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8/8/19

1

Practical Application of Ergonomic Principles: !

Preventing Musculoskeletal Disorders in New Mothers

Sara J. Loesche, MS, OTR/L, CHT August 8, 2019

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Learning Outcomes As a result of this course, participants will be able to: §  List physiological and psychological factors that make

mothers a ‘specialized population’ for occupational therapy intervention

§  List ergonomic risk factors present when postpartum mothers are performing childcare related tasks

§  Discuss a prevention and/or health promotion approach to caregiving for young infants/children and practical strategies for postpartum mothers to implement

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New Mothers – !A Special Population

AOTA,2014

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OT and Ergonomics § Return to work after an injury or illness or in the

presence of disability § Health promotion – assessments and interventions

to optimize function §  Injury prevention education § Consulting with employers and/or insurance

companies to keep workers’ comp costs low

4 AOTA, 2017

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OT and Maternal Health § Women are asking for more support and

information in the perinatal time period § Holistic perspective is needed § Health promotion model and/or prevention model

§  Serving the ‘well’ mom & baby population § Occupational therapy can fill this need § Various methods for delivering the information

§  Face-to-face, virtually, print education

Slootjes, McKinstry, & Kenny, 2016 5

Postpartum Care § Association of Maternal & Child

Health Programs §  “reimagine the postpartum visit

and improve postpartum care and wellness” p.S39.

§ Need for “mother-centered solutions” because we know that improving women’s health can improve maternal and infant health

§ Will mom seek help? 6 Cornell et al., 2016

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Physiological Risk Factors § Soft tissue edema §  Ligament laxity – relaxin & estrogen production § Weight gain (+ ligament laxity = joint discomfort) § Weakened core muscles: Abdominals, pelvic floor § Sleep deprivation § Shift in center of gravity § Emotional stress of new role (plus other roles)

7 Borg-Stein & Dugan, 2007; Robson, Iqbal & Howarth, 2009

Health Risks of Motherhood: !Slippery Slope

Postpartumstress

AnxietyFa=gue

Decreasedselfcare

Increasedriskforphysicalandmentalillness

Impactshealthofen=rehousehold

(Fahey & Shenassa, 2013) 8

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Link to Postpartum Depression § Connection between body posture, pain & PPD

§  Back pain may be a risk factor and comorbidity of PPD §  Mental and physical symptoms & changes are

interdependent (Angelo et al., 2014) § Connection between exercise/wellness

interventions & PPD prevention §  Exercise has psychosocial impact postpartum

§  Weight loss §  Less costly & time intensive than other interventions §  Teaches healthy behaviors to engage in long term

(Lewis et al., 2018)

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Prevention & Health Promotion “Using an evidence-based approach, occupational therapy practitioners can contribute to preventing

pain, increasing function, and promoting meaningful occupations during pregnancy and the postpartum

period” (p.1). §  OT practitioners are seeing women during the perinatal

period in clinics with musculoskeletal diagnoses §  Women expect pain/discomfort during perinatal period –

may not talk about it §  OT can address issues preventatively via health promotion

10 Fernandes, 2018

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When problems begin…

Static Positioning Repetitive Activities Awkward Postures Forceful Exertions

MSD symptoms can begin within

the first few weeks to months

Mother’s symptoms

typically ignored—focus on baby’s

needs

Caring for a newborn or infant can lead to:

Performing child care activities for children from birth to 3 is “perceived to place the greatest demands for physical care on mothers.” (Maynard & Blain, 2005, p. 362)

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Musculoskeletal Disorder § Cumulative Trauma Disorder § Repetitive Stress Disorder/Injury § Overuse Syndrome

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ü Repetitive motion during a task !ü Sustained position over time !ü Forceful movement!ü Awkward postures/positions!ü Pressure points (contact stress)!

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Postpartum Goals

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Fluid,pain-free,

efficientmovement

Careforbaby

Selfcare

Otherroles

Householdtasks

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Maternal Concerns with MSDs §  “Maternal concerns should be taken seriously; a

‘just accept it’ attitude by staff should be replaced by assessment for therapy”

(Robson, Iqbal & Howarth, 2009, p.148) §  “Reassurance and patient education are critical” (Borg-Stein & Dugan, 2007, p. 472)

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Why OT Needs to Address This § Case report of 32 yo female with deQuervian’s

§  SAHM of 2 boys (7 mo. & 3 y.o.) §  Onset from pulling wagon on daily walks §  Relationship to biomechanical strain of child care

recognized BUT … suggestions for tx. were … (Papa, 2012)

§ Miami Herald (2017) Ask the Physician §  Woman with thumb/wrist pain without known etiology,

WAHM who does computer work, gardens & has 3 mo. old

§  Response of deQuervain’s is normal postnatally! …suggestions for tx were …

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Conservative Management (?)

