional benefits to postpartum women with GAD. The intervention, which integrated physical rehabilitation with psychological support, effectively reduced anxiety symptoms, improved pelvic floor function, and enhanced overall quality of life. The high adherence and patient satisfaction rates further underscore the effectiveness and feasibility of this approach. These findings highlight the importance of body-mind integration in postpartum care, suggesting that individualized multimodal interventions can provide superior outcomes compared to traditional single-modality treatments.

Despite these promising results, we acknowledge the limitations of this retrospective study. Future research should include prospective randomized controlled trials to validate long-term outcomes and explore differential responses in various subgroups, such as women who delivered vaginally and those who underwent cesarean section. Such studies would further strengthen the evidence for this promising integrated approach to postpartum care for women with GAD.