PILATES FOR PREGNANCY

Transcription

1 PILATES FOR PREGNANCY

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3 3 Protect your education and your investment DO NOT PHOTOCOPY Any part of this workbook

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5 5 Contents Pregnancy Safe Exercises to Perform by Trimester The Importance of Exercise During and After Pregnancy 6 General Exercise Guidelines During Pregnancy 7 Pilates Guidelines by Trimester 8 General Pilates Guidelines During Pregnancy 9 Comfort in the Pregnancy Class 11 Postural Changes During Pregnancy 12 Performing the Exercises During Pregnancy 13 Problems Which May Arise During Pregnancy 14 Situations to Start Thinking About Referring to Another Specialist or Professional 21 Situations to Start Thinking About Stopping or Limiting Pilates 22 Post Pregnancy Post Pregnancy 23 When Can Post Pregnant Women Attend Classes? 23 Safe Exercises to Perform in the 1 st Trimester 37 Safe Exercises to Perform in the 2 nd Trimester 40 Safe Exercises to Perform in the 3 rd Trimester 42 Programs 1 st Trimester Matwork Program 44 1 st Trimester Matwork & Small Equipment Program 45 2 nd Trimester Matwork Program 46 2 nd Trimester Matwork & Small Equipment Program 47 3 rd Trimester Matwork Program 48 3 rd Trimester Matwork & Small Equipment Program 49 Post Pregnancy Matwork Program 50 Post Pregnancy Matwork & Small Equipment Program 51 Important Questions to Ask Before a Post Natal Client Resumes Pilates 23 Postural Issues Post Pregnancy 24 Performing the Exercises Post Pregnancy 26 Specific Problems Post Pregnancy 27 Why the Stomach May Still Look Large Post Pregnancy 34 When Can Post-Pregnant Women Migrate to Regular Pilates Classes? 35 Situations to Start Thinking About Referring to Another Specialist or Professional 35

6 6 The Importance of Exercise During and After Pregnancy Pregnancy and childbirth have a major impact on a woman s body, both internally and externally. During pregnancy, every system is affected, including respiratory, cardiac/circulatory, hormonal and musculoskeletal. This can lead to shortness of breath, tiredness, swelling, varicose veins, postural changes and issues such as lower back pain, pelvic joint pain, carpal tunnel symptoms, Rectus Diastasis (separation of the abdominal muscles) and urinary incontinence. Exercise is an integral part of a healthy lifestyle. It helps prevent disease, is important for healthy bones and can help reduce stress, manage fatigue and lead to a better overall quality of life. The benefits of exercise do not decrease with the onset of pregnancy, but many women are confused in terms of what they are safely capable of doing as they progress through the normal stages of pregnancy. After childbirth, women are in a state of recovery, and while there are definite limitations, exercise can facilitate a speedy return to normal physical function. Pilates is one of the best methods for exercising while pregnant, and to also regain strength after pregnancy. The highly targeted, modifiable exercises of the Pilates repertoire can effectively accommodate the needs of the pregnant and post-pregnant woman. With careful exercise selection, a Pilates program can make a woman feel stronger, improve injury and decrease the chances of any physical complications occurring. The benefits of Pilates include (but are not limited to): Minimising the physical effects of Pregnancy Building strength in a safe manner Injury management Decrease postural changes Limit the chances of new injuries Better recovery for Post-Pregnancy Maintaining mobility and independence Possible Risks While we have acknowledged the importance of exercising during the pregnancy and post-pregnancy periods, we have to respect the systemic changes that women are also going through. With the exception of those categorised as high-risk pregnancies, exercise limitations are imposed in order to decrease any physical complications for the mother. Women s bodies are particularly susceptible to injury during this time, so exercise selection is of the utmost importance. A poorly constructed program can cause the woman more harm than good. Risks can include: Exacerbating existing conditions Causing new injuries Decreasing mobility for the mother Increasing recovery time post pregnancy Developing chronic musculoskeletal issues

7 7 General Exercise Guidelines During Pregnancy All pregnant women will present slightly differently and react with varying degrees of success to different Pilates exercises. Having said that, there are some general rules to follow when facilitating a Pilates class to pre and post-natal women: 1. Maintain a moderate intensity Due to the cardiac changes, the body is already in an exercised state. Even at rest, the body is already working harder than normal to sustain itself. Try not to increase the heart rate too much by limiting exercise difficulty, allowing longer breaks or by lowering the number of consecutive exercises which target the same muscle group. Unaccustomed vigorous exercise in pregnancy can place the baby at risk by causing a diversion of uterine blood to the skeletal muscles, meaning less blood and oxygen to the baby. 2. Keep cool Avoid hot, humid conditions, wear loose clothing, and stand near fan or air-conditioner if possible. Maintaining a safe temperature is of vital importance as the baby is not able to regulate temperature itself. 3. Stay hydrated Drink lots of water. 4. Warm-up and cool-down well Due to circulatory changes the mother will need to warm-up and cool-down to avoid blood pooling in the legs/feet and leg cramps. 5. Avoid prone, unilateral exercises, wide lunge/stance positions These positions can put extra stress on pelvis. The pelvic girdle and the surrounding structures are compromised during pregnancy and are more susceptible to being damaged by movements that require increased muscular control. 6. Activate Pelvic Floor muscles during all exercises to keep it as strong as possible Any form of activation and strengthening can help with post natal recovery by providing a higher baseline of strength to work with later on. As pregnancy progresses the Pelvic Floor is much harder to feel, so it is important to do as much as possible in the early stages. 7. Stop immediately if feeling unwell Stop if feeling dizzy, nauseous, if vaginal bleeding or leakage of amniotic fluid.

