Physiotherapy for Pregnancy by Cori Castoe (Physio Intern, Indianapolis)

Pregnancy is one of the toughest, if not THE toughest, events that the human body can go through. Therefore, it is no surprise that women can benefit tremendously from exercises to prepare the muscles for pregnancy and labor as well as for recovery.

131024-BounceRehab-034

 

 

 

 

 

 

Role of Hormones in Pregnancy

During a woman’s natural monthly menstrual cycle, there are spikes in estrogen and progesterone that change a woman’s body physiology slightly in order to ovulate and start the menstrual cycle. When a woman becomes pregnant, those levels become significantly higher than they will ever be when a woman is not expecting. The main hormones involved are estrogen, progesterone, and relaxin.

The roles of these hormones include:
• Maintaining uterine lining throughout pregnancy
• Increasing blood circulation to uterus
• Keeping placenta functioning properly
• Relaxing and loosening the ligaments and muscles to make room for baby

 

 BEFORE-AFTER

 

 

 

 

 

 

 

 

Why Loosening of Joints Isn’t All Good

Although the laxity and loosening of ligaments is necessary for the body to make room for a growing womb, these changes don’t come without consequence. The pain in the pelvis is due to instability that arises from the compensation of the surrounding muscles of the pelvic girdle making up for the lack of stability of the ligaments in the joint.

Eventually, these muscles become hypertonic and fatigue causing an inflammation around the loose ligaments. This inflammation leads to several joint issues in pregnancy including problems with the sacro-iliac joint, the pubic symphysis, and lumbar spine.

If the natural relaxation of ligaments is necessary to make room for a growing baby, is this type of pregnancy-related injury just unavoidable? Absolutely not. There are several muscle building exercises that a woman can perform before becoming pregnant and even during pregnancy that can aid in the prevention and treatment of pelvic girdle joint problems.

Often, this type of muscle building preparation can be found through pilates. It used to be a standard, before the research disproved it, that exercise during pregnancy was ill-advised. However, new research is suggesting that low to no-impact pilates can improve patients mentally and physically for labor.  So what does Pilates do?

Pilates was built on several principles with a heavy emphasis on breathing control, concentration, movement, isolation, and centering. These principles can benefit pregnant women in several different ways.

The focus on breathing, especially exhaling, centers and activates deep abdominal muscles and the pelvic floor muscles that need to be kept in shape. Pelvic floor muscles work together with the diaphragm, internal abdominals, and spinal muscles, all of which are subject to lots of wear and tear over the course of a pregnancy.

There has been overwhelming evidence in recent years on the benefits of not only pilates, but other exercise during a pregnancy. Women who were regular exercisers before conceiving are able to continue activities while previously inactive mothers are told to seek the advice of experts before starting an exercise program. Well-conditioned muscles involved in the birthing process may lead to an easier labor with less medical intervention as well as a quicker recovery period. Muscle preparation can also lower the risk for urinary incontinence, pelvic pain, and joint misalignment. However, women are advised to take caution while performing exercises, and even seek pregnancy-specific classes, in order to not cause joint damage by overexertion.

What Exactly Am I Preparing?

During the last trimester of a pregnancy, exercise, while still important, should be performed to the level where there is no discomfort for the mother. Low-impact exercises such as swimming, walking, jogging, and cycling are all approved as they inflict little trauma to the baby. One of the major pregnancy-related injuries that comes about in the third trimester is diastasis recti, which is the separation of the rectus abdominis from the linea alba, or connective tissue running from the sternum to the pubic symphysis in the middle of the “six-pack” abdominals. This injury is most common in the third trimester with 66% of occurrences happening during this period as most of the fetal growth occurs then. The nature of the muscle, in that there is little to no horizontal elasticity to it, also lends to the likelihood of separation.

Ab Separation

Abdominal separation of the Linea Alba

With this in mind, it is clear that preparing the abdominals for pregnancy is also of high importance. While the rectus abdominis is affected most readily, it is less important to work your “six-pack” abs and more important to prepare the deep abdominal muscles. However, it is vital that women activate the correct muscles as doing the exercises incorrectly can do more harm than good. Many people will pull on the neck during crunches putting unnecessary pressure on the cervical spine and not even work any other muscle in the abdominal canister. Pilates also emphasizes pulling the belly button in during these exercises in order to engage the deep muscles. Doing so incorrectly actually pulls sideways and increases the risk for diastasis.

