Copyright 2005 Lippincott Williams & Wilkins Chapter 14 Therapeutic Exercise in Obstetrics

Copyright 2005 Lippincott Williams & Wilkins Why Therapeutic Exercise for Pregnant Women?  Primary conditions unrelated to pregnancy  Disorders related to physiologic changes during pregnancy  Physical and psychological benefits  Preventative measures

Copyright 2005 Lippincott Williams & Wilkins Physiologic Changes Related to Pregnancy – Support Element Endocrine system – Alterations in hormone levels, GI function, etc. CV system – Changes in blood volume, hemoglobin levels, vasodilation. Respiratory system – Increased mucus in respiratory tract, predisposition to coughing, sneezing if pelvic floor and associated muscles are weak.

Copyright 2005 Lippincott Williams & Wilkins Physiologic Changes Related to Pregnancy Base Element Musculoskeletal symptoms should not be considered normal.  COG shifts forward and upward (lumbar lordosis, forward head posture, rounded shoulders, etc).  Changes in hormone – Joint laxity (increased foot pronation).

Copyright 2005 Lippincott Williams & Wilkins Therapeutic Exercise Intervention for Wellness Moderate aerobic exercise (carefully monitored and prescribed) is safe and beneficial for the mother and fetus.

Copyright 2005 Lippincott Williams & Wilkins Exercise Intensity Guidelines  In pregnancy, maternal resting HR is elevated over nonpregnant values by 15–20 bpm.  Mitral valve prolapse occurs more frequently during pregnancy and may be aggravated by heart rates above 140 bpm.  Therefore, reduce exercise intensity by 25% to 60–75% to be safe.  A maximum HR of 140 bpm for novice exercisers and 160 bpm for experienced exercisers.

Copyright 2005 Lippincott Williams & Wilkins Activities to Avoid  Horseback riding  Snow and water skiing  Snow boarding  Ice skating  Diving  Bungee jumping  Heavy weight lifting  High-resistance activities

Copyright 2005 Lippincott Williams & Wilkins Therapeutic Exercise for Common Impairments

Copyright 2005 Lippincott Williams & Wilkins Adjunctive Interventions Hot packs – Safe for back, neck,and extremities. Ultrasound – Sites away from uterus. Ice – Used on joint pain and inflammation. NMES/TENS – Contraindicated (except for TENS during labor and delivery).

Copyright 2005 Lippincott Williams & Wilkins Impaired Muscle Performance Abdominal Strength Goal – Improve muscle balance, posture, support of uterus via pelvic floor, stabilization of trunk and pelvis via lumbopelvic core.

Copyright 2005 Lippincott Williams & Wilkins Exercise Examples  Supine hip and knee flexion with hip abduction and lateral rotation.  Progressive heel slides.  External oblique exercises to counter anterior pelvic tilt in variety of positions.  Concentric and eccentric abdominal contractions in quadruped.

Copyright 2005 Lippincott Williams & Wilkins Quadruped Abdominal Exercise

Copyright 2005 Lippincott Williams & Wilkins Pelvic Floor Strength Importance cannot be overemphasized! Attention to pelvic floor strength should occur early in the pregnancy and continue throughout the duration and into postpartum.

Copyright 2005 Lippincott Williams & Wilkins Impaired Joint Integrity and Muscle Length Joint Hypermobility Greater degree of joint laxity throughout the body during pregnancy.

Copyright 2005 Lippincott Williams & Wilkins Abdominal Muscle Length  External/internal oblique, transversus abdominis, rectus abdominis – all lengthen.  Rectus muscles separate in midline, creating diastasis recti.

Copyright 2005 Lippincott Williams & Wilkins Diastasis Recti

Copyright 2005 Lippincott Williams & Wilkins Corrective Exercise 1.Patient manually approximates recti muscles toward midline. 2.Performs a posterior pelvic tilt. 3.Slowly exhale while lifting head.

Copyright 2005 Lippincott Williams & Wilkins Correction of Diastasis Recti

Copyright 2005 Lippincott Williams & Wilkins Pelvic Floor Muscle Length If coccyx pain is related to pelvic floor tension myalgia, pelvic floor relaxation must be emphasized. 1.Place hand over anal cleft. 2.Place middle finger in cleft and other fingers on buttocks. 3.Pretend to “pass gas” while feeling for cleft bulging out against middle finger.