8 8 Pilates Guidelines by Trimester First Trimester (1-12 Weeks) The mother-to-be may be experiencing morning sickness or be feeling quite tired. This initial stage of pregnancy is where there is the most risk of miscarriage. Pilates is a safe exercise to perform, but the intensity needs to be lighter to avoid the body temperature and heart rate elevating too high, as this can increase the risk of miscarriage. The first trimester is when most of the cardiovascular changes occur cardiac output is increased by 30-50% and the heart rate increases by 15%. These changes can cause the pregnant woman to become easily short of breath and feel dizzy, especially when getting up quickly from lying down. In respect to Pilates exercises, in the first trimester, the amount of sit up abdominal exercises needs to be reduced. Performing too much rectus abdominus strengthening at this stage can increase the risk of the woman developing a Rectus Diastasis. Instead, focus more on T-Zone activation and the Pelvic Floor muscles. Exercises like Bent Knee Fallouts and Lift Foot are great for this Pelvic Floor activation. Second Trimester (13-26 Weeks) The baby continues to grow and will start to show around this time. Throughout the second trimester, there are more series of positions and exercises which need to be avoided. 1. Avoid all abdominal work (except Double Leg Lift) During the second trimester, avoid strengthening the Rectus Abdominus. As the stomach gets bigger, the risk of a pronounced Rectus Diastasis increases with a tighter Rectus Abdominus. Direct and even strong indirect abdominal work should be avoided altogether at this time. 2. Avoid inner thigh work Avoid inner thigh work - the adductor muscles in your thighs all have a common attachment to your pubic symphysis (your pubic bone). When someone is in the advanced stages of pregnancy, their ligaments and joints become more lax. Many pregnant women experience some groin pain as the pubic bone starts to separate. Working the inner thighs when the pubic symphysis is already unstable can cause the pubic bone to separate even more, leading to more pain and discomfort. Sometimes groin pain can become so bad that it can limit a woman s ability to walk or move independently. 3. Avoid prone positions (lying on the stomach) At this stage of pregnancy, lying on the stomach becomes very uncomfortable as the baby is showing. 4. Avoid supine positions (lying on the back) Supine positions are avoided at this stage as many women feel nauseous or dizzy lying in this position. This is the result of the weight of the baby occluding the main blood vessels of the mother. In some severe cases this can cause women to lose consciousness due to the disruption in her circulation. At this stage some danger is posed to the baby as this also decreases the levels of oxygen supplied to the baby.

9 9 Some ladies may report that they feel completely fine during supine, but it is best advised to keep all class participants away from long periods of supine as there is always a chance someone can suddenly respond badly to supine, regardless of previously feeling fine in this position. Third Trimester (27 Weeks to Birth) During the third trimester, the mother s posture changes dramatically due to the baby s increased growth. A lordosis-kyphosis posture becomes more evident. For Pilates, the second trimester guidelines continue; however now avoiding ALL abdominal exercises including avoiding Double Leg Lift, as well as inner thigh work, supine and prone positions. Exercise intensity will need to be greatly decreased at this stage. Be careful with constant changes in position as it may be difficult for the woman to move around. Keep repetition rates comparatively low. Be guided by the mother s comfort levels. Mothers can continue with their workouts as long as they feel comfortable, most women will stop at 36 weeks or so, but if they feeling well there is no reason why they can t continue right through to 40 weeks. Focus on sitting, side lying and standing exercises, and focus on Pelvic Floor activation with all exercises. General Pilates Guidelines During Pregnancy How Long Can Pregnant Woman Attend Their Regular Pilates Classes? It is best to encourage women to begin pregnancy-specific Pilates classes as soon as they learn that they are pregnant. This allows you to start working on the specific things which will help their bodies cope with the upcoming months. A specialised class should not include unsafe exercises, so the expectant mother will not need to worry about hurting herself performing an exercise which she is not meant to be doing in the first place. Pregnant women should be participating solely in pregnancy classes by the time they reach 14 weeks. This can occasionally be stretched to 20 weeks, but left any longer, then you will need to completely modify a normal Pilates class program to be appropriate for pregnancy anyway, so it is best to change them over as fast as possible. Be aware that if you are teaching a group of participants and you are modifying a normal program to suit pregnancy, you are taking away a lot of precious time that you need to instruct the rest of the participants in your class. This can lead to poor performance and a disjointed session for all class participants. In terms of continuity, most women will want to know how long into their pregnancy it will be safe for them to continue attending classes. This will be a collaborative decision between you as the instructor and the woman herself. Women can keep up their Pilates practice until their due date, but can end sooner if so appropriate. Some of the major factors which influence this include: Comfort Can she still exercise without feeling so uncomfortable that she gets no benefit from it? Comfort can be influenced by morning sickness, predisposed injuries, and decreased mobility

10 10 Mobility Sometimes mobility is so badly affected that it is even hard to change positions. Moving around can also be painful, so if it takes longer for someone to change position than the time taken to perform an exercise, it is probably time to think about planning to cease practice until after she has had her child. Injuries Previous injuries, or new problems caused by the laxity of the skeletal system can also start to limit the number or type of exercise which a pregnant woman can perform. Occasionally musculoskeletal issues can become so severe that exercise can be prohibited by an overseeing health professional. Pregnancy classes should be programmed so that it only includes exercises that are safe to do throughout the entire pregnancy. In saying that, there still may be some exercises that certain women find uncomfortable. This will vary between each person and as in any normal class, you can modify or give a different exercise accordingly. Important Questions to Ask Before You Start the Class It is important to obtain some baseline information from all women intending to join your pregnancy classes. The individualistic nature of every pregnancy means that certain people will respond very differently to your program, and even respond differently with the same exercise. Asking a few important questions will give you some insight on to how that individual will cope during the class. 1. How many weeks pregnant are you? This is obviously very important, as programs vary by large margins dependant on the trimester. You will be able to determine exercise type and intensity easily by knowing how many weeks pregnant someone is. 2. How many children have you had previously, and if so how did your body hold up? This gives you an indication of any previous injuries or problems they may have experienced and an idea of how the pregnant woman s body will respond to her current pregnancy. For example, if your client has had several children and experienced debilitating back pain with each, do not be surprised if the same thing happens again. Modify the program to deal more with back care. 3. Has your doctor (or health practitioner) given you any specific exercise limitations? A woman may be given specific exercise limitations due to medical issues such as blood pressure, blood clots, or an incompetent cervix/multiple miscarriages, as well as musculoskeletal pain. It is common for pregnant women to be seeing a doctor, physiotherapist, chiropractor, etc. to help deal with any aches, pains or concerns. It is best to keep continuity of care and abide by the recommendations given by an overseeing health professional. This may be suggestions such as staying away from overhead exercises or focusing on specific muscles to strengthen. 4. Do you have any current pain? This will largely influence what you will be focusing on with Pilates. Injuries will decide which exercises will be appropriate there is no point in programming a lot of arm exercises with

