1. EXERCISE FOR GIRLS & WOMEN

2. 1875: Hutchingson : Women have a sum total of nervous force equivalent to man Women have more organs Nervous force is weakened in each organ Resistance to disease is weakened Women are more sensitive and more liable to derangement 1875: Hutchingson : Women have a sum total of nervous force equivalent to man Women have more organs Nervous force is weakened in each organ Resistance to disease is weakened Women are more sensitive and more liable to derangement Historical Attitudes Towards Women

3. 1875 Dr. King, Obstetrics & Gynecology Women menstruate because of a failure to conceive Menstruate occurs because the organ was not used for it’s intended purpose When an organ is not used = atrophy & disease Therefore, once reaching puberty a woman should be encouraged to marry and immediately impregnated Continuously impregnated as not to menstruate

4. Beigel, Physician: 10-14 days of Bed Rest for Each Menstrual Cycle 10-14 days of Bed Rest for Each Menstrual Cycle

5. International Olympic Committee: Circa 1900 Women should not engage in any activity which they cannot wear a long dress

6. Heart Rate (/min) Seargent Heart Rate Response to Running 540 Yard Run Without Wearing Corsets

7. Fashion allowed more exercise

8. 1928 Modern Olympics 11 women First 800 m Race 11 women First 800 m Race 5 collapsed during the Run 5 collapsed at the Finish Winner collapsed in the Dressing Room 5 collapsed during the Run 5 collapsed at the Finish Winner collapsed in the Dressing Room

11. EXERCISE & GYNECOLOGY

12. AGE OF MENARCHE High School College Sport Ballet Olympic

13. MATURATION AND SPORT Does sport delay maturation? Is maturation unsuccessful for sport?

14. AGE OF MENARCHE High School College Sport Ballet Olympic

15. LATER AGE OF MENARCHE FEWER COMPAINTS IN MENOPAUSE Jazman, Frontiers of Hormone Research 2:22, 1973.

16. ….AS A YOUNG WOMAN… ….AS A YOUNG WOMAN…

17. AMENORRHEA EATING DISORDERS OSTEOPOROSIS FEMALE ATHLETE TRIAD

18. Percent of Athletes HS College Specific Sports INCIDENCE OF ANOREXIA & BULIMA

19. Percent of Population (%) General Athletes AMENORRHEA

20. Marcus eat al, Ann Int Med 102:158-163, 1985 Control Active Regular Cycling Active Amenorrhic OSTEOPOROSIS Incidence of Bone Fractures (%)

21. ACSM RECOMMENDATIONS 1.Serious Syndrome 2.Unrealistic pressures to lose weight in athletics. 3.Sports Medicine Professionals need more education 4.Screening programs should be developed. 5.Develop prevention strategies 6.Educate parents to have reasonable goals for children. 7.Educate the girls 8.More research. 1.Serious Syndrome 2.Unrealistic pressures to lose weight in athletics. 3.Sports Medicine Professionals need more education 4.Screening programs should be developed. 5.Develop prevention strategies 6.Educate parents to have reasonable goals for children. 7.Educate the girls 8.More research.

22. EXERCISE IN PREGNANCY

23. PREGNANCY EXERCISE SKELETAL METABOLISM RESPIRATORY CARDIOVASCULAR ENDOCRINE THERMOREGULATION SKELETAL METABOLISM RESPIRATORY CARDIOVASCULAR ENDOCRINE THERMOREGULATION

25. 1. Safe for mother? 2. Safe for fetus 3. Affect on pregnancy outcome? 1. Safe for mother? 2. Safe for fetus 3. Affect on pregnancy outcome? EXERCISE IN PREGNANCY

27. Weight (kg) Weeks of Gestation (wks) WEIGHT GAIN DURING PREGANACY

28. SKELETAL SYSTEM Lumbar Lordosis Forward displacement of the center of gravity Increased anterior flexion of cervical spine Forward rotation of Pelvis & Femur

29. PREGNANCY EXERCISE 1.Lumbar Lordosis 2.Cervical Spine 3.Pelvis & Femur 4.Center of Gravity 1.Lumbar Lordosis 2.Cervical Spine 3.Pelvis & Femur 4.Center of Gravity 1.Lumbrosacral Pain 2.Compression Syndromes 1.Carpal Tunnel 2.Ulnar Nerve 3.Posterior Tibial 4.Perennial 1.Lumbrosacral Pain 2.Compression Syndromes 1.Carpal Tunnel 2.Ulnar Nerve 3.Posterior Tibial 4.Perennial SKELETAL SYSTEM 5. Increased joint mobility 5. Overextension Injury

