Post- Partum Recovery: Improving Function for Mothers Dr

1

PREGNANT &

LOVING IT!

EFFECTIVELY TREATING

THE PREGNANT PATIENT

DR. NATALIE J. SEBBA,

PT, DPT, WCS, CLT

* Slides or material not to be reproduced or used without written consent of author

Provider Disclaimer

Allied Health Education and the presenter of this webinar

do not have any financial or other associations with the

manufacturers of any products or suppliers of commercial

services that may be discussed or displayed in this

presentation.

There was no commercial support for this presentation.

The views expressed in this presentation are the views and

opinions of the presenter.

Participants must use discretion when using the

information contained in this presentation.

Objectives:

1.Participant will understand the typical physiological changes associated with

pregnancy.

2. Clinician will properly identify common spinal and pelvic alignment impairments of

the pregnant woman.

3. Clinician will understand how to assess a pregnant woman and effectively prescribe

therapeutic exercises associated with this presentation.

4. Following the webinar the clinician will effectively instruct women in proper body

mechanics associated with pregnancy.

5. Learner will verbalize the importance of core and pelvic floor muscle function and

understand the progression of strength development in the pregnant client.

6. The learner will be able to properly educate women on exercise considerations

during pregnancy and how to reduce the risk of diastasis rectus.

7. Participant will understand educational concepts for pregnant women related to

childbirth, positioning during labor and immediate post-partum considerations.

8. Participant will identify proper assessment scales to utilize with this patient

population to improve effectiveness of documentation and reimbursement.

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Normal Physiological Changes

Pregnancy is divided into 3 trimesters.

Each trimester is a little longer than 13 weeks.


1st Trimester

Fatigue

Increased urination

Nausea/vomitting

Generalized malaise

Breast tenderness

Increased abdominal

girth

About 25% of pregnant

women experience slight

bleeding during their first

trimester.

1st Trimester Red Flags

Hyperemesis Gravidarum

Serious medical condition that can result in dehydration, weight loss

and nutritional deficiencies

Management suggestions:

Add fresh ginger to foods

Drink ginger root tea

Blood loss

Significant bleeding, cramping, or sharp pain = CALL doctor

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2nd Trimester:

Noticeable increase weight

Fatigue

Fluid retention

Indigestion

Food cravings

Light-headedness

Heart burn

Constipation/gas

Stretch marks

Braxton Hicks contractions

2nd Trimester Red Flags

Gestational Diabetes:

40% of pregnant women

Risk factors: overweight, >age 35, hx of larger babies


Regular mild to moderate exercise

Nutritional counseling: monitoring carbohydrate and fat intake

Preeclampsia:

Combination of symptoms: fluid retention, severe headaches, blurred

vision, edema


Doctors orders: often bed rest


3rd Trimester:

Braxton Hicks contractions

Painful rib subluxations

Indigestion

Difficulty sleeping

Difficulty breathing

Frequent urination

Low back pain

Symphysis pubis pain

Groin/back pain

Swelling

Spotting

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3rd Trimester Red Flags

Placenta Previa: When the placenta covers the opening in the

mother's cervix.

Previous delivery

> 35 yo

history of previous surgeries, such as a cesarean section (C-section) or

uterine fibroid removal


Doctors orders: often bed rest

Rapid weight gain

Severe abdominal cramps

Transient osteoporosis


Cardiovascular system:

Volume increases 35-50%

Plasma increase>red blood cell increase = “physiologic anemia”

Increased venous pressure in LE

Heart size increases and is elevated

HR increases by 10-20 bpm

Cardiac output increases 30-60%; increased in L side lying

Metabolic system:

Additional 300 calories/day

Expected gain: 25-30 lbs/ 50-60 lbs for multiples

Normal fasting blood glucose levels are lower than standard


Hormonal changes

Estrogen

Levels increase 30x

Relaxin & progesterone: increases ligamentous laity, softens cartilage

Significantly affects pelvic joints, sacrum, coccyx etc.