11 11 someone who is experiencing Carpal Tunnel-like symptoms, as this will make the problem even worse. 5. Are there any positions that you are finding uncomfortable? While side lying is generally well tolerated, there are some instances where this will not be the case. Persisting with an already uncomfortable position will only lead to more problems in the long run. Comfort in the Pregnancy Classes As mentioned previously, comfort is one of the limiting factors which can prevent women from continuing Pilates until their due date. By making women feel as comfortable as possible, you will be increasing their desire to persist with an exercise routine. Lying on the back and stomach will become increasingly uncomfortable for most pregnant women from the second trimester of pregnancy and that is why there are no exercises in the class in these positions. Also remember that lying down on the back can cause dizziness and shortness of breath rather quickly with some women. If someone has really bad morning sickness and nausea, sometimes lying down on the side can even be uncomfortable. As such, you may need to give alternate exercises. Try exercises that are in more upright positions. If someone has bad reflux or heartburn, you may need to avoid any lying down at all. Find alternatives in standing and sitting positions. If you want to try and persist with side lying, having a few cushions underneath the head can have some symptomatic relief. When using the cushion, make sure the head is slightly elevated. When in the side lying position in the third trimester, some women will find it more comfortable for their stomach to be supported. This can be achieved by placing a small cushion underneath the stomach, which will stop them from rolling forwards due to the weight of their stomach. You may not need to do this with everyone in the class. Some women will also feel more comfortable with a pillow between their knees in sidelying. If you do not have cushions, you can use rolled up or folded towels and jackets. As women become more pregnant, they will find it harder to get up and down off the floor. Changing positions will just generally become much more difficult and time consuming. Keep positional changes to a minimum and if you are using Pilates equipment, keep it close to the woman. Alternatively, plan to give them the equipment yourself. Expect your clients to be a bit more dependent on you as opposed to clients in a normal Pilates class.

12 12 Postural Changes During Pregnancy Progressions of spinal position during pregnancy Pregnant women will always move into a lordosis-kyphosis type of posture, particularly as the pregnancy progresses. The pelvis anteriorly tilts (causing an increased arch of the lower back) The shoulders will round/scapula will protract The arches of the feet flatten due to ligamentous laxity, and the knees often roll in The centre of gravity will move forwards All of these changes are due to the increasing weight of the baby, breast size and ligamentous/structural laxity of the skeletal system. As such, there are some general guidelines for structures to strengthen and stretch as the lordosis-kyphosis posture tends to follow a standard pattern of muscle imbalance. Important Muscles to Stretch For pregnant women, the important muscles to stretch are going to be: Quadriceps Hip Flexors Gluteal Muscles Calves Pectoral Muscles Latissimus Dorsi Lower back muscles/quadratus Lumborum

13 13 Important Muscles to Strengthen For pregnant women, the important muscles to strengthen are going to be: Pelvic Floor The sustained pressure on the Pelvic Floor will prove to be difficult to overcome during the later stages of pregnancy. Try to do as much Pelvic Floor work in the early stages to obtain good strength and activation. Pelvic Floor work should be part of a home exercise program. Transversus Abdominus (TA) As the baby matures, the strength of the TA decreases along with the ability to activate it easily. TA strength helps manage back pain and pelvic stability. TA work is safe as it does not make a Rectus Diastasis worse. TA exercise should also be practised at home for best results. Gluteals Gluteal strength is very important as it helps with pelvic stability as well as lower back and hip pain. Good gluteal strength will help with ambulation (walking) and general mobility. Along with the T-Zone, gluteal strength is top priority. Lower Trapezius and Rhomboids As a woman s posture moves towards a thoracic kyphosis, it will be really important to address the regression of her posture. Strengthening the major scapular retractors will counteract postural changes, and will maintain healthy scapular rhythm. Correct scapular movement decreases the chances of head, neck and shoulder pain. Arm Muscles This is more so a bit of forward planning. The physical demands of carrying a baby, picking up a baby, and pushing around heavy objects like prams will require above average arm strength levels. Performing the Exercises During Pregnancy There are some small differences in the way you should be facilitating a pregnancy class in order to get your clients the best result. Resistances, exercise intensity and modifications will usually need to be a bit lighter than what you would normally prescribe for that same person if they were not pregnant. This is due to the lower level of core stability, not only in the trunk, but also in the stabilisers of all your limbs. Force is not distributed as well throughout the body, which means you are generally a little weaker than normal. The movements should be slower and controlled with a lot more focus on their technique, correct posture, and correct activation of all of the stabilising muscles. It is more about control and muscle activation with a moderate workout intensity rather than pushing people to their physical limit. Cue your clients to lift and tighten the Pelvic Floor with all exercises, as this is really important

14 14 Especially during the second and third trimester, using the cue ribs to hips will be irrelevant as the women will not be able to activate their abdominals properly due to the baby. Instead, focus more on cueing the TA and Pelvic Floor. In saying that, you will still need to make sure that there is no excessive arching through the lower back. Correcting rib position can help with this greatly. Allow the women to rest if they require - they will get short of breath much more quickly than usual and this is normal. Sometimes they may even feel dizzy, and need more frequent rests to have a drink or catch their breath. The pregnancy class is not a time to keep pushing them if they feel they need a break. Problems Which May Arise During Pregnancy Musculoskeletal Issues Several hormonal changes occur as a result of pregnancy, some of which relax the ligaments of the mother in preparation for childbirth. Unfortunately this makes the mother more hypermobile and prone to injury. Improving the strength of the stabilising muscles is therefore very important to prevent injury and help pain, as the muscular system will be in greater demand to provide stability for the body. The collective result of - Ligamentous changes Decreased Transversus Abdominus activation, use of the abdominals Changes in posture Can manifest as - Lower back pain Sacro-Iliac Joint (SIJ) and hip pain Pubic Symphysis Joint pain and instability Upper back, shoulder and neck pain Neck, Shoulder and Upper Back Pain With the onset of the increased thoracic kyphosis and breast size, the muscles of the shoulder girdle and neck can become overburdened and very tight. This can cause neck, upper back and shoulder pain. Symptoms Decreased range of motion in the neck and shoulders Headaches Pain and stiffness in the neck and upper back Shoulder impingement/pain in the shoulder joint with movements Elbow pain

15 15 Implications for Exercise Program your pregnancy classes so that most of the arm exercises target the scapular muscles, specifically the lower traps, to help increase activity and strength in the postural muscles. The muscles to target are the Lower Trapezius, Rhomboids and Rotator Cuff muscles When performing the exercises, ensure the shoulders are down and back with the chin tucked in - this applies to not only the start of the movement, but also the throughout it Depending on the severity of the postural changes, overhead or forwards reaching arm exercises may need to be either modified or omitted from the program. If they are included, limit the number of exercises that include these movements as this can exacerbate any ongoing issues. Stretch the Pecs and Lats to improve the posture and take pressure away from the joints. Treatment Pilates is a great way to help upper body pain in pregnancy, but referral to another health practitioner such as a physiotherapist can help further. The pain often cannot be completely eliminated until well after the birth of the baby when the posture and strength/stability returns to normal. Lower Back Pain The lumbar spine is one of the most common areas where women will experience some discomfort during pregnancy. Altered weight distribution, increased lumbar lordosis, increased hypermobility in the lower back joints, and weakened abdominal muscles all contribute to the problem. Symptoms Lower back pain ranges from quite mild to horribly debilitating, and can cause Decreased mobility Limited exercise repertoire Radiating pain down one or both legs Pain with walking, sitting and moving around in bed Implications for Exercise Exercises that should be chosen are the ones that will take the pressure off the back itself, and strengthen the muscles which will help support the spine. Stretch the Quadriceps, Hip Flexors, lower back/quadratus Lumborum and Gluteals. Stretch regularly during class to help keep the body from assuming bad positions, but also to give women a break from performing hard exercises. Advise clients to stand with less of an arch in their lower back. You can do this by cueing them to tuck the pelvis under slightly, similar to that of a posterior pelvic tilt. This cue can often take a lot of pressure and discomfort away from pregnant women and can be the difference between them continuing with an exercise or stopping altogether. Work on strengthening the T-Zone, Pelvic Floor and Gluteals as these will provide the most amount of support of the lower back.

