chapter 14 therapeutic exercise in obstetrics

Chapter 14Therapeutic Exercise in

Obstetrics

Why Therapeutic Exercise for Pregnant Women?

Primary conditions unrelated to pregnancy

Disorders related to physiologic changes during pregnancy

Physical and psychological benefits

Preventative measures

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.

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).

Therapeutic Exercise Intervention for Wellness

Moderate aerobic exercise (carefully monitored and prescribed) is safe and beneficial for the

mother and fetus.

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.

Activities to Avoid

Horseback ridingSnow and water

skiingSnow boardingIce skating

DivingBungee jumpingHeavy weight liftingHigh-resistance

activities

Therapeutic Exercise for Common Impairments

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).

Impaired Muscle Performance

Abdominal Strength

Goal – Improve muscle balance, posture, support of uterus via pelvic floor, stabilization of trunk

and pelvis via lumbopelvic core.

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.

Quadruped Abdominal Exercise

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.

Impaired Joint Integrity and Muscle Length

Joint Hypermobility

Greater degree of joint laxity throughout the body during

pregnancy.

Abdominal Muscle Length

External/internal oblique, transversus abdominis, rectus abdominis – all lengthen.

Rectus muscles separate in midline, creating diastasis recti.

Diastasis Recti

Corrective Exercise

1. Patient manually approximates recti muscles toward midline.

2. Performs a posterior pelvic tilt.

3. Slowly exhale while lifting head.

Correction of Diastasis Recti

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.

Impaired PostureBiomechanical 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.

PainCauses 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

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.

Therapeutic Exercise Considerations

Improve circulationPromote relaxationAvoid increased intra-abdominal pressure by

minimizing abdominal contractions during exercise and ADLs.

Prevent decreased muscle tone and deconditioning.

Prevent neuromuscular discomfort.

Therapeutic Exercise Intervention for Common Impairments

Nerve Compressive Syndromes

Common during pregnancy due to:• Fluid retention• Edema• Soft tissue laxity• Exaggerated postural changes

Common Nerve Compression Syndromes

Intercostal neuralgiaThoracic outlet syndromeCarpal tunnel syndromeLateral femoral cutaneous nerve entrapmentTarsal tunnel syndromePeroneal nerve compression

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.

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.

Carpal Tunnel Syndrome

1. Decrease hand flexion activities.

2. Night splints.

3. Finger mobility exercises.

4. Look at scapula position and correct scapula depression.

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).

Tarsal Tunnel Syndrome

1. Elevation of foot and ankle.

2. Active foot and ankle exercises to reduce edema and compression.

3. Evening posterior splint.

Peroneal Nerve Compression

Discourage prolonged squatting during

exercise and delivery.

Other Impairments

Temporomandibular dysfunctionPatellofemoral dysfunctionJoint discomfort or dysfunctionVaricosis

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.

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.

chapter 14 therapeutic exercise in obstetrics

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