Commonly Treated Conditions- Pregnancy and Postpartum Rehab

The Pregnancy and Postpartum Periods
The prenatal period is a time of great change for a woman, physically, emotionally, and hormonally. As the fetus grows, the overall musculoskeletal system is challenged by altered posture, shortened muscles, potential muscle imbalances, and changes in spinal mobility. These changes may cause pain and dysfunction. In the postpartum phase, fluctuating hormone levels combined with additional physical changes as a result of delivery may also result in musculoskeletal problems such as excessive joint mobility, weakness of the core stabilizers, and altered spinal mobility and function.

What causes dysfunction in the prenatal and postpartum periods?
Fluctuating hormone levels in both the prenatal and postpartum phases may cause excessive joint mobility which can cause pain and dysfunction. Because of the postural changes associated with pregnancy, some muscles become tight to support the changing posture, while others are stretched and become weak. This results in muscle imbalance and a potential for decreased stabilization. Mobility of the spine can be affected in both the prenatal and the postpartum periods as the spine adjusts to the changing posture as the baby grows.

What are symptoms of musculoskeletal dysfunction during the prenatal and postpartum periods?
Symptoms of dysfunction may include pain in the joints of the pelvis or spine, muscular pain in the hips and L/E's, or numbness into the extremities. Weakness may be present in the abdominals, resulting in pain with transitional movements or lifting. Weakness may also be manifested as urinary incontinence in the postpartum period. Muscle imbalance may also cause pain or contribute to urinary issues in the postpartum phase.

How can physical therapy help?
Physical therapists are skilled in evaluating and providing patient centered treatment of musculoskeletal problems. Physical therapists trained in the area of women's health have further knowledge about issues directly related to women as they move through different stages of life, from childbearing years to the post menopausal period. Physical therapists can provide hands on treatment to address spinal and pelvic joint dysfunction, instruct in exercises to address muscle weakness and imbalance, and provide guidance and instruction related to modifications of activities of daily living that may be difficult during the prenatal and postpartum phases.

Who should be referred to a Women's Health Physical Therapist?
Those with:

• Back, sacral, hip, pelvic, rib pain
• Pain in the neck or upper back
• Headaches
• Sciatica, carpal tunnel, thoracic outlet or other nerve symptoms
• Decreased ability to do normal daily activities
• Weak or tight muscles
• Pelvic pain with sexual intercourse, use of tampons or gynecologic exam
• Desire to start or continue an exercise program
• Urinary incontinence

Exercising After Baby
Have you recently had a baby? Are you beginning to think about returning to exercise? Many women begin to think about exercise about 6 weeks after delivering their baby. Although they are still getting to know their new bundle of joy and are still nursing, the new Mom may begin to think about returning to an exercise routine. Questions new mothers have include: How will exercise affect breast milk quality? , When can I begin an exercise routine? How do I get started? and What exercises are good for my weak tummy muscles? A physical therapist trained to work with post-partum women can help to answer some of these questions for you.

Returning to exercise must be done gradually. It is necessary for the new Mom to check with her obstetrician or midwife before resuming an exercise program. Generally, women are given the o.k. to resume an exercise program at their 6 week post-partum visit. If you have experienced a caesarian section, traumatic vaginal birth, large losses of urine, pelvic pressure, heavy bleeding, pain or breast infections please consult with your M.D. before resuming your exercise routine.

It can take a woman many months, a year or more before she feels like she has returned to her pre-pregnant self. Some women may never return to their pre-pregnant level of strength. Women who do not regain full abdominal, pelvic floor and back strength are at potential risk for future injuries.

Your exercise program needs to make you feel good. While exercising, continually monitor how you are feeling. Listen to what your body is telling you. Stop when you are fatigued and do not exercise to the point of exhaustion. It is essential to maintain an adequate fluid intake. This is especially important for breastfeeding moms. Keep a water bottle with you before, during and after you exercise. Also, allow time for adequate rest.

A new mom’s exercise routine must include" Kegels" (pelvic floor muscle strengthening exercises), abdominal strengthening and a cardiovascular component. It is especially important for the new Mom to pay strict attention to correct posture while exercising and while caring for her baby. The loose abdominal wall and increased breast weight during the postpartum period creates abnormal stresses and strains on the postural muscles. A physical therapist can assist you to improve your posture and instruct you in exercises to strengthen your postural muscles.

Many women have concerns that exercise will affect the quality of their breast milk. A number of studies have been conducted on the effects of exercise on breast milk. One study completed by nutritionists in California found frequent, sustained, moderate to high intensity running during lactation did not impair the quantity or the quality of human breast milk. However, extremely intense anaerobic exercise (interval workouts) occasionally altered the taste of breast milk.

When the new Mother begins to exercise, she will find increased endurance, postural strength and improved flexibility. To prevent future risk of injury, it is important to regain your pre-pregnant level of strength and endurance. The Regional and State Representatives from the Section of Women’s Health are able to assist you in finding a qualified therapist in your area – just click on this link (list link for state and regional reps)

From the Women's Health Section of the APTA Written By: Susan Parker, PT

DIASTASIS RECTI
Diastasis recti is a separation of the abdominal muscles, specifically the rectus abdominal muscle, during pregnancy. Any separation larger than 2 cm or 2 finger widths apart is considered significant. It can occur above, below or at the level of the belly button. It is thought to be the result of hormonal effects on the connective tissue and the biomechanical changes that occur during pregnancy. Studies have reported the incidence of diastasis recti to be approximately 27% in the second trimester, 66% in the third trimester, and 62.5% of postpartum women within 92 hours of delivery.

Symptoms such as low back pain, due to the lack of abdominal support that helps to control the pelvis and low back, or difficulty performing tasks such as going from a laying down to sitting may result from a diastasis recti. A simple test may be completed to check for diastasis recti. The woman should be lying down on her back with her knees bent, feet flat on floor. (Remember, this position should only be maintained for a short period of time while checking for a separation if after the 4 th month.) The woman will slowly raise her head and shoulders off the floor reaching her hands towards her feet. The tester will place fingers of one hand horizontally across the midline of the abdomen at the belly button level. If a separation exists, the fingers will sink into the gap. Make sure to check above, below, and at the level of the belly button since it may occur at all three areas.

This condition can be reversed. It is important to perform corrective exercises specific for diastasis recti until there is a separation of 2 cm/finger widths or less. Once this condition has been corrected, the woman may resume regular abdominal exercises, however, should still monitor the abdominal area.
Many women may not even be aware they have a diastasis, but need help to ensure a strong and healthy life as well as preventing future injuries. For more information on diastasis recti and the correction of this condition, contact a physical therapist in your area.

From the Women's Health Section of the APTA Written by : Janet Chamberlin