16 16 Avoid any exercises which hurts the person s lower back. Sometimes these will be exercises that are completely comfortable and safe for others. Make sure to keep resistance and intensity lighter and check correct technique and muscle activation for all exercises, even more so than in normal sessions. Treatment Pilates is a great way to help upper body pain in pregnancy, but referral to another health practitioner can help further. SIJ and Pubic Symphysis Pain The Sacro-Iliac Joint (SIJ) and Pubic Bone are some of the main structures to feel the systemic effects of pregnancy. As the pregnancy progresses, particularly moving into the third trimester, the pelvic ligaments increase in laxity, making both the Pubic Symphysis Joint and the SIJ very unstable. Along with this ligament laxity, the abdominal muscles become less effective and unable to work properly as the baby grows, and the abdominals are usually what will help to stabilise the pelvic joints as well as the ligaments. As the baby descends lower into the pelvis as the birth nears, the pelvis actually needs to expand and open to accommodate the baby s head, causing a lot of pain on both the Pubic Symphysis and SIJ. In extreme cases, the Pubic Symphysis Joint can actually separate, so that the two pubic bones can move independent of each other, which is very painful and debilitating. Pelvic alignment is often poor due to the instability at the Pelvic Joints, which can also be a cause of pain itself. Symptoms of SIJ Instability Pain over the SIJ (which will often be described as one sided buttock or lower back pain) Can be accompanied by pain radiating down the buttock and leg Pain on weight bearing on that side Pain with asymmetrical movements such as walking, stepping onto things, moving one leg Pain with twisting or turning around, both standing and in bed Pain with prolonged periods of sitting or standing Moving between positions can very difficult and/or painful. Especially lowering down to the floor/getting up from the floor, rolling over in bed/on the floor Walking and ambulation can be so painful that walking aides (ie. crutches) may be needed Symptoms of Pubic Symphysis Problems Pain on touching pubic bone Pain radiating in the groin/inner thigh Pain with asymmetrical movements, such as walking, stepping onto things, moving one leg Pain with twisting/turning around, both standing and in bed Pain with abducting (opening) the legs Pain with any inner thigh exercises (adductor exercises) Moving between positions can very difficult and/or painful. Especially lowering down to the floor/getting up from the floor, rolling over in bed/on the floor Walking and ambulation can be so painful that walking aides (ie. crutches) may be needed

17 17 Implications for Exercise Exercise and selection of positions is based on performing movements which will not destabilise the Pelvic Girdle. Using exercises that do not apply any shearing forces through the groin or Sacrum will be the safest. Take care with asymmetrical hip and pelvic movements as these can tend to flare up a sore and unstable Pubic Symphysis. Generally, lunges should be avoided. In terms of Matwork exercises, Kneeling Sidekick (of the Kneeling Series) is a prime example of an asymmetrical movement that pregnant women will not respond to well. Women will respond better to symmetrical exercises such as squats. Take care not to open the legs/abduct the hips too far as this can cause the pubic symphysis to separate more. This means that even though someone may be able to physically move their hip joints through a really large range of motion, this is not advised. Avoid using the adductor/inner thigh muscles at all - they attach onto the pubic bone and strong contractions (both bilateral and unilateral contractions) of the muscles themselves can pull on the pubic symphysis, resulting in further separation at the joint. When side lying, class participants may feel more comfortable with a pillow between their knees Any exercises that are asymmetrical or require small amounts of abduction (ie. Clams) may be performed if the problem is mild. However, great care must be taken to keep the T-Zone tight with these exercises because as you abduct the leg, the T-Zone prevents the hip bones or ASIS of the ilium from flaring out/the pelvis opening which will cause pain. A good cue for this is thinking of drawing the hip bones towards each other along the horizontal line of the T. Treatment of SIJ and Pubic Symphysis Issues The treatment of these pelvic problems in pregnancy is often difficult as the causative factors will not be removed until the baby is born. However, strengthening the Gluteal muscles and T-Zone in a careful manner can help the problem, along with avoiding movements that cause pain. Referral to a health practitioner may be necessary and can help to improve symptoms to a certain extent. The use of a pelvic stability belt designed specifically for pregnancy can also be of assistance in increasing function and decreasing pain.

18 18 Pelvic Floor Weakness/Incontinence This is one of the major issues faced by all women during and after pregnancy. Pelvic Floor issues can not only be a major factor in physical issues, but can also be quite embarrassing for women. During pregnancy, the Pelvic Floor becomes progressively weaker as the baby grows and becomes heavier. Pregnancy Pilates needs to have a focus on keeping the Pelvic Floor as active and strong as possible so that the postnatal recovery is not so difficult. In the past, there have been arguments against Pelvic Floor training during pregnancy, however new research shows that strong Pelvic Floor muscles will not make birthing more difficult. Symptoms Some Pelvic Floor symptoms during pregnancy can include: Urge (desperately needing to go to the bathroom) Frequency (feeling like you have to go to the bathroom even if you just went) Stress Incontinence (leaking urine when performing activities such as coughing, sneezing, laughing, physical activities such as lifting things, walking, jumping Implications for Exercise As there will always be an inescapable increase of pressure on the Pelvic Floor, precautions need to be taken in order to limit any other avoidable stress. The suggested exercise precautions are to limit any more increase in pressure in the abdominal space. No direct, or even (high intensity) indirect abdominal exercises. Increased flexion of the trunk should be avoided. This is another reason why the Abdominal Curl of the Supine Abdominal Series is omitted from exercise programs from the second trimester onwards. No holding of breath during any exercise - not only is this something that people shouldn t do in normal classes, the negative effects of holding one s breath on the Pelvic Floor is immense. There may be the need to decrease the difficulty of an exercise to allow for correct breathing patterns. No heavy resistance in any exercises arm or leg exercises included Treatment The treatment is general Pelvic Floor strengthening. If needed, there are specialist Pelvic Floor Physiotherapists that you can refer to who can help with the problem. Rectus Diastasis During pregnancy, the Rectus Abdominus (or six pack muscle) needs to stretch to accommodate the growing baby. The expansion of the abdominal cavity during growth of the stomach occurs at the Linea Alba. The Linea Alba is a band of fibrous tissue that serves as an attachment point for many of the abdominal muscles anteriorly. The Rectus Abdominus attaches to the Linea Alba directly. In some cases when the Linea Alba is placed under too much pressure, it begins to overstretch. Some severe stretches can turn into tears. This stretching, and the resultant physical manifestation is known as a diastasis (or separation) of the Rectus Abdominus. The Rectus Diastasis will look like a vertical bulge or separation in the midline of the abdomen. This

