Exercise prescription in Post-natal period

-Ms LenitaModerator- Ms Sidhi Mohopatra

• Post- after Natalis- birth

• The period beginning immediately after the birth of a child and extending for about six weeks.

• The average hospital stay for spontaneous vaginal delivery (SVD) is 1–2 days, and the average caesarean section postnatal stay is 3–4 days.

• The mother is monitored for bleeding, bowel and bladder function, and baby care.

Post-partum phases• (Postpartum period: three distinct but

continuous phases. Journal of Prenatal Medicine 2010; 4 (2): 22-25. Mattea Romano, Alessandra Cacciatore , Rosalba Giordano and peatrice La Rosa.)

Phase Duration Main features

Phase 1 (acute phase) 6-12 hours Period of crisis

Phase 2 (sub-acute) 2-6 weeks Major changes

Phase 3 (delayed post-partum)

Up to 6 months Residual complications

Musculoskeletal Neurological

Laxity of ligaments and muscles

Nerve traction injuries

Diastasis Nerve plexus injuries

Decreased mechanical control of abdominal corset

Compression syndromes

Weakened pelvic floor muscles

Bladder/ bowel dysfunction

Back pain Analgesia induced sensory and motor deficit

Musculo skeletal adaptations

• Anatomical and physiological changes during pregnancy have the potential to affect the musculoskeletal system at rest and during exercise.

• The most obvious of these is weight gain. • The increased weight in pregnancy may significantly increase the

forces across joints such as the hips and knees by as much as 100% during weight bearing exercise such as running.

• Such large forces may cause discomfort to normal joints and increase damage to arthritic or previously unstable joints.

• Because of anatomical changes, pregnant women typically develop lumbar lordosis, which contributes to the very high prevalence (50%) of low back pain in pregnant women.

• Balance may be affected by changes in posture, predisposing pregnant women to loss of balance and increased risk of falling

• Numbness of the perineum in the first few hours.• Pain caused by labial tears, episiotomy, oedema and

haematoma.• PFM contractures.

• Increased urine output.

• Urgency, pain on micturation, stress incontinence, retention of urine and occasionally faecal incontinence.

• Women who have had an epidural may have impaired bladder sensation.

Genito-urinary

Vascular Psychological

edema Postpartum depression

Varicose veins Baby blues

DVT Baby pinks

Pulmonary embolism

thrombophlebitis

Impairments Tool

Pain VAS

Pelvic floor weakness digital examination

Abdominal muscle weakness

Palpation

Urinary incontinence Pad method, voiding diary.

Fatigue Brief fatigue inventory

Impaired bladder sensation/ volition

Bowel/ bladder exam

Diastasis Palpation

Compression injuries Sensory, motor exam, NCV

Activity Limitation

Impaired bed mobility

Difficulty in moving out of bed and ambulation

Discomfort while laughing or sneezing

ADL dependence

Thomson`s et al (2002) study proposed (n=1295) that: - - Primiparas= were most likely to report perineal pain and sexual problems. -Caesearean births (when compared to unassisted vaginal deliveries) .Were most likely to suffer exhaustion and bowel problems.Reported less perineal pain and urinary incontinence .Were most likely to be readmitted. -Forceps delivery (when compared to unassisted vaginal deliveries) Reported more perineal pain

Symptoms to look out for / consider referral on include: - Diastasis rectii abdominis- Inability to voluntary contract the pelvic floor - Perineal pain or discomfort - Symphysis pubis pain or referred pain - Back pain or discomfort

• Mother should be encouraged to be mobile and thereby reduce the risk of circulatory and respiratory dysfunction

• If confined to bed for prolonged period of time- controlled and deep breathing exercise and vigorous circulatory exercises should be encouraged

• Pelvic floor muscle exs- for strengthening and pain relieving properties.

• Finding the right starting position for the exercise will be the key to effectiveness.

essential point- •Contract the pelvic floor muscles every time the intra-abdominal pressure increases •A more efficient contraction may be obtained by contracting the transverse abdominus, before engaging the pelvic floor muscles.

Type Mode Intensity Frequency Duration Progression

Aerobic walking, aerobicdance, swimming, cycling.

Moderate 3-4 METS. 50-60% VO2 max. RPE: 12-16

30 minutes per day most days of the week.

20-60 minutes as per patient tolerance.

Increase exercise duration slowly.

FlexibilityAquatic exercise

ROM ex’s full mobility

Strength Light weights/increased reps.

12 reps, individually tailored with monitoring.

Precautions: supine position, increased joint compression.

Procedure indications Precautions

“Squeeze and lift”Slow and fast contractions3 sets of 8-12 contractions.