30. METABOLISM

31. PREGNANCY EXERCISE 1.Increased Resting Metabolism 1.80,000 cal 2.300 cal/day 1.Increased Resting Metabolism 1.80,000 cal 2.300 cal/day 1.Increased metabolism at submaximal work METABOLISM 2. Glucose = primary fuel 2. Hypoglycemia

32. RESPIRATORY SYSTEM RESPIRATORY SYSTEM 1.Chest cavity increases transverse diameter 2.Raised diaphragm 1.Chest cavity increases transverse diameter 2.Raised diaphragm

33. PULMONARY FUNCTIONS RV Tidal Vol. Exp Res Insp Res Volume (ml)

34. PREGNANCY EXERCISE 1.Pulmonary Functions 1.Increased tidal volume 2.Decreased Residual Vol 1.Increased tidal volume 2.Decreased Residual Vol RESPIRATORY SYSTEM 2. Metabolism & Pulmonary Functions 3. 40% increase in Resting Minute Ventilation (V E )

35. RESTING HEART RATE Heart Rate (/min) Gestation (wks) Wilson et al., Am J Med 68:97, 1980.

36. CARDIOVASCULAR SYSTEM Gestation (wks) Percent Increase (%) Blood Volume Cardiac Output

37. PREGNANCY EXERCISE 1.Cardiac Output 1.Heart Rate 2.Stroke Volume 1.Cardiac Output 1.Heart Rate 2.Stroke Volume 1.Decreased Physical Work Capacity 2.Increased Sub- maximal work 1.Heart Rate 2.Stroke Volume 3.Cardiac Output 1.Decreased Physical Work Capacity 2.Increased Sub- maximal work 1.Heart Rate 2.Stroke Volume 3.Cardiac Output CARDIOVASCULAR SYSTEM

38. Heart Rate (/min) Workrate (kpm/min)

39. CARDIOVASCULAR SYSTEM Stroke Volume (cc)

40. Workrate (kpm/min) CARDIOVASCULAR SYSTEM Cardiac Output (L/min)

41. Workrate (kpm/min) CARDIOVASCULAR SYSTEM C (a-v) O 2 (ml/L)

42. PHYSICAL WORK CAPACITY Lowest PWC in First Trimester Highest PWC in Second Trimester Decreases as Body Weight Increases in Third Trimester Lowest PWC in First Trimester Highest PWC in Second Trimester Decreases as Body Weight Increases in Third Trimester

43. ENDOCRINE SYSTEM Gestation (days) HCG Concentration (iu/1000ml urine)

44. PREGNANCY EXERCISE 1.Hormone Changes 1.Physical Work Capacity 2.Joint Injury 3.Gestational Diabetes 1.Physical Work Capacity 2.Joint Injury 3.Gestational Diabetes ENDOCRINE SYSTEM

45. PREGNANCY EXERCISE 1.Increased Sweat Gland Activity 2.Shunt blood to Periphery 3.Fetus >1 o C 1.Increased Sweat Gland Activity 2.Shunt blood to Periphery 3.Fetus >1 o C 1.Dehydration 2.Heat Related Injury 3.Spinal Cord Growth Retardation (1 st trimester) 1.Dehydration 2.Heat Related Injury 3.Spinal Cord Growth Retardation (1 st trimester) THERMOREGULATION

46. 1. Safe for mother? 2. Safe for fetus 3. Affect on pregnancy outcome? 1. Safe for mother? 2. Safe for fetus 3. Affect on pregnancy outcome? EXERCISE IN PREGNANCY

49. FOR THE MOTHER? Exercise Training during Pregnancy 1. Physical Work Capacity 1.Increases during pregnancy 2.Not above Pre-Pregnant Values 2.Lower Exercise Heart Rates* 1.At same workrate 3.Increased Heart Volume* 1. Physical Work Capacity 1.Increases during pregnancy 2.Not above Pre-Pregnant Values 2.Lower Exercise Heart Rates* 1.At same workrate 3.Increased Heart Volume* * Not all studies agree