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Orthosis OralMeds SteroidInjec=on

Ice/Modali=es

Outpa=entTherapy Surgery

Taking Ergonomics Out of the Office

Organization = “Job” of Motherhood

Environment:

Home, Car, Community

Job Tasks: •  Feeding, Bathing •  Changing diapers •  Lifting, Carrying •  Playing

Tools & Equipment: •  Bottles, Baby food •  Crib, Play gyms •  Car seat, Stroller •  Infant carrier

Workers =

New Mothers

Adapted from R. Dahl in Haruko Ha, Page & Wietlisbach, 2006 18

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Teaching Ergonomics in the Home § Study looked at ergonomic education of women

with MSDs §  Cooking, cleaning, grocery shopping, laundry, childcare

§ Emotion and routine attached to these tasks § Behavior changes are needed to decrease

biomechanical strain § Challenges in adherence

§  Be client centered §  More likely to change if clients feel ‘listened to’

19 Cheung et al., 2018

Common Areas of Discomfort

Low Back

Upper Back

Hips Knees

Neck

Shoulders Wrists

Thumbs

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ForcefulExer=ons

Repe==veAc=vity

AwkwardorSta=cPosi=oning

ContactStress

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Common Risk Factors

deQuervain’s Tenosynovitis § Sit et al. (2017) study of 259

Chinese women §  57% reported wrist pain after

childbirth §  Felt new mothers had increased risk

within first 8 weeks due to lack of experience of demands of childcare tasks

§  Hypothesis that other factors were baby’s size, breastfeeding, and attending antenatal classes

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Wrist/Thumb Positioning Tips

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Avoidthe“L”posi=on

Keepaneutralwrist

Uselargerjoints/muscles

Loosenyourgrip

Breastfeeding §  Cross-cradle hold intended for

newborn stage §  Mom semi-reclines with baby tummy-

down against chest – move baby to breast and not breast to baby

§  Positioning pillow to support arm (not baby) & lean back to reduce gravity

§  Avoid the “L” §  Try different positions: Football hold,

side lying, back lying

24 Shepherd, 2015; Roberts, 2011

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Bottle Feeding § Neutral wrist §  Loosen grip on the bottle § Avoid the “L” if possible § Think about baby’s positioning

§  Weight on larger joints §  Reduce strain on fingers & thumb

25 Shepherd, 2015; Roberts, 2011

Stroller Position

26

§ Relaxed shoulders § Soft bend in elbows § Neutral wrist § Neutral forearm § Thumb position § Consider vibration

•  Neutralwrist/FA•  Thumb‘tucked’

•  Wristextended•  Thumbwrapped•  Contactstress

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Lift/Hold/Carry § Avoid the “L” and scoop

baby §  Older children can be picked

up by ‘scooping’ with thumb tucked under the axilla

§ Neutral wrist § Keep baby’s weight on

forearm § Baby carrier for ‘hands free’

holding §  Babywearing International

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Back Pain § Mannion et al. (2015)

§  Back pain and urinary incontinence impact on maternal function @ 12 months postpartum (1574 women)

§  77% were experiencing back pain with wide range of functional impact (>% than impact of UI)

§  Improved function with daily tasks improves quality of life §  If these symptoms are common & impacting function,

we know what care is need to improve it

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Posture Tips § There are ‘normal’ curves in

your back § These curves MUST be

maintained (especially the lumbar or low back)

§ Neutral to anterior pelvic tilt § DO bend at your hips (and

knees) § DO NOT bend at your waist

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FRONT

CERVICAL

THORACIC

LUMBAR

BACK

Disk Pressure through Spine § Supine (laying face up) § Side-lying § Standing § Seated § Standing – bend forward at hips § Seated – bend forward at hips § Standing – bend w weight § Seated – bend w weight