Urinary incontinenceFaecal “Bladder/urethral prolapseNerve injuries

Hypertensive patients.Full bladder Prevent breath hold

Stage Procedure Precautions Progression

Stage 1 The deep abdominals

breathing control Prone, side-lying and quadruped.5-10 reps.10 second holds 10 times

Stage 2 the pelvic tilt.

Avoid tightly flattening abdomen.

Stage 3 the head lift

Avoid sit-up, twisting

Progress to shoulder lift

• ABSOLUTE CONTRAINDICATIONS TO EXERCISE (ACOG)

• Haemodynamically significant heart disease • Restrictive lung disease • Functional weakness of cervix • Premature labour during the current pregnancy • Ruptured membranes

• REALTIVE CONTAINDICATIONS (ACOG) • Severe anaemia • Unevaluated maternal cardiac arrhythmia • Chronic

bronchitis • Poorly controlled type I diabetes • Extreme morbid obesity • Extreme underweight (body mass index <12) • History of extremely sedentary lifestyle • Poorly controlled hypertension • Orthopaedic limitations • Poorly controlled seizure disorder • Poorly controlled thyroid disease

• Head should be in line with the trunk• Maintain natural curves of the spine• Avoid hyperextension• Avoid in toeing• Asymmetrical weight• Shoulders relaxed and arms held loosely at the side

• Fully supported with pillows.• Uncross legs

• Avoid sustained isometric trunk flexion, rotation.• Keep movement within sagittal plane• Perform activities at an appropriate height

• Kneel Sitting:• Bilateral

• Half kneel sitting:• Unilateral-sitting on one Heel,other hip forward flexedWith foot flat on the floor

• Nappy changing--Nappy changing is a another activity that can result in pain

-Positions that increase the risk to the mother should be avoided for eg sitting with knees extended and trunk flexed

-erogonomic positions should be explained to the mother

-suggested positions for nappy changing could be sitting standing and kneeling

• Meditation

• Mental imagery• Deep breathing• Yoga• Jacobsson’s Technique

• Progressive relaxation technique

Musculoskeletal

Genitourinary

Neurogenic psychological

Circulatory

Conditions Diastasis RectiBack painCoccdyniaSymphysis pubis painAfter pains

Stress incontinencefaecal incontinencePerineal tearsLacerationsGenital prolapse

Plexus injuriesCompression syndromes

Postpartum depressionMaternity bluesPuerperal psychosesPND

Varicose veinsEdemaSuperficial vein thrombosisDVTPulmonary embolism

Treatment Thermal/cold modalities, Mob, Relaxation, muscle re-education

PF ex’s, timed voiding techniques, catherterization.

NMES, muscle re-education,

Hospitalization, anti-psychotic drugs, counseling.

Stockings, elevation, ATM’s, general ex’s.

Perineal pain

• Pelvic floor muscle exs- - repeated voluntary contraction and relation will relieve the pain..............repeated pumping action assist venous and lymphatic drainage and the removal of traumatic exudates, thus relieving stiffness and restoring function.

• Ice ( moore & james 1989) compared 3 topical agents with cold therapy in the treatment of post episotomy position. Ice gave better pain relief

• Crushed ice wrapped in a damp disposable gauze or a disposable wash cloth and applied to the affected are for 5-10mins (plastic acts as an insulator therefore effectiveness is reduced)

• Ice cube massage-an ice cube held in a tissue and used by the woman herself while on the bed or sitting in the toilet can give excellent pain relief

• Ultrasound – • To increase temp, in turn increases blood flow and increases repair.

Twice daily and does not interfere with functional acivities - Treatment is best in crooked lying or sidelying position (for better visualisation of area) - Ultrasound head is then appled through a coupling gel medium, and in accordance with local infection guidelines - Pulsed ultrasound is used for analgesic and exudates removing properties - Initial treatment- 3MHz, 0.5W/cm, and 2mins per head sized area was used.

• Effectiveness of physical therapy for pregnancy-related low back and/or pelvic pain after delivery: A systematic review. 2012. (1)

• Pain showed consistent decrease.

• Stabilization ex’s performed under supervision showed better results.

• The Efficacy of a Treatment Program Focusing on Specific Stabilizing Exercises for Pelvic Girdle Pain After Pregnancy A Randomized Controlled Trial. (2) 2004.

• Significant improvements in pain, QOL and function compared to placebo.

•Stabilization exercises in postnatal low back pain. 2011. --The second group showed statistically significant differences in pain reduction.