50. FOR THE MOTHER? 1.Skinfold thickness 2.Maternal Weight Gain 3.Resting Heart Rate 4.Maximal Heart Rate 5.Exercising Heart Rates* 6.Cardiac Output at Submax 7.Stroke Volume at Submax 8.Resting & Orthostatic Blood Pressures 9.VO 2 at submax 10.Resting Metabolism 11.V E max 12.V E submax 1.Skinfold thickness 2.Maternal Weight Gain 3.Resting Heart Rate 4.Maximal Heart Rate 5.Exercising Heart Rates* 6.Cardiac Output at Submax 7.Stroke Volume at Submax 8.Resting & Orthostatic Blood Pressures 9.VO 2 at submax 10.Resting Metabolism 11.V E max 12.V E submax

51. FOR THE FETUS?

52. FETAL HEART RATES Deceleration>15 /minNormal response to mild or transient hypoxia Moderate 100-120/minInitial response to Bradycardiahypoxia Profound<100/minNormal response to Bradycardiaprolonged hypoxia Tachycardia>160/minCompensatory adaptation during hypoxic recovery Deceleration>15 /minNormal response to mild or transient hypoxia Moderate 100-120/minInitial response to Bradycardiahypoxia Profound<100/minNormal response to Bradycardiaprolonged hypoxia Tachycardia>160/minCompensatory adaptation during hypoxic recovery

53. FETAL HEART RATES 1.During Exercise 1.Slight Increase 2.Slight Decrease 3.No change 2.Recovery from Exercise 1.Slight Increase 2.Slight Decrease 3.No change 1.During Exercise 1.Slight Increase 2.Slight Decrease 3.No change 2.Recovery from Exercise 1.Slight Increase 2.Slight Decrease 3.No change

54. FETAL HEART RATES Hon & Wohlgemuth, Am J Obstet Gynecol 81:361-371, 1961. 6/40 Exercise Studies Bradycardia Irregularity Tachycardia 6/40 Exercise Studies Bradycardia Irregularity Tachycardia Cord tightly wrapped around neck (3x) Loop of umbilical cord prolapsed by head Flattened umbilical cord (4”) Fetal distress at birth Cord tightly wrapped around neck (3x) Loop of umbilical cord prolapsed by head Flattened umbilical cord (4”) Fetal distress at birth

55. UTERINE BLOOD FLOW Clearance Times (min) Morris, et al., Lancet 8 Sept 1956; pg 481-484 Human 26 normal 29 Pre-Ec Supine Ex Radioactive Na + Human 26 normal 29 Pre-Ec Supine Ex Radioactive Na +

56. UTERINE BLOOD FLOW Orr, et al., Am J Obstet Gynecol 114:213-217, 1972 Percent Change from Rest (%) 6 Pregnant 2 Non-Pregnant Flow of Uterine Artery 6 Pregnant 2 Non-Pregnant Flow of Uterine Artery

57. Percent of Uterine Blood Flow (%) Curet, et al., J Appl Physiol 40:725-728, 1976 3 mph 10% Exhaustion n=10 Cath 3 mph 10% Exhaustion n=10 Cath UTERINE BLOOD FLOW

58. P O2 (mmHg) Emmanouilides et al. Am J Obstet Gynecol 122:130-137, 1972

59. UTERINE BLOOD FLOW P CO2 (mmHg) Emmanouilides et al. Am J Obstet Gynecol 122:130-137, 1972

60. UTERINE BLOOD FLOW pH Emmanouilides et al. Am J Obstet Gynecol 122:130-137, 1972

61. FETAL GLUCOSE Soultanakis, et al., Seminars in Perinatology. 20(4):315-27, 1996 Glucose (mg/dl) Time (min)

62. FETAL TEMPERATURES Soultanakis, et al., Seminars in Perinatology. 20(4):315-27, 1996 Core Temperature (C o ) Time (min)

63. PREGNANCY OUTCOME 1.Stages of Labor 2.Complications of Labor & Delivery 3.Health of Infant 1.Stages of Labor 2.Complications of Labor & Delivery 3.Health of Infant

64. PREGNANCY OUTCOME STAGES OF LABOR 1.Progressive Cervical Dilation 8 to 24 hrs (same as head) 2.Head moves into birth canal1 – 30 min to birth 3.Passing of the Placenta 1.Progressive Cervical Dilation 8 to 24 hrs (same as head) 2.Head moves into birth canal1 – 30 min to birth 3.Passing of the Placenta

65. PREGNANCY OUTCOME STAGES OF LABOR 1.Duration of Labor 1.Primi- or Multi-parous 2.Mode of Delivery 3.Work of Labor & Delivery 1.Duration of Labor 1.Primi- or Multi-parous 2.Mode of Delivery 3.Work of Labor & Delivery