19 19 bulge is more noticeable when certain movements are performed that increase the pressure within the abdomen, and looks very different to a normal contraction of the Rectus Abdominus. The increase in pressure expands the Linea Alba superficially, and is also sometimes referred to as doming The risk factors/causes of developing a Rectus Diastasis include: Small stature or frame: short waisted women have a higher chance of abdominal stretching due to the baby requiring space and it is indiscriminate of the size of the mother. A large baby will apply more pressure on the abdominal space Putting on excess weight Overly tight rectus abdominus muscles, which can be a result of previous training methods/exercise choice Performing incorrect abdominal exercises in pregnancy Exercising too hard/certain exercises in pregnancy Avoiding a Rectus Diastasis - Exercise Precautions During pregnancy, precautions are established so that a Rectus Diastasis is not exacerbated. 1st Trimester During this early phase, start to decrease the amount of sit up type abdominal exercises, and focus more on the Transversus Abdominus and Pelvic Floor. Performing too much Rectus Abdominus strengthening can increase the risk of a Rectus Diastasis in later stages. 2nd Trimester Omit any direct abdominal exercises, as the abdominal wall is generally stretched at this stage. Side lying Oblique muscle exercises can still be performed as tolerated by the mother (this doesn t have such a demand on the Rectus Abdominus), as well as sitting or standing Pelvic Floor/stability exercises. From this stage activating the abdominals and Transversus Abdominus becomes quite difficult as it becomes inhibited the larger the baby grows. 3rd Trimester No abdominal exercises are to be performed, not even the side Oblique muscles, and no lying on the stomach or back. Support using pillows in side lying positions is common as this can also take some pressure away from the Rectus Abdominus. Take care with heavy overhead arm exercises at this stage as these put the already stretched Rectus Abdominus on further stretch, and these exercises usually need a significant abdominal contraction to stabilise the spine throughout the movement as well.

20 20 Other Pregnancy Issues Morning Sickness Morning sickness is especially common in the early stages of pregnancy. The term itself can be a little misleading as the symptoms of nausea can usually extend beyond the morning and often be worse late afternoon or evening. Sometimes morning sickness can also stay with a mother all the way through a pregnancy and this can have a large impact on her ability to continue with exercise. Morning sickness can be severe with ongoing vomiting and inability to keep foods of fluids down this is called hyperemesis and usually requires medication. In regards to exercise limitations, there aren t any distinct positions or exercises to avoid. Ask plenty of questions during the class, and let women rest whenever they feel the need for it. Avoid certain positions on a case by case basis, and if there are any exercises performed on the Reformer, be aware that the constant movement of the carriage can exacerbate feelings of nausea. If symptoms are too severe then exercise may need to be ceased. Reflux and Heartburn As a baby grows, there is increasingly more pressure in the abdomen as there is less space allocated for its contents. In addition to this, the muscle atop the stomach (Esophageal Sphincter) relaxes. The combination of the abdominal pressure and muscular relaxation allow for digested food and stomach acids to travel up the throat and Esophagus, causing reflux and heartburn. Physiologically, there is nothing in the way of exercise that can improve reflux and heartburn, but precautions can be taken to decrease the chances of the symptoms occurring during exercise. Eat smaller more frequent meals and do not eat immediately prior to a class Avoid lying down exercises or put more cushions under the head to assume a more upright position Dizziness and Shortness of Breath Shortness of breath and dizziness are very common during pregnancy. An expectant mother has to deal with not only changes to her blood pressure, but with a substantial increase in blood volume. This creates a higher workload for the heart and lungs to supply oxygen to the whole body. If the cardiovascular system begins to struggle with the demand, the pregnant woman will start to experience these symptoms. To help clients cope, they can: Move slowly when getting up, down or changing position. This allows the body to adapt within an appropriate time frame Stop and take a few deep breaths if they start to feel uneasy. Then, wiggle the toes and relax.

21 21 As an instructor facilitating a class, allow: Easier modifications for exercises. If using some form of resistance, start with a lower resistance than what is normally used. Rest breaks. Clients may have to stop mid-exercise to let the body recover. Regular drink breaks Choose positions that feel more comfortable, like side lying or sitting. These do not require as much effort to maintain as opposed to standing or exercises that require large movements of the body. Cramps Cramps in the legs and feet are very common in pregnancy, and can often occur doing exercise or a Pilates class. There are several reasons why women cramp during pregnancy: Poor blood circulation in the legs Magnesium and/or potassium deficiency Calcium deficiency Dehydration Overexertion of the calf muscles while exercising Over-pointing the toes in Pilates exercises Insufficient stretching before exercise Infrequently, malfunctioning nerves, which could be caused by a problem such as a spinal cord injury or pinched nerve in the neck or back There are several things that you can do to help prevent cramps during your classes: Try not to point the toes too hard, keep the foot relaxed or move into dorsiflexion rather than plantarflexion When standing, try not grip onto the floor with your toes Choose an easier exercise, or do less repetitions Change body parts that you are exercising more regularly ie shorter series of exercises Drink lots of water and don t get too hot Stretch before and during the class and if you get a cramp Advise your clients to drink lots of water, look at their calcium and magnesium in their diet and stretch a lot at home. Situations to Start Thinking About Referring to Another Specialist or Professional There will be times where intervention from another health professional or specialist will be required. Whilst Pilates is an excellent and safe form of exercise, the effects of pregnancy can be so aggressive that exercise cannot deal with the resultant issues. During these instances, help is needed from another professional. Pain Which is Becoming Progressively Worse Most women will be dealing with some form of discomfort or pain. To a certain extent this is normal. Think about referring to someone else when that pain becomes considerably worse, especially if the increase in discomfort and/or pain is sudden.