Peaks at week 14 and prior to delivery

Connective Tissue

Thoracolumbar fascia: position of extreme length reducing ability to

stabilize trunk

Joint hypermobility

Increase risk of injury to back, pelvic, and LE

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Changes in posture and balance

Center of gravity shift upward and

forward

Increased cervical & lumbar lordosis

Knee hyperextension

Increased base of support

External rotation of hips

“Waddling” gait

Forward rounded shoulders

Scapular protraction

Increased breast size

UE internal rotation

Sub occipital muscle tension


Pelvic floor muscles

Increased weight and load

demand

Risk of urinary incontinence

Pressure on pelvic organs

Risk of pelvic organ prolapse



Diastasis rectus: separation of

rectus abdominus muscle

Visible fascial thinning

Umbilicus change

Etiology unknown

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Diastasis Recti

Symptoms:

Bulging and midline

Low back pain

Associated weaknesses:

Transfers

Body mechanics

Posture

Nerve Compression Syndromes

Occurrence averages as high as 41%

Presentations:

Carpal tunnel syndrome

Thoracic Outlet syndrome

Caused by:

Postural changes of neck and upper quarter

Fluid retention

Hormonal changes

Circulatory compromise


Carpal tunnel syndrome Thoracic Outlet syndrome

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Interventions:

Postural correction

Manual release

Ergonomic assessment

Splints for CTS

Symptoms often persist into postpartum and

increased presentation severity with breastfeeding

Common Spine Symptoms

Postural back pain

50-70% pregnant women experience this pain

Continues into postpartum period for 68% of these women

Symptoms worsen with:

Fatigue

As day progresses

Static postures


Sacroiliac/Pelvic Girdle Pain

Pelvic girdle pain: localized to posterior pelvis and radiates into

buttocks and posterior thigh

Symptoms increased with:

Prolonged sitting

Standing/walking

Climbing stairs

Unilateral standing

Torsion activity

Increased with activity

Not often relieved with rest

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Pubic Symphysis Dysfunction

Often in combination with pelvic girdle pain (PGP)

Symptoms:

Tenderness at symphysis joint

Radiating pain into groin, medial thigh

Increased pain with weight bearing

Joint: Referral Patterns

SIJ Lumbar facet joints

Cook et al. Orthopedic Manual Therapy

Cluster of 3-5 clinical tests

demonstrates the strongest validity

to confirm SIJ dysfunction

Recommended tests include:

Sacral spring

Compression test

Ganslen’s test

Thigh thrust

Other useful testing measures:

ASLR: best identify instability of sacrum

MMT of hip

PROM of hip

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Pelvic Girdle Pain Clinical Practice Guidelines:

July 2017

Clinton, S. et al. Pelvic girdle pain in the antepartum population:

Physical Therapy Clinical Practice Guidelines Linked to the

International Classification of Functioning, Dias ability and Health

From the Section of Women’s Health and the Orthopedic Section of the APTA. Journal of Women’s Health Physical Therapy. Volume 41 (2). July 2017.

Clinical Course:

Common presentation of PGP: 14-30 wks

Presents of LBP or PGP in early pregnancy indicate high

likelihood of increased pain in late pregnancy

Persistent pain in postpartum period presents in7-25% of

women


July 2017

5 Diagnostic categories:

Pelvic girdle syndrome (6%)

Both SIJ and pubic symphysis

Symphysiolysis (2.3%)

Pain only in pubic symphysis

One sides SI syndrome (5.5%)

Double sided SI syndrome

(6.3%)

Constant variation (1.6%)


July 2017

Postural changes:

Magnitude of postural changes during pregnancy is not related to PGB

Pathophysiology:

Changes in ability to manage load transfer due to joint laxity may account for development of PGP

Current studies do not support relationship of relaxinand PGP

Pubic symphysis has been shown to widen as early at 8-10 wks and continues to average of 7mm

PGP more likely to present in women with >10mm separation

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July 2017

Differential Diagnosis

History of trauma, unexplained weight loss, steroid use, drug abuse, HIV, fever, systemically unwell

Special consideration:

Symptoms due to uterine abruption, referred pain from UTI

Hip dysfunction:

Femoral neck fracture, bursitis, impingement, labral irritation

Ensure proper test interpretation based on location of pain

Lumbar spine:

Spondylolisthesis, discal patterns that fail to centralize, diminished reflexes, lumbar disk


July 2017

Examination

Pelvic Girdle Syndrome

Separation

Compression

Hip abduction/adduction

One sided/double sided

SI Syndromes

Thigh trust

Menell’s test

FABER

Pubic Symphysis

Palpation

Trendelenburg

Pelvic Girdle Examination

Compression test/

Separation test

s/I position with painful side

superior.