66. Complications of Labor & Delivery 1. Pre-Mature 2. Caesarean Section 3. Rupture 4. Perineotomy 5. Episiotomy 6. Forceps Delivery 1. Pre-Mature 2. Caesarean Section 3. Rupture 4. Perineotomy 5. Episiotomy 6. Forceps Delivery

67. PREGNANCY OUTCOME Health of Infant 1.Apgar Scores 2.Neonatal Complications 3.Infant Birth Weight 4.Infant Head Circumference 1.Apgar Scores 2.Neonatal Complications 3.Infant Birth Weight 4.Infant Head Circumference

68. APGAR SCORES 012 Heart RateAbsent 100 Respiratory AbsentWeakStrong Cry Effort Muscle ToneLimpSome FlFlex Extremities Reflex (feet) AbsentSomeCry Irritability Motion ColorBlueBody PinkCompletely Limbs blue Pink 012012 Heart RateAbsent 100 Respiratory AbsentWeakStrong Cry Effort Muscle ToneLimpSome FlFlex Extremities Reflex (feet) AbsentSomeCry Irritability Motion ColorBlueBody PinkCompletely Limbs blue Pink Perfect 10

70. Neonatal Complications 1.Asphyxiated Infants 2.Neonatal Morbidity 1.Asphyxiated Infants 2.Neonatal Morbidity

71. PREGNANCY OUTCOME Lamasze 276 Exercise 281 Control Lamasze 276 Exercise 281 Control Minutes Rodway et al. J Obstet Gynec Brt Comm 54:77-85, 1947.

72. BIRTH WEIGHT Naeye & Peters, Pediatrics 69:724-727, 1982. Infant Birth Weight (gms)

73. ATHLETIC TRAINING 729 athletes General population

74. ATHLETIC TRAINING Percent of Sample (%) n=64 n=59 n=27 Disturbances with Pregnancy Competing during Pregnancy Good Pregnancy Outcome Improved Performance after

75. EXERCISE IN PREGNANCY Not Unsafe for Mother or Fetus In moderation No Athletic Competition or Sport Not Unsafe for Mother or Fetus In moderation No Athletic Competition or Sport

76. 1.Physical conditioning during pregnancy results in no detrimental effect on pregnancy outcome. 2.Physical conditioning during pregnancy does not appear to result in the same physiological changes as physical conditioning in the non-pregnant state. 3.Continued athletic training during pregnancy may result in obstetric complications. 4.Athletic training, if discontinued during pregnancy results in no detrimental effects on pregnancy. 5.Pregnancy may improve athletic performance following pregnancy. 1.Continued occupational activity during the last weeks of pregnancy can result in lower infant birth weight which in some cases, is related to poorer infant health.

77. ABSOLUTE CONTRAINDICATIONS FOR EXERICSE IN PREGNANCY Heart Disease Restrictive lung disease Pregnancy induced hypertension Incompetent Cervix Multiple Gestation Hx: Placenta Previa Hx: Breech Presentation Hx: Ruptured Membranes Hx: Premature Labor Heart Disease Restrictive lung disease Pregnancy induced hypertension Incompetent Cervix Multiple Gestation Hx: Placenta Previa Hx: Breech Presentation Hx: Ruptured Membranes Hx: Premature Labor

78. RELATIVE CONTRAINDICATIONS FOR EXERICSE IN PREGNANCY Anemia Maternal cardiac arrhythmia Chronic bronchitis Extreme Morbid Obesity Extreme Underweight (BMI <12) Orthopedic limitations Heavy Smoker Poorly controlled Thyroid Disease Type 1 diabetes Hypertension/pre eclampsia Seizure disorder Anemia Maternal cardiac arrhythmia Chronic bronchitis Extreme Morbid Obesity Extreme Underweight (BMI <12) Orthopedic limitations Heavy Smoker Poorly controlled Thyroid Disease Type 1 diabetes Hypertension/pre eclampsia Seizure disorder

79. MODECV; non-wt bearing as weight increases Discontinue Athletic Training Flexibility for Muscle Soreness Muscle Endurance is OK FREQUENCY3-4/wk (resistance 2/wk) DURATION20-30 min up to 60 min INTENSITYModerate 50-85% (< Ventilatory threshold) Not guided by Heart Rates MODECV; non-wt bearing as weight increases Discontinue Athletic Training Flexibility for Muscle Soreness Muscle Endurance is OK FREQUENCY3-4/wk (resistance 2/wk) DURATION20-30 min up to 60 min INTENSITYModerate 50-85% (< Ventilatory threshold) Not guided by Heart Rates E X R X : Pregnancy