Pressureincreases

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Neck & Shoulders § Head and neck in ‘midline’ and

not bent forward § Shoulders relaxed and away from

your ears (neither elevated or depressed)

§ Shoulder blades (scapula) level and slightly retracted (pulled together)

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Feeding § Breast or Bottle

§ Try to get comfortable before baby latches § Choose a comfortable ‘seat’ § Consider footrest § Maintain lumbar curve of spine § Avoid cervical flexion § Neutral or anterior pelvic tilt

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Floor Play

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•  Keep lumbar curve

•  Neutral to anterior pelvic tilt

•  Avoid cervical flexion

•  Use supports if possible

•  Great time to stretch!

Picking Object Up/Lifting

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§  Be close to the object you are moving §  Face the object head on §  Bend your knees – use your legs, not

back §  Keep a neutral spine (maintain normal

curves) §  Keep a wide base of support §  Keep your heels down §  Avoid combining movements

§  Rotating + bending forward or backwards

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What leads to MSDs when lifting? § Pain reported in low back (64%) followed by neck/

shoulder/upper back (32%) § Occurs during bending, squatting, stooping, lifting

§  Bending while carrying most stressful §  Factors

§  Child’s weight §  Mom’s grip §  Equipment & space constraints §  Strength/fitness of mom §  Reach distance §  Trunk rotation

35 Vincent & Hocking, 2012

Hold/Carrying Baby §  “There is a need … to introduce appropriate

ergonomic training and interventions on infant carrying tasks in order to improve maternal musculoskeletal health during childbearing years & beyond” (p. 855).

§  Burden of carrying in arms > with device §  Options studied

§  Back carry §  Side carry §  Front carry in arms §  Front carry with device

§  Consider biomechanical impact on type of carry

36 Ojukwu, et al., 2017

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Car Seat § Risk factors

§  lift and twist § working in a tight space § pinch strength for

buckles

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Car Seat §  Recommendations

§  Face the backseat head on §  Tuck the thumbs under axilla to lift §  Try to lift in the position you are placing §  Encourage independence when ready §  Buckle release devices

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Stretching

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§  Low back – Lying on back, bring knees into chest § Shoulders – Shrug up/down; shoulder rolls § Upper back – Pull shoulder blades together, apart § Neck – Look up/down, left/right, ear to shoulder,

pull chin back and push forward § Wrists – Wrist flexors (prayer stretch); Wrist

extensors (tennis elbow stretch) § Cat stretch – On all fours, arch back like a cat

Strengthening § Create gentle strengthening programs*

§  Transverse abdominus §  Engage pelvic floor §  Consider postural muscles of back §  UE strengthening without stressing the wrist/thumb

§ Suggestions from Duffin (2012) study §  Keep track of exercises §  If not performed, state why §  Record discomfort during exercise §  Assess improvement, same, or worse §  Feelings before and after exercise §  Use diaper changes as cues to stretch/breathe/etc.

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Summary of Suggestions §  Look at grip and wrist position §  Look at environment: height of objects, reach,

arrangement of items § Decrease frequency of lift/hold/carry

§  Encourage independence, get help when available, get cooperation from child

§ Decrease stress/strain of task §  Consider mood/behavior of child

§ Stretch during the day § Strengthen in preparation for childcare tasks

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Start with ONE change

“Job” of Motherhood

Environment:

Home, Car, Community

Tasks: •  Feeding, Bathing •  Changing diapers •  Lifting, Carrying •  Playing

Equipment: •  Feeding equipment •  Crib, Play gyms •  Car seat, Stroller •  Infant carrier

New Mothers •  Posture •  Positioning •  Stretch •  Strengthen

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Questions?

Sara Loesche, MS, OTR/L, CHT saraloesche@gmail.com

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References §  American Occupational Therapy Association. (2014). Occupational therapy practice framework:

Domain and process (3rd ed.). American Journal of Occupational Therapy, 68, S1-S48 §  American Occupational Therapy Association (2017). Occupational therapy practitioners and

ergonomics. Retrieved from https://www.aota.org/~/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/WI/Facts/ergonomics.pdf

§  Angelo, R., DaSilva, D.C., Zambaldi, C.F., Cantilino, A. & Sougey, E.B. (2014). Influence of body posture on the association between postpartum depression and pain. Trends in Psychiatry and Psychotherapy. 36(1), 32-39.