22 22 Rapidly Decreasing Mobility Pre-existing injuries can be exacerbated by the musculoskeletal changes during pregnancy, and can have a profound effect on a woman s mobility. If a woman starts to have increasing difficulty moving from position to position, or needs walking aids to move around, then they should see another professional. New Injury An expecting mother does not need to have a history of injuries in order to be uncomfortable during pregnancy. If she develops moderate groin, hip or lower back pain, monitor the injury and pain levels every session. If Pilates does not help decrease the symptoms, think about referring onto someone else. Referral sources can be from your own network, or the client s known health practitioners. If you are thinking about referring to another health professional, ensure that you give accurate records and descriptions of the problem you want to be addressed. Health practitioners to refer to: Treating Doctor Physiotherapist Occupational Therapist Musculoskeletal Therapist Massage Therapist Chiropractor Osteopath Situations to Start Thinking About Stopping or Limiting Pilates Whilst Pilates can be performed through a full term of pregnancy, there will be instances where a mother will have to either decrease the frequency of her Pilates, or stop altogether. This sometimes cannot be controlled regardless of the skill of the instructor. A discussion should be had with the client about when it is appropriate to start tapering or ceasing the practice of Pilates, as in most cases, the woman will not know when to stop. Please note that this is a highly individual matter and can be difficult to predict when someone will want to stop their Pilates. Talk to your client about altering/stopping their Pilates program when: All exercise hurts or is creating too much discomfort Persistent morning sickness stops them from attending consistently The ability to perform exercises correctly diminishes. This means that even safe exercises are uncomfortable and cause pain Exercise makes the client become tired way too quickly and struggles to recover for the rest of the day The treating doctor has ordered to cease exercise. This can happen with pregnancies that are deemed high risk Exercises are hurting in all the wrong places, even with corrections to technique

23 23 The client feels either really uncomfortable or completely exhausted after each session Post Pregnancy Postnatal recovery will be largely dependent on the physical state the mother was in before pregnancy and any complications that may have surfaced during the gestational period. With careful exercise selection and observation, Pilates can be used to help aid a quick recovery and leave the new mother with as little complications as possible. When Can Post Pregnant Women Attend Classes? For any women intending to return to exercise after a pregnancy, it is recommended that they be cleared by their treating doctor for any possible complications. Issues during or directly after the birth can occasionally prolong the ability for the mother to exercise safely. As a general rule, women can begin some basic Pilates training 4-6 weeks post-birth. A caesarean birth will be more likely to push exercise back to 6 weeks post birth or later. Before commencing any exercise program, some important information about the birth and mother needs to be gathered in order to develop a program that will suit your client. Important Questions to Ask Before a Post Natal Client Resumes Pilates The following questions will provide enough information to start building a program - what exercises to do or focus on, and also the exercises which need to be avoided. Indications regarding prognosis and the possible rate of physical improvement are another priority of asking these screening questions. 1. What type of birth did you have? Caesarean births require the surgical cutting/separating of the abdominal muscles during the birthing procedure. This makes the muscles around the trunk even weaker than normal, so care must be taken when progressing exercises that may put too much stress on the abs. In most cases, women will be able to resume exercises 4-6 weeks post-birth. A caesarean birth will be more likely to push exercise back to 6 weeks post birth or later. 2. Have you been checked by your doctor yet? Although this sounds trivial, some mothers may not ask their doctor when it is safe to return to Pilates. Be aware that sometimes when a client has been directed not to exercise, this could mean types of exercise like running or heavy resistance training. Pilates can be started much earlier in the recovery period in comparison to general physical training. 3. Did you have any complications such as pelvic floor issues or abdominal separation? Vaginal tearing or other musculoskeletal issues can occur during birth. This will limit the speed of progression, and care needs to be taken so that the complications are not made any worse. Ask the mother if there have been any restrictions placed by their treating doctor. 4. Have you experienced any pain since you gave birth, and if so, has the pain progressed?

24 24 Back, hip, pubic bone, shoulder and neck pain are all common ailments following not only the birth, but also the proceeding nursing involved with taking care of a newborn. Ask about any injuries, but also how they have developed. Is the pain getting worse or better, and is she seeing anyone for treatment of these problems? Someone who is improving over the weeks will not need to tread so carefully with exercise intensity as opposed to another who is battling every day with pain. 5. Have you found anything unexpectedly difficult to do? Sometimes it is better to indirectly gather information about injuries by asking what functional activities have been difficult. Clients may not complain of their back being sore but will immediately tell a story about having a hard time standing up from a chair due to pain. 6. Mobility questions Have you been able to move around without any problems? How have you been with carrying your baby around, picking them up off the floor, etc? These questions can gauge current physical endurance/stamina and movement issues. 7. What exercise have you done so far, and how has your body responded? This is a great question as you will have direct data on what level of intensity and types of movements your client has been exposed to. For example, if a client has tried to go for a light jog and within 5 minutes developed some hip pain, exercise focus should be on the hip abductors and extensors. There are some other questions not related to the birth, or post-birth that can be useful. These attend to previous history, and during pregnancy - quite important if the client is unknown to you. 8. How many children have you had? It can be harder to recover from several pregnancies as opposed to just one. The mother s age during the previous pregnancies can provide further information regarding recovery. Although health care is continually improving, the younger female will generally cope with the physical adaptations of pregnancy much better than someone who is significantly older. 9. Were you suffering from any pain or injuries before you were pregnant? Pregnancy will not magically heal or fix any previous injuries and sometimes they will gradually worsen. Avoid exercises that will further exacerbate any existing comorbidities. 10. How did your body hold up during pregnancy? Any pain that developed during pregnancy will more than likely still be present, possibly to a lesser extent. It will be important to know if there are any movements or positions that may be dangerous. Postural Issues Post Pregnancy Post-pregnancy, Pilates should be used to help correct the postural problems which developed during pregnancy. This means that the muscles to stretch and strengthen are exactly the same as when the mother was pregnant. The main difference is the relative freedom of safe positions allowed and some specific muscles that were avoided in strengthening are the main targets of the Pilates program. The abdominal muscles and Pelvic Floor are a particular focus, as these structures are the most compromised. Due to the lordotic posture most mothers take during pregnancy, Hamstring strength