Different types of diastasis recti can occur. It is important to determine which type of separation has occurred before starting a therapy program

Different types of diastasis recti can occur. It is important to determine which type of separation has occurred before starting a therapy program

The abdominals aren’t the only important muscle group to focus on here. The pelvic floor also needs some attention. Pregnancy and childbirth are the worst injuries the pelvic floor will sustain with 50% of women losing at least partial support and function. Some experts even suggest that the damage to the pelvic floor during pregnancy and birth is equivalent to a major sports injury, therefore it is highly important to exercise these muscles before withstanding labor so that they may retain some function after birth. The pelvic floor is notorious for its difficulty in isolating. Since these muscles are deep within the pelvic girdle and not typically activated during exercise programs.

With pelvic floor work in exercise programs, it is highly important that the right muscles are being activated. To aid in this process, some practices, including bounceREHAB have employed the use of a real time ultrasound (RTUS) machine to direct women how to contract and relax their pelvic floor muscles. Real time ultrasound is a safe, effective, and non-invasive method of giving visual feedback to women to ensure they are contracting the right muscles throughout an exercise program. Training the pelvic floor will also lead to a lower risk of incontinence, where the weakening of the pelvic floor makes it more difficult to hold in urine.

Anatomical View of the Pelvis Floor

Anatomical View of the Pelvis Floor

 

RTUS  (Real Time UltraSound)

RTUS (Real Time UltraSound)

What About After Baby Comes?

Like with prenatal exercise, getting a woman into a postnatal recovery exercise plan is equally, if not more, important. While many women are concerned with getting back their pre-baby body, just regaining the core and pelvic floor strength will be vital to the activities of daily living. After giving birth, women will often experience uterine contractions, fatigue, and mood swings for up to 6 weeks after labor. The return to exercise is very much a call to be made by each woman individually, however, a period of recovery (at least 3-6 weeks) is required. For women who are breastfeeding, intensity of exercise is to be well-monitored because high-intensity exercise may cause a build-up of lactic acid in the mammary glands. This build-up can be very painful and give the milk a sour taste that the baby may reject completely.

Like we saw earlier with prenatal muscular preparation, the recovery period is going to use the same methods of pilates and physiotherapy to regain control of the muscles that were stretched and strained during the duration of the pregnancy and during labor. As mentioned earlier, the pelvic floor sustains the most damage during childbirth and is thus the most important to rehabilitate. As with prenatal preparation, real time ultrasound can be used to again show women how to isolate and rehabilitate the intricate muscles in the pelvic floor. One consequence of pelvic floor dysfunction that occurs in 45% of women is urinary incontinence. While it does seem to dissipate on its own after 6 months, urinary incontinence is most effectively resolved by implication of a specific physiotherapy program.

To aid in regaining stability both in the abdominals and in the pelvic floor, some physiotherapy places will offer “SRC Recovery or Pregnancy shorts”. The SRC range of leggings and shorts help provide stability to the low back, pelvis, and reduce swelling and fluid retention by compressing wound sites. These shorts also provide support in the perineum region to target the pelvic floor more directly and to help prevent urinary incontinence.

SRC Recovery Shorts

SRC Recovery Shorts

SRC compression shorts can be used to help speed recovery while SIJ belts can ease the pain associated with SIJ instability
Alongside strengthening of the pelvic floor comes reinstituting stability in the pelvic girdle. Pelvic girdle pain is a common complaint during pregnancy and needs to be reestablished after birth. Thankfully, the presence of relaxin, the hormone responsible for loosening the ligaments of the pelvic girdle and other joints, in the blood resumes normal levels and some stability is regained naturally. Again, like with other injuries sustained during pregnancy, the pain associated with the pelvic girdle subsides after about 12 months, but physiotherapy and various stabilizing belts can be used to aid in the process of rehabilitation.

Summary

• Exercising while pregnant leads to an easier labor and a speedier recovery period
• The muscles in the pelvic floor and the abdominals need the most attention in terms of which muscles to condition
• Exercises such as pilates are very beneficial because of their breathing techniques and activation of deep core muscles
• Real-time ultrasound can be used to help women isolate muscles in the core both during preparation and recovery
• There are many types of equipment such as belts and shorts to aid in recovery

Cori Castoe
Physiotherapy Intern from Indianapolis USA