Pregnancy and movement disorders
PTA 104 Orthopedic Dysfunctions

Instructional Use Statement

The following information is used for instructional purposes for students enrolled in the Physical Therapist Assistant Program at Lane Community College. It is not intended for commercial use or distribution or commercial purposes. It is not intended to serve as medical advice or treatment.

Contact howardc@lanecc.edu for permissions

Introduction

Prior to clinical education, our priority is to direct you towards tools and resources to ensure your selected interventions and patient communications are safe. The purpose of this lesson is to introduce some of the more common considerations and conditions for pregnant patients you may work with clinically or in settings specific to prevention and wellness promotion. More practice of exercise, positioning, and exercise modifications, and post-pregnancy pathologies (pelvic floor dysfunctions) will be offered in PTA 205/205L. Remember, pregnancy is considered a state of wellness.

Objectives

Describe the anatomical and physiological changes of pregnancy
Describe diagnoses resulting in musculoskeletal and cardiopulmonary impairments associated with changes during pregnancy
Identity absolute contraindications to aerobic exercise during pregnancy
Recognize common postural compensations during pregnancy
Describe precautions with positioning which prevent compromised circulation during pregnancy
Select an appropriate activity modification to prevent and/or reduce pelvic during pregnancy
Select an aerobic exercise which has minimal risk of increasing joint laxity during pregnancy

Pregnancy State on Body Structure and Function

Weight Gain	Averages up to 25-27 pounds; range associated with maternal BMI Increases stress to pelvic ligaments, which have higher elastic qualities
Change to thorax	Hormonally-induced: results in increased chest diameter, ribs flaring up and out
Ventilation	Work of breathing increases 15-20% due to increased demand, hyperventilation during pregnancy and dyspnea with mild exercise mid and late-term
Blood volume	Increases 35-50%
Blood pressure	Decreases in early pregnancy; pressure of uterus on inferior vena cava (IVC) in supine may result in hypotension; venous distension increases in LEs. Signs and symptoms of hypertension may result in serious and/or critical health compromise in the pregnant woman and fetus
Heart Rate	Increases by ~ 10-20 bpm by full term; arrhythmias may develop during pregnancy
Cardiac output	Increases by 30-60%; L side lying position minimizes compression from uterus to aorta
Musculoskeletal	Abdominal muscles are maximally lengthened and functionally weaker Reduced ligamentous strength throughout results in hypermobility/instability of joints and fascia Increased demand on pelvic floor muscles Postural compensations with potential long-standing changes
Metabolic	Average 300 Kcal/day needed during pregnancy due to increased metabolic rate
Endocrine	Enlarged adrenal, thyroid, parathyroid, and pituitary glands; relaxin and other hormones increases laxity
Neurologic	Nerve plexi and peripheral nerve compression due to fluid accumulation and structural changes
Gastrointestinal	"Morning sickness", nausea and vomiting; increased likelihood of reflux, constipation, heartburn, hemorrhoids, etc.

Anatomical Internal Stabilizing Unit - The Lumbopelvic "Core"

Abdominal lengthening, pelvic floor lowering, diaphragm elevation, and increase laxity all contribute to movement dysfunctions and neuromuscular and/or musculoskeletal pain and decreased movement function with pregnancy

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3987347/

Changes in Posture and Balance

Show activity http://www.flickr.com/photos/mahalie/144905384/

hyperextension at knees and weight shift toward the heels (posterior) compensates for increased weight of fetus; results in changes to gait pattern
waddling gait is attributed to posterior weight shift: note the wider base of support and increased external rotation at the hips

Complications associated with pregnancy

Hypertension

Monitor BP at rest and during activity and check for signs and symptoms of emerging hypertension, such as headache, altered vision, significant shortness of breath

Diastasis Recti

Separation of rectus abdominus at linea alba; Diagonistic criteria is >=2cm; condition is not exclusive to pregnancy; may result in abdominal herniation requiring surgical intervention

Postural Back Pain

Prevalence is 50-70%. Treatment plan is similar to treatment in patient population where instability, body mechanics, and postural compensations are primary impairments. Deep heating agents, electrical stimulation and traction are generally contraindicated.

May also present as peripartum posterior pelvic (SI) pain

Coccydynia

Pain in coccyx (tailbone) region; painful sitting; may require manual adjustment for pain relief

Symphysis Pubis Dysfunction and Diastasis Symphysis Pubis

Pubis separates; Pain when lifting one leg at a time, in/out of bed and car, walking up stairs, and transitional movements. Symptoms may not be relieved with rest or decreased WB. Emphasis is on exercise and activity modification and stabilization to decrease torsion.