25 25 is very important, along with lengthening of the Hip Flexors and Quadriceps muscle groups to help gain a more neutral pelvic position, hopefully decreasing the lumbar lordosis. Spinal mobility is another focus, encouraging some thoracic extension and lumbar flexion mobility. Important Muscles to Stretch As mentioned previously, the muscles to stretch are the same as during pregnancy. The main difference will be that there will be some improvement with diligent stretching as opposed to pregnancy where the goal of stretching was to slow the inevitable tightening of these muscles. Quadriceps and Hip Flexors Gluteals Pectoral Muscles Latissimus Dorsi Lower back/quadratus Lumborum Important Muscles to Strengthen Although care still needs to be taken, Pilates post-pregnancy has a much wider scope as there are significantly less restrictions placed on exercise selection. Programs should intend on regaining the strength of damaged and weakened muscles, but to also improve the general capacity of the mother so that nursing her new child is less difficult. Pelvic Floor By far one of the most affected muscles during pregnancy, the Pelvic Floor can also get damaged during the birthing procedure. Multiple pregnancies within close proximity of each other usually leave the mother with a Pelvic Floor that has not had the time to recover its strength. Not only does the Pelvic Floor help with continence issues, it also is an important part of the T-Zone, which greatly aids in the stabilisation of the lumbar spine. Transversus Abdominus (TA) The TA coupled with the Pelvic Floor is needed for stability of both the spine and pelvis. The TA will be very weak and is made worse with a caesarean birth. Good TA training will help with issues such as Rectus Diastasis and general low back pain. Internal and External Obliques The Obliques are one of the major muscle groups required to help control excessive movement of the trunk. Strengthening the Obliques will counteract the lordotic posture that is present throughout pregnancy and will also help with the resting rib position so that the ribcage does not sit flared out. Strengthening the Obliques also helps to decrease the pressure on Rectus Abdominus, resulting in the repair of a Rectus Diastasis. Hamstrings Partially due to postural changes, but also position limitation during pregnancy, the hamstrings are a neglected muscle group. Strengthening the hamstrings can help with controlling pelvic positioning which in turn can help with decreasing a lordotic posture.

26 26 Gluteals Strength through the pelvis and hips are incredibly important, as this helps with movement, weight transfer and distribution and injury prevention and management. Gluteal strength will not only help with this, but if a client wishes to return to her athletic endeavours, the Gluteals need to be powerful. Lower Trapezius and Rhomboids The Lower Traps and Rhomboids need to be strong in order to counteract increasing breast size and feeding. Strong Scapular muscles decreases the chances of upper back, neck and shoulder pain as it allows for efficient movement of the shoulder girdle. These muscles provide a good base for arm strength. Thoracic Extensor Muscles/Erector Spinae These help to correct the kyphosis, and as they usually require lying on your stomach to perform the exercises to strengthen these, they will have not been worked at all throughout the pregnancy. Arm Muscles The arms need to be strong for carrying the baby and all the equipment required to keep the baby happy - bags, prams, capsules, toys, etc. Strong arms take the pressure away from the skeletal joints, decreasing the chances of pain in the neck or shoulder. Performing the Exercises Post Pregnancy Post-pregnancy exercise guidelines take into consideration the recovery of the Pelvic Floor, healing the Rectus Diastasis and Transversus Abdominus strengthening. The body is still undergoing major healing processes and this has to be respected. Resistance, intensity and exercise modifications will initially need to be lighter than what is normally used for the same client. The combination of decreased core and joint stability, general deconditioning and lowered endurance will lessen the level of the exercise program that can be prescribed. Women may respond quickly to a good program but using a low level initially can decrease the chances of injury. When performing exercises, the movements should be slower and controlled. Emphasis should be placed more on technique, correct posture, and correct activation of all of the stabilising muscles, similar to the beginning stages of rehabilitating any moderate to severe injury. The neural system requires the time to become efficient in moving again and using all the muscles that were out of action during pregnancy. Once correct positioning and activation is established, intensity can be increased. Cue to lift and tighten the Pelvic Floor with all exercises This will help with the Transversus Abdominus activation. Constant reminders will trigger motor learning processes in the client s brain which will eventually lead to automatic activation during exercise.

27 27 Check T-Zone, Obliques and spinal positions with all exercises During each exercise, in every single session check that the women have their T-Zone and obliques properly activated in the correct spinal position. Use of the obliques to prevent the back from arching and ribs from flaring during exercise will need to be re-taught. Be careful with clients who have a Rectus Diastasis or Pelvic Floor Issues Be wary or those with the Rectus Diastasis or Pelvic Floor issues and spend even more time with them on their technique and checking them. Modify to safer/easier exercises when needed Modifications to safe exercises will be common as each woman will react differently, depending on their current strength and injury levels. The progression of abdominal exercises will be largely individual and generally cannot be prescribed uniformly as there are too many variables which can affect the abdominal series. Specific Problems Post Pregnancy Lower Back, Upper Back, Neck and Shoulder Pain Any pain that the woman had whilst pregnant can often continue to cause pain post pregnancy, until she has regained her previous strength, stability and posture. The ligaments do return to their prepregnancy laxity, however the woman s abdominals are usually so stretched and weak that their core stability is terrible, predisposing them to injuries. New pain can also often arise at this time due to the increased load of carrying a baby, poor postures whilst feeing the baby and lifting heavy items such as prams. The same precautions and implications for during pregnancy will apply to post pregnancy. As stated previously, there will be a wider range of exercises to choose from, as there aren t as many positions which are prohibited. Respect still needs to be paid to weakened structures and muscles during pregnancy and the birth itself and program progressions should reflect this. Remember that the important muscles to stretch are going to be: Quadriceps Hip Flexors Gluteals Calves Pectoral Muscles Latissimus Dorsi Lower back/quadratus Lumborum The important muscles to strengthen are going to be all of the muscles that will improve the posture, as correcting postural imbalances will take significant pressure away from and joints and structures causing musculoskeletal pain. Also all of the stabilising muscles of the body are important as the body will still be unstable for a period of time post pregnancy. These include: Oblique Muscles Transverse Abdominus and Pelvic Floor Deep Neck Flexors Rhomboids and Lower Trapezius

28 28 Rotator Cuff Muscles Thoracic Extensors (Erector Spinae) Gluteal Muscles Hamstrings Pelvic Floor Problems Regardless of how well someone has dealt with the issues of pregnancy and birth, there will be some form of Pelvic Floor weakness. The level and severity of the weakness will have large variances between each pregnancy and also depend on whether they had a caesarean section or natural birth, and any Pelvic Floor trauma in the natural birth. In the best case scenario, with a little bit of Pelvic Floor retraining, recovery is fast and free of complications. Pelvic Floor muscle tearing during labour, Pelvic Floor prolapses and nerve damage can slow improvement. Normal Prolapse of the Bladder and Bowel Symptoms Prolapse of the Small Intestine Prolapse of the Uterus and Vagina Pelvic Floor problems can manifest in different ways, the major symptom being incontinence. Types of incontinence can include - Stress incontinence (laughing or running) Urge (desperately needing to go) Frequency (feeling like you have to go to the bathroom even if you just went) Weakness (can feel like a sense of heaviness around the pubic region) Pelvic Floor weakness can contribute to and manifest as musculoskeletal issues. The Pelvic Floor is important in assisting in the activation of the Transversus Abdominus, which in turn helps the stabilisation of the spine. If the Pelvic Floor is weak then the chances of lower back and pelvic pain increase due to the instability. Decreased stability and control of the lumbar spine leads to unfavourable muscular activation and power.