Assess resting symptoms

Apply downward pressure at

iliac crest for 30 seconds

Positive is pain

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Distraction

test/compression test:

Pt is supine, clinician crosses

arms over pelvis

Apply posterior-lateral force

at the ASIA for 30 seconds

If no pain present, apply

series of thrusts through the

ASIS

Positive is pain


Thigh thrust

Patient supine, stand on non-

involved side

Involved hip and knee flexed

to 90 and clinician places

hand under sacrum

Downward pressure applied

through femur

Positive is pain in posterior

hip or near SIJ


Menell’s Test

Supine , involved leg is positioned into 30 degrees abduction and 10

degrees flexion at hip

Clinician first compresses and then distracts the leg in sagittal plane

Positive is pain

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FABER

Patient supine, clinician

passively flexes, abducts and

externally rotates the

involved leg to place heel on

opposite knee

Positive is pain at SIJ or pubic

symphysis

Hip pathology indicated with

pain at medial femur and

knee or in inguinal region


Sacral spring test

Pt is prone

Downward pressure at S3

repeated vigorously

Positive is pain with

downward pressure


Gaenslen’s Test

Pt supine with painful leg

near edge of bed

Raise non-painful knee

toward chest to hip at 90

degrees

Drop painful leg just off the

table

Downward force applied to

lower leg while counterforce

of flexion applied to flexed

leg

Positive is pain with the

torque movement

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Active Straight Leg Raise:

Pt is supine and asked to

raise involved leg 6” above the table

Then clinician stabilizes pelvis

and pt repeats

Perform B if B involvement

suspected

Positive is pain without

support, relieved with

support

Trendelenburg:

Patient stands with back to

clinician and actively flexes

hip and knee to 90 degrees

Positive is flexed hip

descends and pain at pelvic

joint


Hip PROM

Flexion

Abduction/Adduction

Internal/External rotation

Positive is increased pain

Lunge

Patient asked to step forward

and shift weight over forward

leg.

Then flex forward hip and

knee to 90 degrees

Positive is increased pain

Diastasis Recti Examination

Diastasis Recti (DR)

3 locations:

2” above umbilicus

At umbilicus

2” below umbilicus

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Fingertip Measurement

Hook lying position

Place fingertips horizontally across abdomen @umbilicus, above and below

Gently curl head/shoulder upward

Exhale throughout

Palpate for medial muscle belly on each side of finger (intra-rectus distance (IRD))

Determine # of finger widths


Finger width documentation:

Measure your finger widths in cm

Document actual cm distance

Research based standards:

>1.5 cm (Gilleard and Brown, 1996)

>2 cm (Lo et al.,1999)

>2.5 cm (Candido et al., 2005)

>2 finger widths during a partial sit-up (Bursch, 1987; Sheppard, 1996)

The Functional Core

4 muscle groups:

Diaphragm

Transverse Abdominus

Multifidi


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Functional Core Weakness

Common symptoms of weakness include:

Mid and low back pain with movement

Instability through pelvis, pelvic girdle, hips and lumbar

spine

Urinary and/or fecal incontinence

Poor balance reactions

Abnormal breathing patterns with movement

Carrying low during pregnancy

Increased waddling gait with pregnancy

Alignment Interventions

Clinton et el:

NO evidence that spinal manipulation and/or mobilization is harmful

to the antepartum female or fetus

Normal movement in all directions if advocated despite hypermobility

or laxity


Shot Gun

Addresses superior migration of

the painful pubis with weight

bearing

Technique:

Pt hook lying with B hip

abduction

Cued to push outward ward

against resistance for several

bouts

Then do a strong and quick

adduction isometric against

resistance

SI belt helpful after correction

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Anterior Rotation of Innominate

Pt supine, painful side flexed at knee and hip into flexion

Opposite leg neutral

Clinician then resists hip flexion and extension for 3-5 bouts

Concordant movement pnshould then be re-assessed and relieved

Opposite used for posterior rotation

Manual therapy

Soft tissue mobilization

Myofascial release

Muscle assisted ROM

Muscle Spasm: Referral Patterns

Psoas Multifidus

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Gluteus maximus


Adductor magnus Piriformis


Quadratus Lumborum Abdominals

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Pelvic floor muscle tension:

Results in pelvic pain

Referred abdominal pain

Unsafe Postures & Exercises

Prone with knees at the chest and buttocks elevated

Risk: Air embolism

B straight leg raises

Risk: Risk of diastasis and low back pain

Elevated fire hydrant exercise

Risk: Risk of SIJ and lumbar vertebrae stress

Elevated quadruped hip extension

Risk: Hyperextension of lumbar spine

Unilateral weight bearing exercise

Risk: SIJ irritation

Diastasis Rectus Risk Reduction

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Strengthening


Proper activation is critical

Learning to activate with ALL movement is essential

• Place fingers on the inside of your pelvic

bones.

• As you exhale, gently pull in on your lower

abdominal muscles, like trying to zip a tight

pair of pants.

• Hold contraction for 5 seconds while

counting out loud.

Strengthening


Strengthening

TA and core progression

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Strengthening

TA and core progression

Strengthening


Upward/inward lift of muscles

Strengthening


Common mistakes with activation:

Holding breath

Tightening stomach muscles

Squeeze buttocks and adductors

Bear down or push down through the muscles

Don’t fully relax the muscles between contractions

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Strengthening


Endurance activation: target slow twitch fibers

Sustained contraction, adequate rest duration

Exercise ideas:

Begin with 3 sec hold, 10 sec rest x 5

Increase reps to 10 as able

Slowly increase duration of hold, maintain 10 sec rest

Goal 10 sec hold

Quick activation: targets fast twitch fibers

Quick activation, full contract and relax

Exercise ideas:

Begin with cadence of 1 sec contract: 3 sec relax

10 quick activations at 1:3 cadence

Slowly increase speed to 1:2 cadence

Ex progression: 5 quick contractions, 10 sec rest x 3-5

Stretching

Cervical region:

Cervical, levator scapulae, upper traps, pectoralis

Mid spine:

Pectoralis, rhomboids, latissimus dorsi, upper trap, levator scapulae

Lumbar spine/pelvis:

Abdominals, hip flexion, gluteals, piriformis

LE:

TFL/IT band, quadriceps, adductors, abductors, gastroc/soleus

Body Mechanics: Getting out of Bed

DO follow these steps:

1. Bend your knees and scoot to side opposite

which you will get out of bed.

3. Roll on your side toward the side you are getting

out on.

4. Drop your legs off the bed.

5. Cross your arms as shown in the picture with

your bottom arm bent at the elbow and your upper

crossed so your palm is on the bed.

6. Exhale as you push up to sitting using your elbow

and hand.

REVERSE these steps to safely get into bed.

Do NOT: Sit straight up in bed from a laying doing

position. This puts a high amount of stress on your

back!!

1 2 3

4 5 6

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Body Mechanics: Picking Up Items from Floor

X

DO: Bend with your knees to lower yourself toward the item.

Do NOT: Bend at your back to pick up the item.

DO: Bring/hold the item close to your body when you are lifting it.

Body Mechanics: Positioning

Sleep position Body pillow:

Leachco Snoogle Body Pillow:

U shape Total Body Pillow:

Body Mechanics: Positioning

Standing posture: Sitting posture:

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Support Devices

SIJ support

Serola SI Belt: $44

SIJ/abdominal support

Mother to Be: $39

Support Devices

Compression stockings

Over the counter is typically 12-15 mmHg

Ideally 20-30 mmHg

SmartWool PhD Graduated Compression Socks

Panty hose: no compression at abdomen

Generalized Exercise Recommendations

Strongly recommended that women

continue mild to moderate exercise based

on pre-pregnancy fitness levels.