§  Borg-Stein, J. & Dugan, S. (2007). Musculoskeletal disorders of pregnancy, delivery, & postpartum. Physical Medicine and Rehabilitation Clinics of North America, 18(3), 459-476.

§  Cheung, T.W.C, Clemson, L, O’Loughlin, K. & Shuttleworth, R. (2018). Ergonomic education on housework for women with upper limb repetitive strain injury (RSI): A conceptual representation of therapists’ clinical reasoning. Disability and Rehabilitation, 40(26), 3136-3146.

§  Cornell, A., McCoy, C., Stampfel, C., Bonzon, E., & Verbiest, S. (2016). Creating new strategies to enhance postpartum health and wellness. Maternal and child health journal, 20(1), 39-42.Duffin, C. (2012). Postnatal exercise improves muscle tone and relieves back pain. Primary Health Care, 22(10), 7-8.

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8/8/19

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References (continued) §  Fahey, J.O & Shenassa, E. (2013). Understanding and meeting the needs of women in the postpartum

period: The perinatal maternal health promotion model. Journal of Midwifery & Women’s Health, 58, 613-621.

§  Fernandes, J.G. (2018). Occupational therapists’ role in perinatal care: A health promotion approach. American Journal of Occupational Therapy, 72, 7205347010.

§  Haruko Ha, D., Page, J., & Wietlisbach, C. (2006). Work evaluation and work programs. In H.McHugh Pendelton, & W. Shultz-Krohn (Eds.), Pedretti‘s occupational therapy practice skills for physical dysfunction (6th Edition ed., pp. 264-307) Mosby Elsevier.

§  Lewis, B.A., Schuver, K., Dunsiger, S., Samson, L., Frayeh, A.L., Terrell, C.A.,… Avery, M.D. (2018). Rationale, design, and baseline data for the Healthy Mom II Trial: A randomized trial examining the efficacy of exercise and wellness interventions for the prevention of postpartum depression. Contemporary Clinical Trials, 70, 15-23

§  Mannion, C.A., Vinturache, A.E., McDonald, S.W., & Tough, S.C. (2015, June). The influence of back pain and urinary incontinence on daily tasks of mothers at 12 months postpartum. PLOS ONE, 10(6), 1-18.

§  Maynard, S. A., & Blain, L. G. (2005). Women, work, and childcare: Where have we been? Where are we going?, Work, 24(4), 361-367.

§  Ojukwu, C.P., Anyanwu, G.E., Anekwu, E.M., Chukwu, S.C. & Fab-Agbo, C. (2017). Infant carrying methods: Correlates and associated musculoskeletal disorders among nursing mothers in Nigeria. Journal of Obstetrics & Gynaecology, 37(7), 855-860.

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References (continued) §  Papa, J. A. (2012). Conservative management of De Quervain’s stenosing tenosynovitis: A case report.

Journal of the Canadian Chiropractic Association, 56(2), 112-120. §  Roberts, D. (2011). Preventing musculoskeletal pain in mothers: Ergonomic tips for lactation

consultants. Clinical Lactation, 2(4), 13-20. §  Robson, S.E., Iqbal, J. & Howarth, E. (2009). Medical disorders in pregnancy: A manual for midwives.

Oxford, UK: Blackwell Publishing. §  Sanders, M., & Morse, T. (2005). The ergonomics of caring for children: An exploratory study. The

American Journal of Occupational Therapy, 59(3), 285. §  Shepherd, S. (2015, March). Nursing wrist pain. Today’s Parent; Toronto, 32(3), 64.

§  Sit, R.W.S, Tam, W., Chan, D.C.C., Yip, B.H.K., Tam, L.W.Y., Chow, L.L.Y, … Wong, S.Y.S. (2017). A pilot cross-sectional study of postpartum wrist pain in an urban Chinese population: Its prevalence and risk factors. Pain Physician, 20(5), p.711-719.

§  Slootjes, H., McKinstry, C., & Kenny, A. (2016). Maternal role transition: Why new mothers need occupational therapists. Australian Occupational Therapy Journal, 63, 130-133.

§  Vincent, R. & Hocking, C. (2012). Factors that might give rise to musculoskeletal disorders when mothers lift children in the home. Physiotherapy Research International., 18(2), p.81-90.

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