29 29 Causes Symptoms can arise due to several issues affecting the Pelvic Floor - Weakness - this occurs due to the weight of the baby during gestation. Tearing and trauma from the birthing process - a caesarean birth may be chosen to help prevent further damage to the Pelvic Floor. Nerve damage - the nerves that supply the Pelvic Floor can be damaged during a traumatic birth. Decreased innervation lowers the ability of the Pelvic Floor to activate - leading to more weakness and decreased tone. The most severe case of Pelvic Floor issues is a prolapse, where the ligaments suspending the organs are stretched and the organs then sit lower in the body, or in extreme cases may even be actually pushed out of the orifices of the body. Parts of the body that can prolapse include the bladder, vagina, rectum and bowel. It is important to note that regular Pelvic Floor rehab involving Pilates will not be able to fix the base problem of a prolapse the exercises will help but a bad Prolapse usually requires surgery. Implications for Pilates Pilates is an excellent choice of exercise modality, mostly due to the fact that - There is a concerted effort to focus on the Pelvic Floor and its activation during all exercises. Modifications can be made and different equipment can be utilised to cater for all levels of rehabilitation. Exercise can be progressed to a high level, which can help everyday activities and movements that require good control in the body. Although there are no hard and fast rules in terms of progression or exercise choice, there are some protocols of exercise that need to be followed in order to keep people safe and prevent further complications. 1. Start with basic Pelvic Floor activation Once women can start Pilates, training should commence in how to properly activate the Pelvic Floor. In a perfect world, this happens very soon after the pregnancy. Regaining activation may be the hardest part of rehabilitation but persistence pays off. 2. T-Zone retraining When the Pelvic Floor is working, complete the T-Zone retraining by including Transversus Abdominus activation. Begin teaching the T-Zone contraction without any movement at all, ie. keeping the body still. When activation without movement is efficient, actual exercises and movements can be included. 3. Supine Abdominal Series with the feet down Begin with the feet down Supine Abdominal Series as these exert the least amount of pressure in the abdominal cavity and provide the best support of the body. Bent Knee Fallouts are a great starting point to achieve awareness of the T-Zone in conjunction with movement. Once the exercise can be performed with good control of the spine, pelvis, and with consistent T-Zone activation, more challenging exercises can be attempted.

30 30 4. Don t go straight into more advanced abdominals and be aware of repetitions When starting to perform stronger abdominal exercises such as Abdominal Curl, be aware that strong superficial abdominal contractions will bear down on the Pelvic Floor with a greater intensity. If the Pelvic Floor is not strong enough to deal with the large changes in pressure, it will deactivate. This is the reason why it is not advised for a postnatal woman to go straight into high-volume Abdominal Curls without any prior T-Zone retraining. 5. Keep the T-zone on It should go without saying that the abdominal exercises need to be performed with the T- Zone on throughout the whole movement, otherwise Pelvic Floor problems will be exacerbated. 6. Encourage correct breathing patterns as per the basics of Pilates The combination of holding the breath with a strong Pelvic Floor contraction can cause incontinence in the long term. This is because holding the breath can create exponential increases in abdominal pressure, further pressing down and weakening the Pelvic Floor. 7. Advise clients that the exercise intensity may be lighter Explain to clients that in the beginning stages exercise intensity and modifications may be much lighter or easier than what they are used to, regardless of how strong the muscles in the periphery are. Once the Pelvic Floor catches up to the strength of the rest of the body then the intensity can be increased. This means that during the start of their rehab program, women may feel like they are not doing much exercise, but for them to return to high intensity training this phase of training needs to be consolidated. 8. Only progress so far that the T-Zone can be maintained Stronger, higher intensity exercises can be introduced only if the T-Zone can stay on. 9. Women should be strongly advised not to try and return to their normal activities without the correct progression or build-up of exercise. This includes general exercise like running, heavy weight lifting and circuit training. Doing so usually slows down recovery or even sometimes will make problems much worse. 10. Refer to a Health Care Practitioner if a client has a prolapse If a client reports of having a prolapse, this is a definite situation for client referral as they will mostly likely need surgical intervention. 11. Refer to a Health Care Practitioner if a client has any other major problems Refer on to a specialist Pelvic Floor Physiotherapist or gynaecologist if anyone has major problems.

31 31 Rectus Diastasis Aesthetically, a large Rectus Diastasis can be the most worrying for women after their pregnancy. Even through clothing, a Rectus Diastasis can be easily visible. From a rehab perspective, a Diastasis can become so progressively bad that surgery is required to repair the Linea Alba. Structural damage such as this can affect stability, back pain and function and athletic performance in the long term. Clinical Signs The severity of a Rectus Diastasis can be checked by palpating, or pressing into the skin approximately two centimetres below the belly button and asking the client to contract their abdominals. Upon contracting, the Linea Alba will rise superficially and create a tent, or dome in the midline of the abdomen, along with a separation or hole of the Rectus Abdominus muscles. Determining the degree of the Rectus Diastasis can be made by measuring the separation of the Rectus Abdominus. The measurement value is expressed as the number of centimetres or finger widths worth of separation. A separation of greater than three finger widths or 2.5 centimetres is generally described as significant, and attention needs to be paid in order to successfully rehabilitate it. Significant Rectus Diastasis several fingers can be placed in between the two sides of the Rectus Abdominus muscle Mild Rectus Diastasis you can see the doming of the Rectus Abdominus upon performing the sit-up movement Apart from the obvious doming, clients can also complain of weakness through their abdominals and a stretching or pulling sensation around the midline of their abdomen. These symptoms become more apparent with physically demanding activities such as lifting children, pushing a pram and getting out of cars. The concurrent weakness of the abdominal corset can also lead to back pain. Implications Post Pregnancy Resolving a Rectus Diastasis is about decreasing the reliance of the body on the Rectus Abdominus by strengthening the rest of the abdominal muscles, especially the Transverse Abdominus. With the decrease in Rectus Abdominus activity, this allows time for the Linea Alba to heal and the Rectus Abdominus to close back together. This is another reason why it is really important to advise women to try and not get back into extremely high intensity exercises which require strong stabilisation through the trunk.