An alternative intervention for urinary incontinence: Retraining diaphragmatic, deep abdominal and pelvic floor muscle coordinated function. 2010Improved self reported symptomsImproved quality of lifeDecreased leakageNo change in PFM strength

• A comparison of high- versus low-intensity, high-frequency transcutaneous electric nerve stimulation for painful postpartum uterine contractions. 2007

• Women treated with HI TENS experiences lesser pain and discomfort than LOW TENS.

• However discomfort of stimulation was higher in HI TENS group.

• Transcutaneous Electrical Nerve Stimulation After Caesarean birth. 2007.

• Decreased pain• Parameters used: carbon electrodes, frequency: 100 pps

and pulse duration: 140-170 msec.

• Effect of behavioural training with and without pelvic floor electrical stimulation on stress incontinence in women. 2003.

• No significant improvement in NMES group in terms of decreased leakage.

• Parameters: Frequency: 20 Hz, Current: biphasic, pulse width: 1 millisec, duty cycle: 1:1 and intensity: 0-100 mA.

• Therapeutic ultrasound for postpartum perineal pain and dyspareunia. Cochrane review. 2009

• Decreases in acute pain and edema• Increased bruising at 10 days• Decreased long term discomfort.

• A randomised controlled trial to compare the effectiveness of icepacks and Epifoamwith cooling maternity gel pads at alleviating postnatal perineal trauma. 2000.

• Ice packs showed greater beneficial effect on pain, bruising and oedema.

• Comparison of application times for ice packs used to relieve perineal pain after normal birth: a randomised clinical trial. 2007.

• 10, 15 and 20 minutes application showed no significant differences in pain.

• Adverse events from spinal manipulation in the pregnant and postpartum periods: a critical review of the literature. 2012.

• SMT could be performed safely in post-partum women with precautions.

PT treatment interventions

• 5-10 reps of each exercise.

• Bridging

Progression: weight shifts

Progression: single leg bridge

Alternate with opposite UE and LE

• 1. Ferreira CWS, Alburquerque-Sendn F. Effectiveness of physical therapy for pregnancy-related low back and/or pelvic pain after delivery: A systematic Review. Physiotherapy Theory and Practice, 2012; 1-3. (published online).

• 2. Stuge B, Lærum E , Kirkesola G, Vøllestad P. The Efficacy of a Treatment Program Focusing on Specific Stabilizing Exercises for Pelvic Girdle Pain After Pregnancy A Randomized Controlled Trial. SPINE Volume 29, Number 4, pp 351–359, 2004.

• 3. Vairajothi K, Chitra TV, Baranitharan R, Mahalakshmi V. A comparative study of the therapeutic effect of pelvic floor exercises and perineometer among women with urinary stress Incontinence. IJOPT, 2005, volume 5; number 1, pg 33-36.

• 4. Amar TA. Stabilization exercises in postnatal low back pain. Indian Journal of Physiotherapy and Occupational Therapy. 2011, Vol. 5, No.1.

• 5. Hsiu-Chuan Hung et al. An alternative intervention for urinary incontinence: Retraining diaphragmatic, deep abdominal and pelvic floor muscle coordinated function. Manual Therapy 15 (2010) 273–279.

• 6. A randomised controlled trial to compare the effectiveness of icepacks and Epifoamwith cooling maternity gel pads at alleviating postnatal perineal trauma. Midwifery, 2000; 16, 48-55.

• Hay-Smith J. Therapeutic ultrasound for postpartum perineal pain and dyspareunia. Cochrane Database of Systematic Reviews 1998, Issue 3.

• 7. Doumulin C et al. Pelvic floor rehabilitation , Part II: Pelvic floor re-education with interferential currents and Exercise in the Treatment of Genuine Stress Incontinence in Postpartum Women --A Cohort study. PHYS THER. 1995; 75:1075-1081.

• 8. Goode PS et al. Effect of behavioural training with and without pelvic floor electrical stimulation on stress incontinence in women. 2003. JAMA 2003- vol 290, no 3.

9. Stuber KJ, Wynd S, Weis CA. Adverse events from spinal manipulation in the pregnant and postpartum periods: a critical review of the literature. Chiropractic & Manual Therapies 2012, 20:8

10. Sonia MJV Oliveira et al. Comparison of application times for ice packs used to relieve perineal pain after normal birth: a randomised clinical trial. PHYS THER. 1995; 75:1075-1081.

11. Hay-Smith J. Therapeutic ultrasound for postpartum perineal pain and dyspareunia (Review). 2009 The Cochrane Collaboration.

• Textbook of obstetrics and Gynaecology Jill Mantle.

• Jeffcoate’s principles of obstetrics and Gynaecology.