May benefit from a stabilization belt or Mother-to-Be corset

Varicose Veins

Increased leg discomfort or "heaviness". Increased risk for DVT due to stasis in LEs. May need compression stockings to facilitate venous return. Can also affect pelvic floor vessels (hemorrhoids)

Joint Laxity

Decreased tensile strength during pregnancy and up to 5+ months post-partum;

Emphasis is on activity modification and aerobic exercise which minimized WB stresses

Nerve Compression

Attributable to postural changes, fluid retention, hormonal changes, circulatory changes.

Carpal tunnel incidence is higher during pregnancy.

May benefit from splinting as well as activity modification to decrease stress/strain to nerve pathways

Cesarean Birth

Gentle mobilization of soft tissue and postural/body mechanics education; instruction in anterior lumbopelvic splinting techniques during acute healing phase to protect incision from strain

Urinary Incontinence

Diastasis Recti Test

Although predominantly related to pregnancy, diastasis recti, a separation or stretch of the linea alba can occur in men

Activity Modification for Posterior Pelvic Pain and Pubis Dysfunction

Goal is to increase symmetry through the pelvic region to minimize strain to joints

sidelying with pillow between knees
avoiding hip abduction positions/exercises
avoiding/minimizing activities which require WB through a single leg (ex. instruct on step-to vs. step-over-step during stair climbing)
avoid sitting on soft surfaces to decrease demand on static and dynamic posterior and anterior pelvic stabilizers
instruct in moving both legs together in/out of care and in/out of bed

Show quiz question

Introduction to Exercise Considerations During Pregnancy

Be sure to check the patient's history and with the supervising PT about risk factors, particularly prior pregnancy-related complications, diabetes, and prior fitness level
Low to no-impact exercise activities are preferred due to the increased laxity within the musculoskeletal system
Relative perceived exertion (RPE) should be mindful of increased blood volume and cardiac work during pregnancy. Guideline is not to exceed 6-7/10 RPE.
Avoid exercised-induced overheating to protect fetal health and development
Supine positioning can result in increased compression to the inferior vena cava from the uterus; avoid prone positioning
One in 10 (1:10) women have been shown to have chronic post-partum pelvic pain

limit supine positioning to <=5 minutes due to risk of postural hypotension
instruct in positioning techniques to minimize risk when supine

Gentle and progressive spinal stabilization and postural control exercises should be included as tolerated during pregancy and post-partum
Stress incontinence may begin during pregnancy and persist post partum; treatment can include biofeedback and internal mobilization in addition to targeted pelvic and core muscles
Sample Programs

https://www.therapeuticassociates.com/pregnancy-exercises-to-help-strengthen-your-pelvic-floor-core-and-posture-muscles/
www.jospt.org/doi/pdf/10.2519/jospt.2014.0505

Supine pregnant.jpg

Criteria for Discontinuing Exercise

If any of these are observed during supervised exercise, communicate with your supervising PT and their physician. PTAs educate patients in signs and symptoms of overexertion for self-monitoring during unsupervised exercise

Persistent pain in chest, pelvic girdle, or low back
Leakage of amniotic fluid
Uterine contractions after exercise (mild uterine cramping during exercise is a normal exercise response)
Vaginal bleeding
Decreased fetal movement
Persistent shortness of breath
Irregular HR/tachycardia
Syncope
Swollen, hot calf (think "DVT")
Difficulty in walking

Recall your knowledge of general medical conditions: when there are signs and symptoms of infection, inflammation, or metabolic disorders, exercises may require modification or physician clearance may be needed to insure exercise can be applied safely.

Absolute Contraindications for Exercise

Patients in high risk pregnancy categories may not be able to safely participate in any form or mild to moderate exercise. Absolute contraindications include:

Incompetent cervix (early dilation)
Vaginal bleeding
Placenta previa (potential instability of placenta)
Twins, triplets, etc (multiple gestation)
Pre-eclampsia ( pregnancy-induced hypertension)
Rupture of membranes (loss of amniotic fluid)
Premature labor - labor begins <= 37th week of gestation
Comorbidities (hx of heart, thyroid, and /or respiratory disorder
Maternal Type 1 diabetes
Slowed uterine growth