81. PRECAUTIONS 1.Thermoregulation 2. Injury 3. Supine Exercise (>4 months) 4. As pregnancy progresses 1. Move to non-weight bearing 2. Decrease intensity increase frequency PRECAUTIONS 1.Thermoregulation 2. Injury 3. Supine Exercise (>4 months) 4. As pregnancy progresses 1. Move to non-weight bearing 2. Decrease intensity increase frequency

82. E X R X : Pregnancy DISCONTINUE: 1. Pain or Bleeding 2. Dizziness or Faintness 3. Pubic Pain 4. Palpitations 5. Back Pain 6. Shortness of Breath 7. Difficulty Walking DISCONTINUE: 1. Pain or Bleeding 2. Dizziness or Faintness 3. Pubic Pain 4. Palpitations 5. Back Pain 6. Shortness of Breath 7. Difficulty Walking

83. EXERCISE IN POST-PARTUM

84. Beginning In 1974 Infants Refused to Nurse following Maternal Exercise 7% Beginning In 1974 Infants Refused to Nurse following Maternal Exercise 7%

85. Wallace & Rabin, Int J Sports Med 12:328-331, 1991 Lactic Acid (mM/L) Concentrations of Lactic Acid in Blood and Milk following Maximal Exercise

86. Wallace et al, J Women’s Health 3:91-96, 1994 Lactic Acid (mM/L) Concentrations of Lactic Acid in Milk following a Normal Workout & Maximal Exercise

87. SOUR MILK? PERCEPTION OF TASTE Accept Reject Lactic Acid Concentration

88. THE RELATIOSHIP BETWEEN TASTE AND LACTIC ACID CONENTRATIONS IN MOTHER’S MILK DetectRecognize

89. EXERCISE GUIDELINES FOR LACTATION Only for Women who have Problems 1.Nurse before Exercise 2.Collect Milk before Exercise 3.Discard first 30-60 min post exercise milk production 4.Exercise below Ventilatory Threshold 1.Nurse before Exercise 2.Collect Milk before Exercise 3.Discard first 30-60 min post exercise milk production 4.Exercise below Ventilatory Threshold

90. IN MENOPAUSE Increased Risk of Disease Heart Disease Hypertension Hyperlipidemia Breast Cancer Symptoms of Menopause Hot Flash Insomnia Fatigue Nervousness/Depression Increased Risk of Disease Heart Disease Hypertension Hyperlipidemia Breast Cancer Symptoms of Menopause Hot Flash Insomnia Fatigue Nervousness/Depression

91. STUDIES ON MENOPAUSAL SYMPTOMS Subjects 11 Pre 7 Peri- 11 Post Exercise Walk/Jog Swim Dance Aerobic Games 4/wk for 6 wks Moderate Subjects 11 Pre 7 Peri- 11 Post Exercise Walk/Jog Swim Dance Aerobic Games 4/wk for 6 wks Moderate Subjects 9 Post 4 Control Exercise Walk/Jog 3/wk for 12 wks Moderate Subjects 9 Post 4 Control Exercise Walk/Jog 3/wk for 12 wks Moderate Subjects 10 Post 10 Control Exercise Walk/Jog 3/wk for 12 wks Moderate Subjects 10 Post 10 Control Exercise Walk/Jog 3/wk for 12 wks Moderate PENN STATE SAN DIEGO STATE IU

92. Changes with Training (%) CHANGES IN POSTMENOPAUSAL SYMPTOMS WITH TRAIING

93. IN OLD AGE

95. IMMERSION EXERCISE McMurray, R.G., et al. American Journal of Obstetrics & Gynecology. 158(3 Pt 1):481-6, 1988 12 pregnant women 15, 25, 35 weeks 8-10 wks postpartum 20 min of immersion 30 o C 20 min of exercise @ 60% VO 2 max (bike) 20 min supine recovery 12 pregnant women 15, 25, 35 weeks 8-10 wks postpartum 20 min of immersion 30 o C 20 min of exercise @ 60% VO 2 max (bike) 20 min supine recovery

96. IMMERSION EXERCISE McMurray, R.G., et al., International Journal of Sports Medicine. 9(6):443-7, 1988 HR water <HR land Q water >Q postpartum PVR water <PVR postpartum Pregnancy has increased demand, yet water reduces those demands