No evidence indicating need to reduce

intensity but should be aware that heart

rate with vary as well as respiratory rate.

Use Borg scale of perceived exertion:

between 12-14

Never exercise to exhaustion

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Exercise Contraindications

Incompetent cervix/early

dilation

Vaginal bleeding

Placenta previa

Pre-eclampsia

Maternal heart disease

Maternal Type 1 diabetes

Gestational diabetes

Severe anemia

Extreme fatigue

Overheating

Diastasis recti

Absolute: Precaution:

Labor and Delivery Considerations

Cesarean is indicated with:

Placenta previa

Placenta abruption

Transient osteoporosis

Severe pubic symphysis separation

Breech position

Labor and Delivery Preparation

Vaginal birth preparation exercise:

Visual imagery: concentrate on a relaxing image throughout pregnancy for use later with delivery

Muscle setting: guided contract/relax from feet to head

Focus on the contrasting sensations

Add deep breathing

Selective tension: progression of muscle setting by focusing on relaxing one area while the other is contracting

Breathing: slow, deep diaphragmatic breathing

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Labor and Delivery Preparation

Second stage labor techniques:

While bearing down, take a breath in, contract the

abdominal wall and slowly breathe out

PRECAUTION: holding breath (Valsalva) will increase

tension and resistance in the pelvic floor and create

adverse effects on cardiovascular system

Maintain relaxation in legs and pelvic area

Between contractions perform total body relaxation

With delivery: focus on “letting go” and breathing with light pants or groans to encourage relaxation of the PF


Cesarean Delivery

Transversus abdominus muscles

Weakened by incision/trauma

Leads to poor core support

Scar tissue development

Leads to scar sensitivity

Abdominal surgery

Lifting restrictions

Incision considerations

Constipation


Effect of vaginal

childbirth on the pelvic

floor:

Neurological

compromise:

Stretch and compression of

pudenal nerve (S2-4)

Muscular impairment:

Stretching of pelvic floor

Tearing or episiotomy of

tissues/muscles

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Postpartum Education: Return to exercise

Post vaginal delivery

When she feels ready and

has been cleared by MD

Precautions:

Bleeding increases

Adequate warm up and cool

down to protect joint laxity

Prone knee to chest position

for 6 wks

Post cesarean delivery

6-8 before resuming

moderate aerobic exercise

Preventative exercises as

soon as able:

Ankle pumps, AROM of LE,

walking

Initiate basic pelvic floor

exercise

Deep breathing and huffing

to prevent pulmonary

complications

Posture

Post-Partum Exercise Guidelines

ACOG Recommendations:

Exercise benefits include:

It helps strengthen and tone abdominal muscles.

It boosts energy.

It may be useful in preventing postpartum depression.

It promotes better sleep.

It relieves stress.

30 min of moderate intensity aerobic exercise 5

days weekly

Commonly Used ICD-10 Codes

ICD-10 Code Description

R10.2 Pelvic pain

M54.5 Low back pain

O26.9 Pregnancy-related condition, unspecified

R29.3 Abnormal posture

S33.6 Spain and strain of SIJ

M53.2X8 Spinal instabilities; sacral and

sacrococcygeal region

M62.0 Diastasis rectus

M53.2X7 Spinal instabilities; lumbosacral region

M62.830 Muscle spasm of back

M25.55 Pain in hip (R:M25.551/L:M25.552)

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Assessment Scale Recommendations

Pelvic Girdle/SIJ Pain

Pelvic Girdle Questionnaire

Low Back Pain

Oswestry Questionnaire

General Function:

SF-8

Questions?

Also, make plans to join us

for:

Postpartum Recovery:

Improving Function for

Mothers

November 30th

[email protected]

Documents

Post- Partum Recovery: Improving Function for Mothers Dr