Copyright 2005 Lippincott Williams & Wilkins Impaired Posture Biomechanical Element Restore ideal alignment 1.Lordosis intervention - Frequent inner core activation in various positions. 2.Wall abdominal isometrics. 3.Kyphosis intervention – Facilitate strengthening to scapular upward rotators, thoracic erector spinae, stretch pectoral muscles.

Copyright 2005 Lippincott Williams & Wilkins Pain Causes Include:  Biomechanical strain from increased body mass and dimension.  Postural changes such as lumbar lordosis creating joint stress.  Aggravation of preexisting conditions.  Muscle fatigue from overload, particularly pelvic floor. Pregnant Woman are particularly susceptible to:  Lumbar pain  Posterior pelvic pain  Nocturnal back pain

Copyright 2005 Lippincott Williams & Wilkins High Risk Antepartum  20% of all pregnancies include bedrest prescription.  Woman who delay childbearing may expect a higher incidence of obstetric complications resulting in bedrest.  General strengthening, circulation exercises, and relaxation exercises are indicated to prevent secondary conditions as a result of bedrest.

Copyright 2005 Lippincott Williams & Wilkins Therapeutic Exercise Considerations  Improve circulation  Promote relaxation  Avoid increased intra-abdominal pressure by minimizing abdominal contractions during exercise and ADLs.  Prevent decreased muscle tone and deconditioning.  Prevent neuromuscular discomfort.

Copyright 2005 Lippincott Williams & Wilkins Therapeutic Exercise Intervention for Common Impairments Nerve Compressive Syndromes Common during pregnancy due to: Fluid retention Edema Soft tissue laxity Exaggerated postural changes

Copyright 2005 Lippincott Williams & Wilkins Common Nerve Compression Syndromes  Intercostal neuralgia  Thoracic outlet syndrome  Carpal tunnel syndrome  Lateral femoral cutaneous nerve entrapment  Tarsal tunnel syndrome  Peroneal nerve compression

Copyright 2005 Lippincott Williams & Wilkins Intercostal Neuralgia  Described as intermittent pain in the rib cage or chest from flaring of the rib cage.  Intervention includes spinal elongation with arms overhead in supine, sitting, or standing postions, and trunk sidebending away from the pain.

Copyright 2005 Lippincott Williams & Wilkins Thoracic Outlet Syndrome 1.Strengthening of upper back and scapular muscles. 2.Lengthening of pectoral muscles. 3.Support can be provided through good brassieres and manufactured supportive devices.

Copyright 2005 Lippincott Williams & Wilkins Carpal Tunnel Syndrome 1.Decrease hand flexion activities. 2.Night splints. 3.Finger mobility exercises. 4.Look at scapula position and correct scapula depression.

Copyright 2005 Lippincott Williams & Wilkins Lateral Femoral Cutaneous Nerve Entrapment 1.Exercises to balance hip muscles. 2.Lying on side to draw uterus away from compressed side. 3.Soft tissue mobilization techniques for IT band. 4.Strengthening for underused synergists to ITB (e.g., posterior gluteus medius).

Copyright 2005 Lippincott Williams & Wilkins Tarsal Tunnel Syndrome 1.Elevation of foot and ankle. 2.Active foot and ankle exercises to reduce edema and compression. 3.Evening posterior splint.

Copyright 2005 Lippincott Williams & Wilkins Peroneal Nerve Compression Discourage prolonged squatting during exercise and delivery.

Copyright 2005 Lippincott Williams & Wilkins Other Impairments  Temporomandibular dysfunction  Patellofemoral dysfunction  Joint discomfort or dysfunction  Varicosis

Copyright 2005 Lippincott Williams & Wilkins Summary Many physiologic changes that occur during pregnancy affect a woman’s ability and motivation to exercise. Adherence to precautions, contraindications, guidelines, and a safe exercise program can be established for pregnant women. Exercise during pregnancy has many benefits including prevention or assistance in treatment of impairments.

Copyright 2005 Lippincott Williams & Wilkins Summary (cont.) Therapeutic exercise focuses on key postural muscles affected by changes during pregnancy. High risk pregnancy may require bedrest. Specific exercises may be performed and are beneficial for high-risk patients. Therapeutic exercise is beneficial postpartum, even after cesarean section.